Carl Heneghan BM, Bch, MA, MRCGP

Deputy Director Centre for Evidence-Based MedicineUniversity of Oxford

I am here to learn EBM Because?

• I wanted a day of work • Formulate an answerable questions

• Two acronyms PICO - RAMbo

• Right to Wrong,•Wrong to Right, •Wrong to Wrong

Rapid appraisal of RCTs

Always bring your book Do not volunteer in a teaching

session Use the GATE appraisal tool Randomization pink & blue bunnies Maintenance Blinding or Objective

Five steps in EBM

1. Formulate an answerable question2. Track down the best evidence 3. Critically appraise the evidence for:

Validity Impact (size of the benefit) Applicability

4. Integrate with clinical expertise and patient values

5. Evaluate our effectiveness and efficiency keep a record; improve the process

Participants

Intervention Group (IG) & Comparison Group (CG)

Outcome

IG

CG

+ -+- DC

BA

Representative?

Allocation?

Selection?

Maintenance of allocation?

VALIDITY

comparable groups?treated equally?compliant?

Maintenance?

Measurementsblind subjective? ORobjective?

QUESTION:

Randomizedconcealed Allocation?

Measurement of outcomes?

DESIGN:

No maths

Validity for an intervention study - 10 seconds

Two ways to summarize results of studies that compare groups

Ratio Difference

No maths

Potter’s where to buy www.thinknatural.com

The first question: Has the result happened by chance

The more information - the more certain we are

Diagnosis

Who is this have you met him before

Half the time I don’t know what I am doing

Specificity is no good to me given a positive test

Is It unreasonable to ask what happens if you have a positive test think false positive rate

Systematic Reviews

Mother’s Kiss

Café Rule

FAST

Group Summary

Changes in the past 12 months

A Worldwide survey of 43 EBM practitioners

0- 1 2 3 4 to 5 6 to 8 >80%

5%

10%

15%

20%

25%

30%

35%

40%

Changes in the last 12 months

Questions that people have looked at this week

Paul, Ulf, Rossalyn, Jennifer, Mark, Tricia, Helen, Mark, Robyn, Krishna

Group 1 Aspirin for the primary thrombosis

prevention in the antiphospholipd syndrome

Rovustatin to prevent vascular events in men and women with elevated CRP

The accuracy of single serum progesterone measurement in the diagnosis if ectopic pregnancy

Questions that people have looked at this week

Matthew, Miriam, Amitava, Daniel, Matt, Julia, David, Barbara, Gregory,

Narayana Group 2 In diabetic patients does aspirin

prevent CVD In elderly patients does MD

intervention therapies reduce the incidence of falls

In patients with suspected heart failure does BNP accurately predict disease compared to the gold standard

Questions this weekMike, Clare, Murtala, Mogamat, Haren,

Anee, Daniel, Nuno, Eve Lena, Dini

Group 3 Does Steroid Treatment improve

renal recovery in patients with induced acute interstitial nephritis

Is early compared to late haemodialysis better for survival in critically ill patients with ARF

Does pre operative compared to post operative chemo and radiotherapy improve survival in rectal cancer patients with resectable disease

Questions that people have looked at this week

Carl, Kamlesh, Albin, Mark, Noran, Angel, Orla, Vicky, Robert, Roopa,

Sashidar Group 4 Antibiotics versus placebo for

postoperative infection after appendicectomy

Anaesthesia awareness and the Bispectral Index

Predicting functional impairment with aging

Anticoagulation Treatment in Central Venous Thrombosis

Questions his weekDan, Iben, Annabel, Robert, Nastiti, Chidimma, Annette, Katherine, Richard

Group 5 Does a statin reduce CVD in Middle

aged men with no IHD, but a high cholesterol

What is the evidence that every pregnant women needs to have folic acid to reduce neural tube defects

Does sugar make children hyperactive

Does socioeconomic status determine caesarean rate Does CPAP improve mortality in pulmonary odema What is the evidence goserelin reduces chronic pelvic pain Does C section reduce perinatal mortality in breech presentation

Questions this weekKaren, Su-May, LakshimiSiobhan, Norita, Sridhar, Rowena, Mia, Bijay Group 6 When searching does Google or

Pubmed produce higher quality evidence

Is aspirin effective in primary prevention of CVD in diabetics

Is vitamin c effective for the symptoms of the common cold

In patients with FH of thalassaemia does using a risk counselling tool increase number going to screening

Introduction of new

ideas

Presenting new

material and concepts

Practice and

consolidation

Using real examples,

real language

Debriefing and

Reflection

Evidence Learning cycle

Developing your EBM skills What resources might you use

How are you going to develop your EBM skills

What are you going to differently after this workshop

ResourcesResource How many of you

Up to date 14

Clinical Evidence 6

Trip database 10

Google All!

Google scholar 20

Pubmed central 9

Bandolier 11

Cochrane (abstracts free, full text maybe not) including DARE

Athens

EMBASE

BestBets (Emergency Dept) 12

Drug Infozone

E medicine

Info retriever

Essential Evidence Plus

What things are you going to differently

1. Use GATE tool more 14. Join CEBM mailing list/discussion list

2. Read EBM journal 15. Try to translate things into lay terms

3. Set up journal club 16. Teach others EBM skills

4. Keep book of questions 17. Use PICO and RAAMBO to design research

5. Start blog (see Ami’s on CEBM site!)

18. Better reviewer for journals

6. What is I2? Look up heterogeneity

19. Use pubmed clinical queries…with patient in the room…demonstrate to colleague

7. Try BMJ updates/Evidence updates

20. Increase understanding of EBM in Prosthetics…and other specialties.

8. Keep record of changes to practice

21. More questioning at work

9. Do a systematic review…. 22. Librarians to use more pre-appraised resources

10. Engage colleagues in implementing changes

23. Look back at studies we are using to see if they are really valid/how big is benefit

11. Research designs 24. Do MSc in EBM

12. Try different study designs eg observational

25. Apply for grants to do course/systematic review

13. Write a letter about an article to NEJM

26. Influence journal editors to present things better.

Postcards:What three things are you going to do differently

Amanda.burls@dphpc.ox.ac.uk

Questions

Recognize: your questions Select: which questions to

pursue Guide: how to ask and answer Assess: how well & what to

improve

What Pushes Us … ?

Toward curiosity Prove colleagues

wrong Keeps coming up Risk of patient

harm Want to do better Anxiety Avoid litigation Internet informed

patient

AwayTimeWe already know the

answerFatigueAccessInferiority complex-

anxiety-afraid of admitting knowledge gaps

CynicalLazinessLack of supportPrevious failure at

searchingLack of resourcesNoone else does itFear of change

The Real ‘Three R’s’ of Learning

Resilient

Reflective

Resourceful

FAQ: How Long … ? Proficient?

Quickly Mastery?

Lifetime

Human expertise takes >10,000 hours, >10 years

→Deliberate practice