Evidence Informed Practice The pipeline from research to patient care

1
Evidence Informed PracticeThe pipeline from
research to patient care

• Professor Paul Glasziou
• Centre for Evidence Based Medicine
• University of Oxford

2
From Evidence to PracticeOverview

• The steps from research to practice
• Roles of clinical librarians
• Organising
• Answering Services
• Teaching/Coaching

3
BP Control Rates
Trends in awareness, treatment, and control of
high blood pressure in adults ages 1874
Sources Unpublished data for 19992000
computed by M. Wolz, National Heart, Lung, and
Blood Institute JNC 6.
4
Leaks between research practice
0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 0.21
5
Studies (primary research studies
sound unsound)
Systems (bottomline /- ref) Synopses (user
summary of research) Systematic Reviews
CATs (search appraise synthesis)
6
Is bed rest ever helpful?A systematic review of
trials

• 10 trials of bed rest after spinal puncture
• no change in headache with bed rest
• Increase in back pain
• Protocols in UK neurology units - 80 still
  recommend bed rest after LP Serpell M, BMJ
  1998316170910
• evidence of harm available for 17 years
  preceding...

Allen, Glasziou, Del Mar. Lancet, 1999
7
(No Transcript)
8
(No Transcript)
9
Evidence missing from pipeline
Aware Accept Target Doable Recall Agree
Done
Valid Research

• BARRIERS
• Question recognition
• Skills in EBM
• Evidence Resources
• Time (substitution)

10
From Evidence to PracticeOverview

• The steps from research to practice
• Roles of clinical librarians
• Organising
• Teaching/Coaching
• Question-Answering Services

11
Organising the overload
12
Rule 31 Review the World Literature Fortnightly

• "Kill as Few Patients as Possible" - Oscar London

13
Organising I systematic reviews - 10 done in
therapy
14
Bimonthly just in case journalValid, Relevant
(almost) No Effort!
Organising II Alert services

• 100 journals scanned
• Is it valid?
• Intervention RCT
• Prognosis inception cohort
• Etc
• Is it relevant?
• GPs specialists askWill this change your
  practice?

www.evidence-basedmedicine.com
15
Managing InformationA comparison of sectors

• The Airline industry
• Boeing 777 manuals
• 24 binders
• 10 feet shelf space
• Conversion to CD
• Reduced search by 60

• The Health Industry
• Memorize the manuals
• Exams, audits, etc to check

16
Teaching coaching
17
Just in Time learningInterns information
needs

• Setting 64 residents at 2 New Haven hospitals
• Method Interviewed after 401 consultations
• Questions
• Asked 280 questions (2 per 3 patients)
• Pursued an answer for 80 questions (29)
• Not pursued because
• Lack of time
• Forgot the question
• Sources of answers
• Textbooks (31), articles (21), consultants (17)

Green, Am J Med 2000
18
Questions are (missed) opportunities

• Most of our questions are NEVER answered
• When answered, the information is likely to be
  neither the best nor up-to-date

19
Information pullSteps in EBM process

• Formulate an answerable question
• Track down the best evidence
• Critically appraise the evidence
• Integrate with clinical expertise and patient
  values

20
Just in Time learningThe EBM Approach to CME

• Shift focus to current patient problems(just in
  time education)
• Relevant to YOUR practice
• Memorable and behaviour changed!
• Up to date
• Skills and resources for best current answers

21
Team EBM

• Multidisciplinary journal clubs
• Focus on questions not journals
• Discuss search appraisal as well as content
• Involve health team ( librarian)
• Example In NIDDM, is blood better than urine
  monitoring for long-term control?
• SR of 4 trials No difference between urine
  BloodCoster S. Diabetic Medicine, 2000,
  17755-61

22
Teaching EBM works best if integrated with
practice
Coomarasamy, BMJ 20043291017
23
EBP for TeamsSession 1 formulate questions

• In NIDDM is urine monitoring as effective as
  blood glucose monitoring as measured by HbA1c
  control
• Should all diabetics be on aspirin?
• Most audit
• Are aerobic or resistance exercises helpful for
  diabetic control?
• Both improve control audit purchased 12
  pedometers
• Who needs to see the podiatrist?
• High risk
• What is the best test for neuropathy?
• Monofilament
• How can we improve compliance?
• Simple regimes, education, reminders (dosette box)

24
Possible Q-A roles
Greenhalgh, BMJ 2002324 524-9.
25
Question Answering Services
26
Questions in the NHS

• Clinical Questions asked
• 620,000 health care workers
• 100-200 Million questions per year
• Clinical Questions Answered
• Services (lt 1/2)
• Medicine Information 500,000/year
• Clinical Librarians - 50-100,000/year
• Special services - several ,000/year
• Other sources
• Colleagues, books, , not answered

27
Plans for Q-A services in NHS

• A Project Board 6 projects envisaged
• Establishing and supporting a network
• Developing quality standards for question
  answering and service provision
• Establish a national repository of clinical
  questions and answers, available to those
  providing services.
• Strategy for, and supporting specialist training
  for informaticists/librarians involved in
  services.
• Promoting question-answering skills amongst users
  of clinical information.
• An NeLH-based portal for users of Clinical
  Question Answering Services

28
From Evidence to PracticeSummary

• The steps from research to practice
• Roles of clinical librarians
• Organising
• Teaching/Coaching
• Question-Answering Services

29
(No Transcript)
30
Possible Roles for Q-A Centre

• Soon
• Administer network of services (including
  contacts database)
• Facilitate sharing of best practice and
  innovation
• Develop quality standards for services
• Archive analysis of asked questions
• Later
• Commission independent evaluations of the service
• Establish ongoing feedback mechanism for end
  users
• Foster education of end-users in EBM
• Improve service usage

31
National Questions Archive?

• 6 of 12 services provide a searchable archive
• No national archive
• Currently NOISE (National Organisation for
  Information Support for Effectiveness), a group
  representing query-answering services from across
  the UK is creating a database of questions and
  answers.
• It is helping to avoid the duplication of effort
  and to improve turn around times.
• It is exploring whether it could offer a service
  to validate answers, although experience shows
  that those running such services do not always
  like using other people's answers! - Bandolier,
  2001