Searching where there is light : a rough guide to evidence based practice

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Searching where there is light ? a rough guide
to evidence based practice

• Andrew Booth Reader in Evidence Based
  Information Practice, School of Health and
  Related Research (ScHARR), University of
  Sheffield

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Outline

• Evidence Based Practice (EBP) Where Have We
  Come From?
• What are the Strengths and Limitations of EBP?
• EBP The Challenges that lie ahead
• Making our own Practice Evidence-Based

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Evidence Based Practice (EBP) Where Have We
Come From?
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Brief Chronology - 1

• 1972 Cochrane - Effectiveness and efficiency
  Random reflections on health services
• 1980s - Oxford Database of Perinatal Trials
• 1986 - Levels of evidence
• 1991 - Clinical Epidemiology McMaster Uni
• 1992 - First use of term Evidence Based
  Medicine
• 1993 - First Cochrane Colloquium and establishing
  of Cochrane Collaboration

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Brief Chronology - 2

• 1994 Centre for Reviews and Dissemination and
  UK Cochrane Centre, Centre for Evidence Based
  Medicine, Critical Appraisal Skills Programme
• Late 1990s Centres for Evidence Based Nursing,
  Pathology, Mental Health, Dentistry

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Other significant achievements

• NHS Research and Development programme
• NHS Health Technology Assessment
• National Institute for Health and Clinical
  Excellence (NICE)
• Clinical Evidence
• National Library for Health
• Campbell Collaboration

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Evidence based medicine is

• "the conscientious, explicit, and judicious use
  of current best evidence in making decisions
  about the care of individual patients.integrating
  individual clinical expertise with the best
  available external clinical evidence from
  systematic research.
• Sackett, D.L. et al. (1996) Evidence based
  medicine what it is and what it isn't. BMJ 312
  (7023), 71-72).

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The Five As

• Ask a focused question
• Acquire the evidence
• Appraise the studies
• Apply the findings
• Assess the impact
• ...and your own development

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What are the Strengths and Limitations of EBP?
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A Triumph of Marketing!

• Clinical Epidemiology how sexy is that??!!

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Achievements

• Paradigm that has migrated across healthcare
• Approach adapted and adopted across other sectors
  e.g. Education, Social Services etcetera
• Makes decision-making more explicit and more
  rational
• Attempts to tackle postcode lotteries and other
  inequalities

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Criticisms of EBM

• EBM elevates experimental evidence over other
  forms of knowledge
• Definition of evidence within EBM is narrow and
  excludes information important to clinicians.
• EBM is not evidence-based it does not meet
  its own empirical tests for efficacy
• Usefulness of applying EBM to individual patients
  is limited
• EBM limits patients right to choose what is best
  in their individual circumstances

Cohen et al (2004)
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These Criticisms are

• Criticisms of EBM 1.0
• No longer appropriate to EBHC Vista

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EBP The Challenges that lie ahead
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The Challenges

• Wider definition of evidence
• Greater variety of research designs and question
  types
• Increasing use of question-led (and
  solution-focused) approaches
• Increased utilisation of mixed methods
  approaches
• More varied toolbox of evidence products
• More tailoring of evidence to individuals

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Wider definition of evidence

• e.g. Clinical decisions require
• empirical evidence,
• experiential evidence,
• pathophysiologic rationale,
• patient goals and values,
• knowledge of system features.

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Greater variety of research designs and question
types

• Continued expansion of included research designs
• Needs questions - What do people want or need?
• Process questions - Why/how does it work?
• Implementation questions - What is required to
  make it work?
• Correlation questions - What relationships are
  seen between phenomena?
• Attitude questions - What do people think? What
  are their experiences?
• Economic questions - How much does it cost and
  with what benefit/harm?

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Increasing use of question-led (and
solution-focused) approaches

• Closer match between research priorities and
  research commissioning (possible elimination of
  own account research)

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Focusing on Uncertainty
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Database of Uncertainties about the Effects of
Treatments (DUETs)

• Draws on 3 main sources to identify uncertainties
  about effects of treatments
• patients', carers' and clinicians' questions
  about the effects of treatments
• research recommendations in reports of systematic
  reviews and clinical guidelines
• ongoing research, both systematic reviews in
  preparation and new 'primary' studies

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Exact Nature of Uncertainty
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Important Distinction

• Knowledge Support
• Knowledge support syntheses summarize research
  evidence and strive for greater general
  applicability and contribution to the knowledge
  pool. Cochrane-style systematic reviews are
  examples of high quality knowledge support
  syntheses.

• Decision Support
• Decision support syntheses include summarizing
  evidence as well as other tasks required to
  support decision-making in a particular context,
  such as determining recommendations for action
  and considering factors relevant to implementing
  change.

The Oil Platform
The Gas Station
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The Rise and Rise of Systematic Reviews
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Epidemiology of Systematic Reviews (SRs)

• 8,633 reviews published (1996-2003)
• Four reviews per day (2003)
• One in five SRs published by Cochrane
  Collaboration, HTA reports (2/5) and academic
  literature (2/5)
• Only Cochrane reviews are regularly updated.
• Since 2001 rate of updated reviews has plateaued
  at 200 p.a.
• 1,000 updated reviews required p.a. to achieve
  2-year update time.

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8
Average Cochrane Review includes 6
studies Covering all RCTs on Cochrane Trials
Register (300,000 references 270,000 trials)
requires 25,000-45,000 Reviews
Excludes new drugs and procedures
This only includes RCT based reviews excludes
diagnostic, qualitative, observational designs
Source Mallett Clarke, 2003
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Increased utilisation of mixed methods
approaches

• More holistic approaches to include satisfaction,
  quality, costs and patient value

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More varied toolbox of evidence products

• Increasing numbers of decision aids enabled by
  technology
• Continued growth of integrated care pathways
  movement
• Rapid Evidence Assessments
• http//www.gsr.gov.uk/professional_guidance/rea_to
  olkit/how_to_do_an_rea/index.asp

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More tailoring of evidence to individuals

• More utilisation of large patient/population
  datasets
• More tailoring to individual patient context
• More tailoring to individual clinician context

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mYGoodlife
pages from your personal data

• Clinical Trial Opportunities
• Whipps Farm Hospital is recruiting for patients
  with hypertrophic cardiomyopathy in your Region.
  You are eligible!!

• Latest Health Evidence
• YOU will have a 23 reduced risk of stroke if you
  change your medication to Xocetil
• YOUR blood pressure can be lowered by 5 with
  Lochol

• My Appointments
• Optician 15/05/08
• My Medications
• Atenolol 70mg renewal due 08/04/2008

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A Challenge for/from EBM

• Evidence based practice's biggest future
  challenge is one of knowledge translation,
  ensuring that practitioners base their
  day-to-day decision making on the right
  principles and on current best evidence.
• All too often practitioners are unaware of the
  available evidence or fail to apply it. Because
  practitioners values often differ from those
  of users, even those who are aware of the
  evidence risk making the wrong recommendations if
  they do not involve users in the decision making
  process. (Guyatt et al, 2004)

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Making our own Practice Evidence-Based
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'and even evidence-based librarianship!
Dont get mad, get rid of the even!
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A brief chronology

• 1995 First mention of Evidence Based
  Information Practice
• 1997 First mention of Evidence Based
  Librarianship
• 2001 - First EBL Conference, Sheffield
• 2003, 2005, 2007 2nd , 3rd and 4th EBL(IP)
  Conferences (Canada, Australia, USA)
• 2005 - Evidence Based Practice A Handbook for
  Information Professionals (Textbook)
• 2006 Evidence Based Library and Information
  Practice (Open Access Journal)

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What is EBLIP?

• an approach to information practice that
  promotes the collection, interpretation, and
  integration of valid, important and applicable
  user-reported, practitioner-observed and
  research-derived evidence.
• The best available evidence moderated by user
  needs and preferences, is applied to improve the
  quality of professional judgements. Booth,
  2004 After McKibbon, 1995

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Implementing Research in Practice

• "Individuallibrarians must apply the results of
  research routinely to library and information
  service practice, to the development of
  information policy, and to other information
  issues important to..institutions
• Using Scientific Evidence to Improve Information
  Practice The Research Policy Statement of the
  Medical Library Association

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So what about uptake?

• Lindsay Glynn, then Editor of EBLIP, posted
  message in 2006 asking for EBL success stories
  hoping to hear how people had used evidence to
  assist in their decision making as well as
  whether the applied evidence has a positive or
  negative result once implemented (Glynn, 2006,
  p. 1).
• Responses were minimal - EBL still has a way to
  go before it is practised regularly and
  systematically (Glynn, 2006 2).

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Is EBLIP what we want/need?

• 1. Evidence based library and information
  practice (EBLIP) is not relevant.
• 2. EBLIP is learning from experience.
• 3. EBLIP is service improvement.
• 4. EBLIP is all consuming.

c.p. early experience of Sackett in UK
Partridge, HL. et al (2007)
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The evidence For and Against

• Yet another thing to think about
• I dont have time to do it
• I have no capacity to work harder
• There is no evidence

• We should be doing it anyway
• I cant afford not to do it
• Then work smarter
• Then make it

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Hill Review

• there is a fear that healthcare libraries will
  have difficulty in surviving unless librarians
  can show that they support the mission of the
  organisation and be part of the evidence based
  health care movement. Ultimately all NHS
  organisations exist to provide the best possible
  patient care. The challenge for health care
  librarians is to demonstrate that the services
  they provide actively support clinical care.
• Hill, P. (2007) Report of a National Review of
  NHS Health Library Services in England From
  knowledge to health in the 21st Century. 

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Future roles for information professionals?

• Emphasis on Knowledge Transfer
• Getting research implications to policy makers,
  clinicians, patients
• Providing decision support not simply knowledge
  support
• Tailoring knowledge to the audience, context and
  individual patient
• (c.p. outreach/clinical librarian/info specs in
  context)

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New models for the next decade?

• EBPLIB1.0 helping others with their information
  search and retrieval
• --------------------------------------------------
  ---------------
• EBPLIB2.0 helping others with their knowledge
  translation
• EBLIP2.0 - helping ourselves with our own
  knowledge translation
• EBPLIB3.0 fully interacting as genuine members
  of the EBP team
• EBLIP3.0 fully interacting to address genuine
  information practice concerns of our users

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References - 1

• Booth, A., and Brice, A. (2004). Evidence-Based
  Practice for Information Professionals A
  handbook. London, Facet Publishing.
• Cohen AM, Stavri PZ, Hersh WR. A categorization
  and analysis of the criticisms of evidence-based
  medicine. Int J Med Inf 2004 73(1) 35-43

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References - 2

• Guyatt G et al (2004) Evidence based medicine has
  come a long way (Editorial) BMJ. 329(7473)990-1.
• Mays N, Pope C, Popay J. Systematically
  reviewing qualitative and quantitative evidence
  to inform management and policy making in the
  health field. Journal of Health Services
  Research Policy 2005 10(Suppl 1) 620
• Partridge, HL. et al (2007) The practitioners
  experience and conception of evidence based
  library and information practice an exploratory
  analysis. In Proceedings 4th International
  Evidence Based Library and Information Practice
  Conference, Chapel Hill-Durham, NC, USA.