MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C317A9.2C35EFB0" This document is a Web archive file. If you are seeing this message, this means your browser or editor doesn't support Web archive files. For more information on the Web archive format, go to http://officeupdate.microsoft.com/office/webarchive.htm ------=_NextPart_01C317A9.2C35EFB0 Content-Location: file:///C:/0539D757/ebm_talk_general_mar99_ppt97.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Master Set of CEBM Slides: July 1996

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‹header› = ;
‹da= te/time› = ;
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‹#= › = ;
Centre for Evidence-Based Medicine
‹#= 250;
------=_NextPart_01C317A9.2C35EFB0 Content-Location: file:///C:/0539D757/ebm_talk_general_mar99_ppt97_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C317A9.2C35EFB0 Content-Location: file:///C:/0539D757/ebm_talk_general_mar99_ppt97_files/slide0341.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Master Set of CEBM Slides: July 1996
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Centre for Evidence-Based Medicine
What I’ve done / do/don’= t do
lDone: I’ve gotten out of date and retrained in Internal Medic= ine twice
lDo: I r= un an in-patient General Medicine service (all comers) at a UK DGH:= 3;
»208 admi= ssions last month
<= span class=3DB1B style=3D'position:absolute;left:-4.15%'>»strive t= o use evidence at the bedside
lDon= 217;t: I’ve cancelled my journal subscriptions (and give away the JCI and BMJ) =
l
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=
Centre for Evidence-Based Medici= ne
<= u>The Problems:
lWe need evidence (about the accuracy= of diagnostic tests, the power of prognostic markers, the comparative efficacy and safety of interventions, etc.) about 5 times for every in-patient (and twice for every 3 out-patients).
lWe get less than a third of it
------=_NextPart_01C317A9.2C35EFB0 Content-Location: file:///C:/0539D757/ebm_talk_general_mar99_ppt97_files/slide0343.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Master Set of CEBM Slides: July 1996
=
Centre for Evidence-Based Medici= ne
<= u>The Problems:
lTo keep up to date in Internal Medicine, I need to read 17 articles a day, 365 days a year
lNeed to read
<= span class=3DBB style=3D'position:absolute;left:-4.72%;top:.3em'>lDon= 217;t
<= span class=3DBB style=3D'position:absolute;left:-4.72%;top:.3em'>lNor do= es anyone else
------=_NextPart_01C317A9.2C35EFB0 Content-Location: file:///C:/0539D757/ebm_talk_general_mar99_ppt97_files/slide0344.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Master Set of CEBM Slides: July 1996
=
Centre for Evidence-Based Medici= ne
Median minutes/week spent= reading about my patients:
lSelf-reports at 17 G= rand Rounds:
<= span style=3D'font-size:75%'>lMedical Students:   90 minutes
<= span style=3D'font-size:75%'>lHouse Officers (PGY= 1):   0  (up to 70%=3Dnone)
lSHOs (PGY2-4): 20  (up to 15%=3Dnone)
lRegistrars: 45  (up to 40%=3Dnone)
lSr. Registrars 30  (up to 15%=3Dnone)
<= span style=3D'font-size:75%'>lConsultants:
<= span style=3D'font-size:86%'>»Grad. Post 1975: 45  (up to 30%=3Dnone)=
<= span style=3D'font-size:86%'>»Grad. Pre &n= bsp; 1975: 30  (up to 40%=3Dnone)<= /div>
This summarises = the data from about 12 DGH’s around the England and Scotland.

In summary, HO&#= 8217;s (who don’t read at all) are being taught by old farts (who read 30 minut= es a week).
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Performance deteriorates, too
lDeterminants of the clinical  decision to treat some, but not other, hypertensives:
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-size:75%'>1Level of blood pressure.
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-size:75%'>2Patient’s age.&= #13;
3The physician’s year of graduation from medical scho= ol.
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.34%;top:.3em;font-size:75%'>4The amount of target-organ damage.
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Centre for Evidence-Based Medici= ne
No wonder, then, that CME is growing
l
lBig, and getting huge. <= /div>
lUsually instructionally (fact) oriented.
lSeveral randomised trials have shown= that it does not improve clinical performance.
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Centre for Evidence-Based Medici= ne
Three solutions
lClinical performance can keep up to date:
1by learning how to practice evidence-based medicine ourselves.
2by seeking and applyi= ng evidence-based medical summaries generated by others.
3by applying evidence-based strategies for changing our clinical behaviour.
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When did EBM begin ?
lCertainly in post-revolutionary Paris.
lArguably in B.C China.
lSome late-comers named it in 1992.<= /span>
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Centre for Evidence-Based Medici= ne
What evidence-based medicine is:
lThe practice of EBM = is the integration of
<= span class=3DBB style=3D'position:absolute;left:-4.72%;top:.3em'>lind= ividual clinical expertise
»with the
lbest available external clinical evidence from systematic research.<= span style=3D'mso-tab-count:3;width:27.77%'> and
<= span class=3DBB style=3D'position:absolute;left:-4.72%;top:.3em'>lpat= ient’s values and expectations
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I.Individual Clinical Expertise:
lClinical skills and clinical judgement
lVital for determining whether the <= /span>evidence (or guideline) applies to the individual patient at al= l and, if so, how
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II. Best External Evidence:
lFrom real clinical research among intact patients.
lHas a short doubling-time (10 years).
lReplaces currently accepted diagnos= tic tests and treatments with new ones that are more powerful, more accurate, more efficacious, and safer.
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III. Patients’ Val= ues & Expectations
lHave always playe= d a central role in determining whether and which interventions take place lWe’re getting better at quantifying and integrating them
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What EBM is not:
<= span class=3DBB style=3D'position:absolute;left:-4.72%;top:.3em'>lEBM is= not cook-book medicine
»evidence= needs extrapolation to my patient’s unique biology and values
<= span class=3DBB style=3D'position:absolute;left:-4.72%;top:.3em'>lEBM is= not cost-cutting medicine
»when eff= icacy for my patient is paramount, costs may rise, not fall
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Centre for Evidence-Based Medici= ne
Evidence-Based Medicine:
The Practice
lWhen caring for pati= ents creates the need for information:
1Translation to an answerable question   (patient/manoeuvre/outcome).
2Efficient track-down = of the best evidence
»secondary (pre-appraised) sources        = e.g., Cochrane; E-B Journals
»primary literature
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Evidence-Based Medicine:
The Practice
3Critical appraisal of the evidence for its= validity and clinical applicability &e= grave; generation of a 1-page summary.
4Integration of that critical appraisal wit= h clinical expertise and the patient’s unique biology and belief= s è action. =
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-size:75%'>5Evaluation of oneR= 17;s performance.
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We needn’t always c= arry out all 5 steps to provide E-B Care
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-family:"Monotype Sorts";font-size:75%'>= mAsking an answerable question.
<= span style=3D'text-shadow:auto'>è= Searching for the best evidence.
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-7.12%;top:-.15em;font-family:"Monotype Sorts";font-size:120= %'>èCritically-appraising the evidence.
mIntegrating the evidence with our expertise and our patient’s unique biology and values <= /span>
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-family:"Monotype Sorts";font-size:75%'>= mevaluating our performance
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Centre for Evidence-Based Medici= ne
We’ve identified 3 different modes of practice
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-family:"Monotype Sorts";font-size:75%'>= è“Searching & appraising”
»provides= E-B care, but is expensive in time and resources <= /div>
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.72%;top:.3em;font-family:"Monotype Sorts";font-size:75%'>= è“Searching only”
»much, qu= icker, and if carried out among E-B resources, can provide E-B care= 3;
<= span style=3D'mso-special-format:bullet;color:#FAFD00;mso-color-index:5;positio= n: absolute;left:-4.51%;top:.3em;font-family:"Monotype Sorts";font-size:75%'>= è“Replicating” the practice of experts
»quickest= , but may not distinguish evidence-based from ego-based recommendations=
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Even fully EB-trained clinicians work in all 3 modes
è“= ;Searching & appraising” mode for the problems I encounter daily.
è“= ;Searching only” mode among E-B resources for problems I encounter o= nce a month.
= è“Replicating” the practice of experts mode for problems I encounter once a= decade(and crossing my fingers!).
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Centre for Evidence-Based Medici= ne
Patients can benefit
lEven if <10% of clinicians are capable of practicing in the “searching & appraising” mode (5% of GPs) &= #13;
lAs lon= g as most of them practice in a “searching” mode within high-quality evidence sources (70-80% of GPs):
»Cochrane Library, E-B Journals, E-B Guidelines, etc
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Centre for Evidence-Based Medici= ne
Three solutions
lClinical performance= can keep up to date:
1by learning= how to practice evidence-based medicine ourselves. 2by seeking and applying evidence-based medical summaries generate= d by others. 3by applying evidence-based strategies for changing our clinical behaviour.
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Information required
within seconds
l   Systematic reviews, periodically updated, of randomised trials of the effects of health care (from all sources, and in all languages):

    &nb= sp; The Cochrane Collaboration.
Cochrane symbol<= /font>
CDSR display of = options
Stroke graphical= display
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Cochrane Systematic Reviews (522; another 500 in preparation)
Database of Abstracts of Reviews of Effectiveness (1895)
Registry of Randomised Controlled Trials (218,355)
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Content-Location: file:///C:/0539D757/ebm_talk_general_mar99_ppt97_files/slide0061.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Master Set of CEBM Slides: July 1996
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Centre for Evidence-Based Medici= ne
Information required
within seconds
l   CD-Evidence-based journals = of 2º  publication:
lÊ screen 50-70 clinical journals per week for clinical articles that pass critical appraisal quality filters è conclusions likely to be true. =
lË select the subset that are clinically relevant.
lÌ summarise as “more-informative” abstracts.
lÍ add commentaries from clinical experts.
lÎ introduce with declarati= ve titles.
covers of ACPJC = and EBM
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Centre for Evidence-Based Medici= ne
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