Evidence-Based Practice Lecture Notes PDF

Dr. Ronahi Yonis MBChB,FKBMS Lecture 2 Evidence-based… …Medicine 5- …Healthcare …Practice You are in an era where evidence- based medicine is dominant  "€ if - Eh at  · Argument that: e ✗ – Health service delivery should be bas...

Dr. Ronahi Yonis MBChB,FKBMS Lecture 2 Evidence-based… …Medicine 5- …Healthcare …Practice You are in an era where evidence- based medicine is dominant  "€ if - Eh at  · Argument that: e ✗ – Health service delivery should be based on best available evidence – Best evidence = findings of rigorously conducted research – Evidence of · effectiveness (of drugs, practices, interventions) · cost-effectiveness (in a system with where should money be spent to gain the maximum utility?)  a Ineffective and inappropriate interventions waste resources that could be used more effectively Variations in treatment create ui inequities Previously practices influenced (too much) by: f- doctor opinion – Professional opinion * – Clinical fashion ✓ Iim - Es– Organizational and social culture – Historical practice and precedent - Ñ÷so - Research showed that clinicians have often Persisted in using health care interventions that are ineffective ↑ ✗  Failed to take up other interventions known to be effective Tolerated huge variations in practice E 2  · Treatment of eclamptic seizures with MgSO4 used successfully in USA for 60 years · Benefit clearly demonstrated · But by 1992 only 2% of clinicians were using it in UK # ✗ The origins of evidence-based ← healthcare Archie Cochrane’s book Effectiveness and efficiency: random reflections on health services (1972) set out principles of evidence-based practice Criticised medical profession for failing to take account of research.  Sources of Evidence – Systematic Reviews (2) “It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials.” Archie Cochrane (1979) ✗ Prof Archibald L Cochrane, CBE (1909 – 1988) www.cochrane.org/index.htm  Cochrane called for register of all RCTs Group in Oxford led by Iain Chalmers responded to this: – Produced register of all x RCTs in obstetrics and gynaecology – Systematic reviews and meta-analyses of data and evidence produced by RCTs – Becomes the first ‘Cochrane Centre’ Other Cochrane Centers set up elsewhere The Cochrane Collaboration’s logo shows a systematic review of seven RCTs comparing (cheap) corticosteroid treatment for pregnant women at risk of giving birth prematurely versus placebo. 1972: first RCT published (showing likely benefit of intervention in reducing infant mortality) By 1979: seven RCTpublished. If a meta-analysis had been conducted then, it would have indicated very high probability of benefit 1989: a systematic review is finally published, showing reduction in likelihood, of death of baby due to x complications associated with prematurity, of 30% -50% SYSTEMATIC REVIEWS & META-ANALYSIS quantitative pooling of É&% results of individual ! I 4 Mj 9 studies Systematic £" Meta-analysis review tÉÉs Research ↳ A systematic review will not necessarily include a meta-analysis if, for example, clinical Difference heterogeneity is too great. Because no systematic review was published until 1989, tens of thousands of babies suffered / died / needed more expensive treatment than would have been necessary x - E y  0 ✗  · Systematic reviews and meta-analyses e - & have become very important in informing evidence - base. ·✗As doctors you need to have an understanding of these methods and be able to critically appraise them.  Useful to clinicians becaus e: · By appraising and integrating findings, they :offer both quality control and increased certainty · They offer authoritative, generalisable and up-to-date conclusions F- · They may reduce delay between research discoveries and implementation - performat.io# -  · They can help to prevent biased decisions ÷ ⇐ being made · They can be relatively easily converted into guidelines and recommendations - · However, doctors need to be able to access systematic reviews and to appraise them to be satisfied about the quality of the evidence  · Medical journals – Many reputable, peer-reviewed journals publish systematic reviews · e.g. The Lancet, BMJ, New England Journal of Medicine etc. · See module handbook · See also Leicester library: http://www.le.ac.uk/li/clinical/digital/evidence/ebpindex.ht m ✗ · Cochrane Collaboration – the Cochrane library includes four databases (and links to other resources ): – The Cochrane Database of Systematic Reviews – The Database of Abstracts of Reviews of Effectiveness – The Cochrane Controlled Trials Register – The Cochrane Review Methodology Database · The NHS Centre for Reviews and Dissemination – A national centre to lead the review, management and dissemination of research findings in Britain · NIHR Health Technology Assessment Programme – Aims to produce high quality research information on the costs, effectiveness and broader impact of health technologies – Includes primary research AND systematic reviews a Practical criticisms of-0 EBP · May be an impossible task to create and maintain systematic reviews across all specialities · May be challenging and expensive to disseminate and implement findings · Lots of methodological arguments about meta- analyses and systematic reviews · RCTs are seen as the gold standard but not always feasible or even necessary/desirable (e.g. due to ethical - considerations)  · Evidence-based practice is now well ← established - But… · Many ineffective practices continue s - · Some effective practices are not - implemented - · Existence of evidence doesn’t ensure implementation of evidence-based practice  · Evidence exists, but doctors don’t know about it – Dissemination ineffective? Doctors not incentivised to keep up-to-date? · Doctors know about the evidence but don’t use it – Why not? Habit? Organizational culture? Professional judgment? · Organizational systems cannot support innovation – E.g. because managers lack ‘clout’ to invoke changes · - Resources not available to implement change – Financial or human resources: change management is - complicated and demanding process  ✗ · You are in the era of evidence-based health care · Your practice needs to be informed by the best available evidence · Despite criticisms of EBP, it is vital that the doctors of tomorrow can access, appraise, and act on evidence.