Transcript The New Role of Evidence Based Medicine

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The New Role of Evidence Based
Medicine
Walter Rosser, MD,CCFP,FCFP,MRCGP (UK)
Professor and Head
Department of Family Medicine
Queen’s University
Kingston, Ontario, Canada
Rosser, Walter. “The New Role of Evidence Based Medicine.” [Online] 10 September 2004.
Plan for Discussion
 Introduction
 Criticism Against Evidence Based Medicine
 A New Role for EBM
 Some Tools of Value to the Practitioner
 Conclusion/Discussion
Introduction
 The concept of evidence based medicine has
been evolving over the past 30 years.
Methods to critically appraise clinical
information and classify it according to the
strength of evidence (A,B,C,D,E.) was first
presented in a Canadian Medical Association
Journal series on how to critically appraise
literature in the early 1980’s.(1)
Introduction
 In the late 1980’s and early 1990’s, the
Journal of the American Medical
Association published a similar series on
how to critically appraise literature. (2)
 Concepts emerging from the literature on
“critical appraisal” promoted what has
become known as evidence based
medicine (EBM), suggesting that
clinicians should use critically appraised
information in clinical practice for optimal
care of their patients
Criticizing EBM
 Attempts over the past 1 ½ decades to implement
EBM in Canada, the United States, the UK and
Europe generated a controversy that has questioned
the value of EBM in clinical practice. (3)
 Many practicing physicians regard EBM as an
academic exercise for medical students that has no
relevance to clinical practice
 Often the translation of results from RCT’S conducted
in teaching hospitals is not appropriate for Family
Practice (4)
Criticizing EBM
 It is impossible for any clinician to have the
time to critically appraise even one article per
week let alone the number that would need to
be appraised to answer questions (estimated
at 3.5 per clinical session) arising in a busy
practice.
 Governments, hospitals and HMO’S have
used the jargon of EBM to justify decisions,
directives, or incentives that are seen by
clinicians as inappropriate.
Criticizing EBM
 Critically appraised “evidence” has been used
to support politically inspired justification for
what are perceived by clinicians as “bad”
decisions that are not in the best interests of
patients or the institution.
 EBM is seen by some to promote
“therapeutically nihilistic” approaches to
medical practice since critical appraisal of
commonly used therapies often concludes
that they provide little or no benefit
Criticizing EBM
 EBM is also said by some to promote “cook
book” medicine, using evidence from
population-based randomized controlled trials
to dictate required treatments, irregardless of
the physician’s judgment or the patient’s
wishes.
 Family physicians often find that EBM often
does not address or answer questions that
arise in their practice.
Criticizing EBM
 Some practitioners find that evidence based
therapy is different than the standard practice
in their community and worry about increased
medical-legal risk
 There is an argument that EBM has made
generalist medical practice less attractive to
medical students for a career.(5)
Criticizing EBM
 The student argument is that to be a good
physician, you must know everything there is
to know in your field and this is only possible
in narrow subspecialties.
 Resistance to adopting EBM has created a
“Time Gap “ between development of
research proven evidence of good or poor
therapy and widespread adoption that has
been estimated as long as 15 years.
A New Role for EBM
 How can all these concerns be addressed?
 How can the individual clinician deal with the
time required to properly critique even one
article per week let alone what is needed in
practice?
 As a first step, all practicing physicians need
to understand the basic principle of EBM and
critical appraisal.
A New Role for EBM
 There are at least two reasons that support
this statement.
 By understanding the principles of EBM,
clinicians can critique third party sources that
provide evidence based information so they
can be confident about the quality.
 They may also need to rapidly assess quality
of studies that are sensationalized in the
popular press and often bring patients into
the office with demands or questions.
A New Role for EBM
 There are a growing number of organizations
and agencies that are using very transparent
methods to critically appraise literature on
common medical problems and choosing the
best available evidence.
 An example of such a site that chooses the
best available guidelines is
www.gacguidelines.ca
 A list of other critically appraised sites is
available on Table 1.
A New Role for EBM
 If all practitioners had the skill to:
 Do a rapid literature search on one or two search
engines
 Rapidly critically assess the media’s study of the
week
 Be able to judge the quality of critically appraised
information provided by a third party,
…then the gap between evidence and practice would
quickly narrow.(6)
A New Role for EBM
 Presence of an internet connection in every
practitioner’s office will signal a revolution in
the practice of Family Medicine.
 Basic information about any problem or
symptom, no matter how rare or unusual, can
be obtained within a few minutes by the
clinician.
 Best available evidence, recently updated is
there for any patient within the time
constraints of a visit to a busy practice.
A New Role for EBM
 While the clinician can access whatever information
is needed in the office, he/she may also receive
education while integrating EBM into practice.
 CAPRE stands for “critically appraised practice
reflection program” which includes identifying a
patient with a specific problem, providing the patient
with EBM information answering their questions and
then determining if they did or did not follow the
advice. The CAPRE program is at
www.meds.queensu.ca/capre
A New Role for EBM
 The final step, all on line, is to feed back to
the program a description as to whether the
patient adopted the recommendations or not,
and for the physician to self assess to
determine if he or she might have presented
the information more effectively.
 The new role of EBM is in assisting the
physician in diagnosing and managing their
patients and being educated on line
Some EBM Tools
 The GAC site provides an example of the
new generation of web based tools.(9)
 The site is jointly sponsored by the
Government of Ontario and the Medical
Association.
 Medical librarians do literature searches on
common problems selected by a consultation
process between physicians and the
government health insurance plan.
Some EBM Tools
 All guidelines on the topic are identified (23 on
asthma)
 The guidelines are then scored by 3 trained
community physicians (there are 80 available) using
a validated scoring system. (Cluzeau)
 Scored guidelines are then rank ordered and
assigned an “apple” score according to the quality of
critical appraisal methods used to produce the
guideline.
 4 apples = excellent, 3 apples = good, 2 apples =
fair, 1 apple = poor.
Some EBM Tools
 The best available guideline is then
summarized on one page so the practicing
clinician can easily access the information
they need in their office.
 See attached copy of the example Asthma:
Inhaled Glucocorticosteroids in
Adults and Children (10)
Some EBM Tools
 The table labeled “Some foraging tools” offers
a list of some of the available EBM materials
taken from the book titled “Evidence Based
Family Medicine”(7)
 The table titled “Some EBM Web sites” is
similarly drawn from “Evidence Based Family
Medicine”
 These tables provide you with an idea of what
is available to assist incorporating EBM into
practice.
Some EBM Tools
 The Book “Evidence Based Family Medicine”
includes a CD-Rhom that hotlinks all these sites. The
book references other programs like the GAC web
site and the CAPRE web site. (8)
 CAPRE provides patient information and a
physician/patient partnership program that includes
written agreement between physician and patient
over evidenced based approaches to therapy. (See
example in handout)
Some EBM Tools
 For those interested in teaching EBM, the CD




Rhom accompanying “Evidence Based
Family Medicine” includes a series of ideas
on how to teach critical appraisal in four
different environments:
The clinic
Small groups
Web based courses
Using the Bedford Murder
Some EBM Tools
 The Bedford Murder is a murder mystery built
around learning critical appraisal
principles.(11)
 As the mystery unwinds, questions arise
about the likelihood of a character contracting
a disease or dying of cardiovascular disease
in the next 10 years.
 This strategy breaks the image of EBM being
only for academics.
Some EBM Tools
 Use of hand held systems providing evidence
based information is presently available and
provides promise for the future of
incorporating EBM into every practice.
 “Info Retriever” is the most widely used tool
for this purpose
Conclusion
 EBM is not widely accepted by practitioners as a
good approach for clinicians
 The argument of its necessity for practice of medicine
has been presented
 Some tools to assist us in using and teaching
students and residents how to incorporate EBM into
their practice are offered.
 These ideas should stimulate some discussion and
your opinions about the value and need for EBM