clinical decision making or evidence based practice · clinical decision making (cdm): using...
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Clinical decision making
or
Evidence based practice
Sarah Dean with thanks to
Stuart Logan, Paul Glasziou, Rod Jackson & Mark Perry
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Aims of the afternoon Discuss the role of empirical evidence in clinical practice
Think about the quality of evidence we use
Why & how to structure focussed questions
Give you a couple of short cuts to useful evidence
Practise critical appraisal of research
Think about how to apply evidence to practice
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Clinical Decision Making (CDM): Using
evidence to improve practice
Adapted from: Sackett DL, Rosenberg MC, Gray JA, Haynes RB, Richardson WS. Evidence based medicine:
what it is and what it isn't. BMJ. 1996;312: 71-72.
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The “best” evidence depends
on the type of question
Level Treatment Prognosis Diagnosis
I Systematic Review of …
Systematic Review of …
Systematic Review of …
II Randomised trial
Inception Cohort
Cross sectional
III
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Hierarchy of reliability (for treatment interventions!)
5
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The demand for EBP
The existence of a research-practice gap
Errors in the interpretation of research evidence
Pressure from “payers” for justification for
services
Pressure from families for more involvement in
decision-making
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The demand for EBP
The existence of a research-practice gap
Errors in the interpretation of research
evidence
Pressure from “payers” for justification for
services
Pressure from families for more involvement in
decision-making
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Arch Dis Ch 2001;84:24-30
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11
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The need for EBP
The data explosion
Changes in clinical practice More teamwork
More management in primary care
Less continuity of care
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5,000?
per day
1,500
per day 95 per
day
Medic
al Art
icle
s P
er
Year
Rule 31 – Review the World Literature Fortnightly "Kill as Few Patients as Possible" - Oscar London
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Is keeping up to date Mission Impossible?
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EBP does not consist of:
Sole reliance on evidence from
RCTs
Making decision by the simple
application of guidelines
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Structured questions provide a
framework which helps:
Identify your information needs
Guide your search strategy
Decide the extent to which evidence
applies to your particular problem
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Sources of evidence
http://www.tripdatabase.com/
https://www.evidence.nhs.uk/
17
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Sources of evidence
18
http://www.testingtreatments
.org/new-edition/
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Structuring questions is not about
designing the perfect study – it is
about helping you use existing
evidence to inform practice
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Getting the question right
Who
What
Why
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Clinical Problem
Population
Intervention
Comparison
Outcome
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Clinical Problem
Populationop
ulation
Interventionnt
ervention
Comparisono
mparison
Outcometcome
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Clinical Problem
P
I
C
O
Exposure
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In India, should birth attendants clean
newborn babies in the community with
chlorhexidine swabs?
Ppulation
Intervention
Comparison
O
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Should Sarah take inhaled steroids
for her asthma?
Plation
Iention
Crison
Oe
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Clinical Problem
Population
Intervention
Comparison
Outcome
Study Question
Population
Itervention
Cmparison
Outcome
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Clinical Decision Making
What are the treatment options
and the possible outcomes
For each treatment option, how
likely is each possible outcome?
What is the relative value of each
outcome?