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Blekinge kompetenscentrum Evidensbaserad vård
23-04-121
Evidensbaserad MedicinUlf Eriksson2013
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-122
Aware Accepted Applicable Able Acted on Agreed Adhered to
UnsoundResearch
SoundResearch
Systems(bottomline +/- ref)
Synopses(user summary of research)
Systematic Reviews and CATs(search; appraise; synthesis)
(1)
(2)
(3)
(4) Quality Improvement• Skills• Systems
Evidence-Based Medicine• Questioning• Skills in EBM• Evidence Resources• Time (substitution)
Patient Choice• Decision Aids• Education• Compliance aids
(5)
~20%
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-123
Hur väl känner du till EBM?
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Blekinge Centre for CompetenceEvidence-based Health Care
23-04-12
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Blekinge Centre for CompetenceEvidence-based Health Care
http://bit.ly/EBMbook
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-127
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-128
EBM som metod
•EBM – en samling metoder för att söka, värdera och tillämpa kunskap.
•Metodiken används i och för kompetensutveckling, kunskapsbasering, ständigt lärande
•EBM baseras på ämnet Klinisk epidemiologi
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-12
EBM - Väger samman:
• Bästa tillgängliga evidens
• Kontext -Egen kunskap, situation, tillgång till vård, etiska överväganden mm
• Patientens/vårdtagarens/klientens värderingar önskemål etc
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1210
Steg 4 - Implementing.
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1211
EBM - network
•Centre for EBM–Oxford
www.cebm.net–Toronto www.cebm.utoronto.ca/
•Teachers and developers of EBM–Courses, workshops–Conferences
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1212
Fundera över kunskapsutvecklingen inom biomedicin…
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1213
Den Medicinska Kunskapsutvecklingen:
• För att hålla sig fullt informerad inom en medicinsk specialitet så behöver man läsa 17 artiklar om dagen, 365 dagar om året,
• och till det ägnar man ungefär 1 tim i veckan att läsa...
• Man hinner inte• och ingen annan heller.
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1214
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1215
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1216
Metoder som kan ha mönstrats ut för långsamt
• Sängläge vid akut hjärtinfarkt• Långvarig vila mot akut okomplicerad ryggsmärta• Tidig röntgen vid akut ryggont utan annan misstänkt sjukdom• Syrahämmande läkemedel vid funktionell dyspepsi• Operation (Nefropexi) mot rörlig njure• Blindtarmskirurgi vid diffusa bukbesvär (”Kronisk appendicit”)• Förebyggande uttagning av visdomständer som inte brutit fram• Neuroleptika mot oro hos äldre (utan psykos)• Rutinmässig lungröntgen eller EKG inför operation
•Källa SBU
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1217
• Acetylsalicylsyra (ASA) efter hjärtinfarkt och slaganfall.• ACE-hämmare vid hjärtsvikt eller hjärtinfarkt.• Blodproppsförebyggande behandling före stora operationer• Trombolys vid hjärtinfarkt• Betablockerare efter hjärtinfarkt• Rådgivning för rökavvänjning• Mini-intervention vid risk-drickande• Strukturerad psykosocial behandling av alkoholmissbruk• Rådgivning om fluortandkräm för att förebygga karies
•Källa SBU
Metoder som kan ha införts för långsamt
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1218
Evidence-based Medicine:Fem-stegs-metoden
Centre for Evidence-Based Medicine
1 Ask
2 Acquire
3 Appraise
4 Apply
5 Assess
•Doer
X
XX
X
(X)
•User
X
X
X
•Replicator
X
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1219
Steg 1 – ASK – Formulera en fråga
För patienter med…., som….
om man ….
jämfört med att….
för att uppnå/undvika…
Formulera en kliniskt fokuserad
fråga i
PICOPICO-format
PP for Patient:
II for Intervention:
CC for Comparison / Control:
OO for Outcome:
http://www.cebm.net/index.aspx?o=1036
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1220
Translate your PICO to Search Terms
• Patient, or group of patientsoften same
• InterventionOften Subheading / Keyword
• ComparisonOften Placebo, SOP or none!
• Outcome!Use POEMs: Patient Oriented Evidence that Matters!
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1221
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1223
Fundera över studietyper…
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1224
Step 2: The “best” evidence depends on the type of question
What are the phenomena/problems?– Observation (e.g., qualitative research)
What is frequency of the problem? (FREQUENCY) – Random (or consecutive) sample
Does this person have the problem? (DIAGNOSIS)– Random (or consecutive) sample with Gold Standard
Who will get the problem? (PROGNOSIS)– Follow-up of inception cohort
How can we alleviate the problem? (INTERVENTION/THERAPY)– Randomised controlled trial
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Grimes, D. A.,Schulz, K. F. (2002). An overview of clinical research: The lay of the land. The Lancet, 359(9300), 57-61
2013-10-17+18
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Grimes, D. A.,Schulz, K. F. (2002). An overview of clinical research: The lay of the land. The Lancet, 359(9300), 57-61
2013-10-17+18
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Grimes, D. A.,Schulz, K. F. (2002). An overview of clinical research: The lay of the land. The Lancet, 359(9300), 57-61
2013-10-17+18
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-12Centre for Evidence-Based Medicine
EMBASE, CINAHL, m fl
Steg 2 – Acquire- Informationsökning
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1229
Step 2 - What’s your Search Strategy?
•What do I do If I get:–To many hits–To few hits–Nothing useful at all
•Problems with: –Database - where to look–Search engine - how to look–Search terms - how to perform search
•ASK A LIBRARIAN!–Bring your PICO!–Evidencebased Librarianship!
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1230
Copyright ©2001 BMJ Publishing Group Ltd.
Haynes, R B. Evid Based Med 2001;6:36-38
Figure "4S" levels of organisation of evidence from research.
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1231
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1232
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1233
Steg 3 Appraisal : Kritisk granskning
http://bit.ly/EBMcasp
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Blekinge kompetenscentrum Evidensbaserad vård
Steg 3 Hjälpmedel för Kritisk granskning
23-04-1234
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1235
Steg tre - Kritisk granskning:
Svarar på TVÅ viktiga frågor om medicinsk information
HUR bra/farligt/effektivt är det?
Hur SÄKER är du på det?•Level of evidence: 1a – 5
www.cebm.net•GRADE
www.gradeworkinggroup.org
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1236
Level of Evidence – exemplet BehandlingLevel Therapy 1a SR (with homogeneity) of RCTs
1b Individual RCT (with narrow Confidence Interval)
1c All or none
2a SR (with homogeneity ) of cohort studies
2b Individual cohort study (including low quality RCT)
2c "Outcomes" Research; Ecological studies
3a SR (with homogeneity) of case-control studies
3b Individual Case-Control Study
4 Case-series (and poor quality cohort and case-control studies )
5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"
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37
Conceptualizing quality
Further research is very unlikely to change our confidence in the estimate of effectHigh
LowFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
ModerateFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Very low Any estimate of effect is very uncertain
2013-10-17+18
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1238
Steg 3 Appraisal : Svara på TRE frågor
• Är det sant?
• Är det signifikant?– Statistiskt?– Kliniskt?
• Är det relevant?
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Patients/Participants
Intervention Group Comparison Group
OutcomesTime
P
I C
O
T
PICO(T): the 5 parts
Adapted from Rod Jackson, www.epiq.co.nz2013-10-17+18
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1240
©
Steg 3 - Open the GATE to Appraisal
Population P=
Outcomesa=
TimeT=
EG= CG=Exposure Group Comparison Group
b=
c= d=
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1241
Using evidence more comprehensively(SRs & MA) Studies
RR (95% CI)A
B
C
D
E
F
G
H
Total0.51 (0.38,0.98)
0.1 0.2 1 5 10favours placebofavours treatment
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Blekinge kompetenscentrum Evidensbaserad vård
2013-10-17+18
Impact of searching on correctness of answers to clinical questions
Right to Right
Wrong to Right
Right to Wrong
Wrong to Wrong
McKibbon
(GP or IM)
28% 13% 11% 48%
Quick Clinical
(GPs)
21% 32% 7% 40%
Hersh
(Med students)
20% 31% 12% 36%
Hersh
(Nursing)
18% 17% 14% 52%
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1244
Steg 4 - Implementing.
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1245
Forskningspatienter
Forskningsrapport
Verkligapatienter
Problem med att implementera forskningsresultat
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1246
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-12
Evidence-Based Medicine:Steg 4
NNTonline
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-12
Evidence-Based Medicine:Steg 4
NNTonline
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1249
Steg 5 – Assess -Tid för Reflektion
• How often am I in this situation?
• What do I usually do?
• What do my colleagues do?
• Is there a better way of doing this?
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1250
•Tack
http://www.cebm.net
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Blekinge kompetenscentrum Evidensbaserad vård
23-04-1254
Hemuppgift:
Nästa du får ett problem som handlar om en patients behandling eller diagnos:
1 Formulera en PICO-fråga
2 Berätta hur du fick svar
3 Beskriv hur nöjd du blev med resultatet
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Blekinge kompetenscentrum Evidensbaserad vård
2013-10-17+18
Forskningspatienter
Forskningsrapport
Verkligapatienter
Problem med att implementera forskningsresultat