Evidence-Based Practice: Providing Best Care for Our

Patients

Mark C. Wilson, MD, MPHAssociate Dean, Graduate Medical Education

Associate Program Director, Internal MedicineCarver College of Medicine – University of Iowa

Process of Integrating Evidence July 9, 2015

The Disclaimer …

• I’m a General Internist• I’m an EBM Enthusiast

• Since 1992, I’ve Been a Member of the International EBM Working Group

• Teach at McMaster University• Co-Author of Users’ Guides to Medical Literature

Disclosures

• I have no financial conflicts of interest

• I periodically lapse into substandard English language, honed in West Texas public schools

• Over past 25yrs, my passion is to educate next generation of physicians to be better than their faculty

Welcome to

IOWA!

How Do You Spell Iowa?

a) Illinoisb) Idahoc) Iowad) Ohio

How Do You Spell Iowa?

a) Illinoisb) Idaho

c) Iowad) Ohio

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Today’s RoadMap Objectives

1. Explore Just What ‘EBM’ Is, including Why Bother?

2. Gain Insights from Actual Patient Care

3. Encourage Your Investment to Grow these Enduring Clinical Skills

Chat with Your Neighbor(s)

1. What attracted you to travel to this conference? … aside from it being in Iowa!

2. What perceptions/experiences have you had regarding ‘Evidence-based Clinical Practice’?

Some UI Resident Perspectives on ‘EBM’

• It’s just Up-to-Date (electronic text)

• Evidence applied as a blunt hammer• Difficult

• Too time consuming to get any helpful info• Overwhelming jargon

• Hindrance• Painful• Is not consistent with local practice preferences

A Quick Tour Thru the Evolution of ‘Evidence-Based

Medicine’

EBM: It’s a Paradigm Shift• “When defects in an existing paradigm accumulate

to the extent that the paradigm is no longer tenable, the paradigm is challenged and replaced by a new way of looking at the world”

• “A new paradigm for medical practice is emerging”

• “Evidence-based medicine requires new skills of the physician”

JAMA 1992; 268:2420-5

EBM: What it is• “Evidence-Based Medicine is the conscientious,

explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

• “Practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

EBM: What it is and what it isn’t. Br Med J 1996; 312:71-72

EBM: What it is

• “Evidence-Based Medicine is about solving clinical problems.”

Users’ Guides to the Medical Literature:A Manual for Evidence-Based Clinical Practice 3rd

ed, 2015

Core Principles ofEvidence-Based Medicine

1. The better the overall research, the more confident our clinical decisions

2. Evidence alone is never sufficient to make clinical decisions

Core Principles ofEvidence-Based Medicine

1. The better the overall research, the more confident our clinical decisions

2. Evidence alone is never sufficient to make clinical decisions

EBM is a Process

It’s an explicit approach to solving clinical problems …

It’s a philosophy of patient care

A Process to Become Better Faster Clinicians

Ask

Acquire

AppraiseApply

Action

Patient Dilemma

Evidence Cycle of EBM

Why Do We Need this Process?

“A Major Problem with Medical Knowledge …

It Doesn’t Smell When It’s Wrong or Becomes Out of Date”

Brian Haynes, MD, PhDEditor, ACP Journal Club

1960

1965

1970

1975

1980

1985

1990

0.5 1.0 2.0

Odds Ratio of Death (Log Scale)

Favors Tx Favors Ctrl

4 316 7 1783

1 23

2 65

3 143

67 4753167 48154

Ro

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ne

Sp

ecif

ic

Rar

e/N

ever

Exp

erim

enta

l

No

t M

en

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ne

d

21

6

111281

2

6

510

878

1243 1 5

15

1 1 2

87

2

153929

22 545223 5767

17 3311

26511110 2544 p < 0.01

65 47185

27 612530 634633 657143 2105954 22051

p < 0.001

p < 0.0001

Antman. JAMA 1992; 268: 240

Hoot Groups• Get into pairs (or 3)• Identify a Couple of

Reasons Why Docs were Slow to Adopt Thrombolytics in Acute MI

• Report in 3 minutes

Why Docs Use Ineffective Rx

• Clinical Experience and Belief Structure• Love of Pathophysiological Model• Over-Reliance on Surrogate Outcomes• Ritual and Mystique• Patients’ Expectations (real or assumed)• A Need to Do Something

(Errors of Omission Worse that Errors of Commission)

• Nobody Asks the Question

Doust J, Del Mar C. BMJ 2004; 328:474

Ask

Acquire

AppraiseApply

Action

Patient Dilemma

Evidence Cycle of EBM

Let’s Venture onto My Ward Team(Take 1)

Mrs. Jones was transferred out to us from CVICU after urgent cath for severe CP & anterior ST elevations; normal cath and repeat EKG had diffuse ST elevations …

Resident: In addition to NSAID, I plan to start colchicine

Me: Hmmm … why don’t you bring the best evidence about this tomorrow for the team

Let’s Venture onto My Ward Team(Take 2)

Mrs. Jones was transferred out to us from CVICU after urgent cath for severe CP & anterior ST elevations; normal cath and repeat EKG had diffuse ST elevations …

Resident: In addition to NSAID, I plan to start colchicine

Me: Really… I don’t recall anything about colchicine & pericarditis

Resident: It’s common practice to use colchicine to prevent recurrence

Me: Really … Wow, do you recall any specifics about the added benefit?

Resident: Well, we always use it on Cardiology …

What If Our Cupboard Is Bare?(i.e. we don’t know everything …

like answers to their questions!)

• Affective Responses & Losing Control

• Or … Ego Stable & Shift into a Cognitive Response

• Embrace that c/w ‘Adaptive Expertise’• Allows experts to continuously learn during

the process of problem-solving

• Unanticipated challenges become opportunities for learning

Academic Medicine 87: 1-5, 2012

Not All Clinical Research Evidence is Created Equal

1st Core Principle:The better the research evidence, the more confident our clinical decisions

BIASBIAS

Hierarchy of Evidence

1. Systematic Reviews of RCTs

2. Randomized Controlled Trials

3. Cohort studies

4. Case-Control studies

5. Case series

6. Case reports

7. Unsystematic observations

Ask

Acquire

AppraiseApply

Action

Patient Dilemma

Evidence Cycle of EBM

Applying Evidence

“Knowing is not enough. We must apply. Willing is not enough, we must do.”

Johann Wolfgang von Goethe1749 – 1832

If EBM is about Using Evidence …

How Should We Treat Deep Venous Thrombosis?

1. Traditional: Admit to hospital 7d for IV heparin while wait for warfarin to take effect

2. Alternative: Use 7days of SQ LMWH as outpatient while wait for warfarin to take effect

Ahh, … The Best Evidence

• RCT at 15 Centers in Canada• 500 patients with acute proximal DVT• Enoxaparin 1mg/kg SQ bid versus

Standard continuous heparin infusion• Equal rates of recurrent VTE (5-6%)

& major bleeding rare (1-2%)• 50% of LMWH group never hospitalized

Levine, et al. NEJM 1996; 334:677-81

How Would You Treat These Patients With New DVTs?

• 43 y/o truck driver whose husband is a nurse

• 68 y/o man 2wks after knee replaced who participates in rehab program 3X/week

• 75 y/o woman with metastatic ovarian cancer who is non-communicative after stroke 2yrs ago and has no advance directives & no family

So We Wrestled with the 2nd Core Principle . . .

Evidence Alone

NEVER

Makes Clinical Decisions

Evidence-Based Clinical Practice

• Specific Circumstances

• Research Evidence

• Patient Values & Preferences

Clinical Expertise

Haynes, Devereaux, & Guyatt. BMJ 2002; 324: 1350

Ask

Acquire

AppraiseApply

Action

Patient Dilemma

Evidence Cycle of EBM

You’re Getting Ready to Start the Day in Clinic with the Ambulatory

Block Resident

Cochrane Database of Systematic Reviews

Cochrane Database of Systematic Reviews

This Feels Complicated … Do We All Need Advanced EBCP Skills?

A) ‘Evidence-Based Practitioners’• Adept at using the entire evidence-based cycle• Advanced critical appraisal skills; can use original

literature if needed• Can be leaders

B) ‘Evidence Users’• Have appreciation for strong evidence• Can seek out and use pre-appraised summaries

Guyatt, BMJ 2000; 320:954-5

Consider …

Aiming to steadily get further in your skills.There are great tools & resources to help you.

Ultimately, You have to decide what to aim for …

1.Evidence-based practitioner (a.k.a. enthusiast) with broad capabilities

2.Evidence User with focused abilities to use pre-appraised evidence-based summaries

Core Principles ofEvidence-Based Medicine

1. The better the research evidence, the more confident our clinical decisions

2. Evidence alone is never sufficient to make clinical decisions