The onus on us?

Evidence-based Practice



What is EBM?



What EBM is not.



Do we need EBM?



Is Obstetrics and Gynaecology a
special case?

Evidence-based practice:

the reactions



Incensed - practice is evidence-based



Indifferent - there is no evidence to use



Enthusiastic but disillusioned - great
idea but where is the ‘wherewithal’ to
do it

What evidence-based

practice is:

Evidence-based medicine is the
conscientious, explicit and judicious
use of current best evidence in
making decisions about the care of
individual patients. Its
philosophical base dates back to
the sceptics of post-revolutionary
Paris (Bichat, Louis, Magendie).

What evidence-based

practice is:

The practice of EBM requires the

integration of



individual clinical expertise

with the



best available external clinical
evidence from systematic research.

What evidence-based

medicine is:



Good doctors use both individual clinical
expertise and the best available external
evidence, and neither alone is enough.

Without the former, practice risks becoming
evidence-tyrannised, for even excellent
external evidence may be inapplicable or
inappropriate for an individual patient.

Without the latter, practice risks becoming
rapidly out of date, to the detriment of
patients and patient-care.

What is Evidence-based

Practice

Clinical Skills

Keeping
up to date

Clinical question

Audit

Find the Evidence

Apply to Practice

Critical Appraisal

What is evidence-based

practice?

Clinical Skills

Keeping
up to date

Clinical question

THE

PATIENT

Audit

Find the Evidence

Apply to Practice

Critical Appraisal

What evidence-based

medicine is:



this definition also helps us identify
and understand what evidence-
based medicine is not.

Evidence-based medicine

is not “cook-book”

medicine:



Patients cannot go through a ‘treatment
tunnel’ assuming the same management is
appropriate and the same outcomes
important to each



External clinical evidence can inform, but can
never replace, individual clinical expertise



Your clinical accumen decides whether the
external evidence applies to the individual
patient at all and, if so, how it should be
integrated into a clinical decision.

Evidence-based medicine

is not “cost-cutting”

medicine:



The aim is to give most benefit to
each individual patient



To apply the most efficacious
interventions which will maximise
their function, quality, and quantity
of life



may raise rather than lower the
cost of their care.

EBM is neither old-hat nor

impossible to practice:



The former argument falls before the evidence:

of striking variations in the integration of
patient values into our clinical behaviour

of striking variations in the rates with which
clinicians provide interventions of established
benefit and uselessness to their patients.

in the inability of clinicians to keep abreast of
important medical advances reported in
primary journals

EBM is not restricted to

randomised trials:



Practising EBM requires the best clinical
evidence with which to answer our clinical
questions.

On diagnostic tests: a proper cross-
sectional study of patients clinically
suspected of harbouring the target
disorder, not a randomised trial.

On prognosis, a proper follow-up study of
patients assembled at a uniform, early
point in the clinical course of their disease.

Levels of Evidence

I. Systematic Review of RCTs
II.

RCT of appropriate size and power

III. well-designed cohort or case-

controlled studies

IV. non-experimental studies from

more than one centre

respected authorities,descriptive

studies

Do we need EBM?



What do you need to do to keep
abreast?

20,000 medical journals

General physician - 19 articles per day
every day of the year

Clinicians need Information

If asked:



we need it twice a week,



we get it from our text books &
journals.

Clinicians really need

information!

If shadowed:



we need it up to 60 times per week
(twice per every three patients), and
it could affect eight decisions per day.



but we get only 30% of it,



and that comes from passers-by

textbooks are out of date/journals too
disorganised/library closed/ too far

Textbooks?



Antenatal Steroids?

clear beneift since the first trial

since 1972 just improved the precision
of the confidence intervals?

textbooks 1990, 1991, 1992 - “ there
is no role for antenatal steroids”

Luteal Progestagens - HMB



1960 first subjective study



1987 first RCT no benefit



1995 first review no benefit



1995 38% of prescriptions for
HMB by

GPs



1998 RCT of 21 day progestagens

87% reduction

Textbooks?



Tranexamic acid

first RCT 1967

first RCT comparing it against another
Rx 1988

first systematic review 1995

first meta-analysis 1998

Textbooks

Our textbooks are out-of-

date



Fail to recommend Rx up to ten
years after it’s been shown to be
efficacious.



Continue to recommend therapy up
to ten years after it’s been shown
to be useless.

Time spent reading around

one’s patients is slim:

Self-reports from Oxford (medians):



Medical Students: 60 minutes per week



House Officers:

none



S.H.O.’s:

10 minutes



Registrars:

90 minutes



Senior Registrars: 45 minutes



Consultants:

Post 1975: 60 minutes

Pre 1975: 30 minutes

Time spent reading around

one’s patients is slim:

Self-reports (median minutes last week):



Medical Students: 60-120



House Officers:

0-20 (up to 75%=none)



S.H.O.’s:

10-30 (up to 15%=none)



Registrars:

10-90 (up to 40%=none)



Senior Registrars: 10-45 (up to 15%=none)



Consultants:

Post 1975: 15-60 (up to 30%=none)

Pre 1975: 10-45 (up to 40%=none)

Time spent reading vs.

time spent driving:

Self-reports - Leicester GPs (medians):



Travelling to and from the library = 60
minutes



Reading re patients in the library = 10
minutes



Median ratio of travelling to reading = 1.8

The Slippery Slope

years

since

graduatio

r = -0.54

p<0.001

...
...

. ..

. . ....

....
....

...

knowled

current

best

care

Performance deteriorates,

too



Screened 6,000 steelworkers and
found 300 untreated, uncontrolled
hypertensives.



Evaluated and confirmed their
hypertension over the next 3
months.



Then got them into the offices of 85
local GPs.

6 months later, only 2/3

had been started on Rx

Determinants of the clinical decision

to treat some, but not others:

The level of diastolic blood pressure.

The patient’s age.

The amount of target-organ damage.

Performance deteriorates,

too

Determinants of the clinical decision

to treat some, but not other,
hypertensives:

The doctor’s year of graduation
from medical school.

Do we Need EBM?



Vulnerable Health Carers



‘Questioning’ patients

Running Summary



Clinicians need information, but most
of our needs are never met:

Our textbooks are out of date.

Important and relevant information lost in
the deluge of information irrelevant to us