Foundations of Evidence-based Healthcare:  Roadmap to scientifically informed medical practice Peter Wyer MD Associate Professor of Medicine Columbia University Medical Center Co-chair, Section on Evidence Based Health Care New York Academy of Medicine

Scientifically Informed Medical Practice and Learning - SIMPLE Model “Knowledge does not extend from those who consider they know to those who consider they do not know. Knowledge is built in the relationship between human beings and perfects it self in the critical problematization of these relations.” Paulo Freire Critical Problematization Clinical Action Scientific Evidence Suzana Silva, Sicily Conference, Italy 2009 | JECP 2010

WHAT WE KNOW YOU WON’T DO Carefully define questions arising in the course of patient care using a structured format such as “P-I-C-O” Interrupt your busy practices in the midst of patient care to perform lit searches Spend hours pouring over primary literature to appraise the quality of included evidence Work through book length presentations of clinical guidelines for the purpose of evaluating the trustworthiness of the recommendations Use ornate diagrams of smily vs frowning faces or complex decision analyses to explain the probabilistic implications of research findings to your patients Gabbay and LeMay Practice Based Evidence for Healthcare 2011

WHAT WE BELIEVE YOU MUST DO (To Achieve Evidence Literacy) Learn the organization of design related information Learn to utilize information resources, including librarians, efficiently Learn the principles underlying evaluation of evidence quality Learn the principles underlying evaluation of the quality of clinical guidelines

Alternatives to Evidence Literacy Regulators Payers Industry Consultants The evidence illiterate practitioner

Evidence Literacy Primer Defining information needs The hierarchy of evidence-based resources The quality of evidence

The Hierarchy of Information

Hierarchical Escalation of Information from Research SUMMARIES Tertiary data Collection Enrollment of stakeholder groups and systematic reviews SYNTHESES Secondary data collection Enrollment of individual studies STUDIES Primary data collection Direct enrollment of human subjects

Multiple questions within a clinical area Clinical Guidelines Multiple studies on a single question Systematic Review Direct observations involving human subjects Trials, Cohort studies

Databases

Garbage In Garbage Out

Systematic Reviews: The Primary Unit of Evidence What defines the quality of evidence?

Determinants of Evidence Quality (GRADE system categories) Incomplete evidence Risk of bias Indirectness Inconsistency Imprecision

Completeness of Evidence

Risk of Bias Capitals vs Maple Leafs

Indirectness Wrong population Wrong comparisons Wrong dosages Wrong outcomes

Inconsistency and Imprecision

The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis* Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008

Drunk Using Lamp Post