The Protocol At the time of discharge, death, or month’s end, each patient was reviewed and consensus reached on: ¶The primary diagnosis: the disease, syndrome or condition most responsible for the patient’s admission to hospital

The Protocol (cont.) ·The Primary Intervention the treatment or other manoeuvre that constituted our most important attempt to cure, alleviate, or care for the primary diagnosis traced into the literature to determine its basis in evidence the Consultant’s “Instant Resource Book” bibliographic data base searches

Primary Interventions were Classified by Level: Evidence from Randomised Control Trials (better yet: systematic reviews of all relevant, high-quality RCTs) Convincing non-experimental evidence (unnecessary & unethical to randomise) Interventions without substantial evidence

Conclusions from E-B oriented General Medicine: 82% of our patients received evidence-based care. treatments for 53% were justified by RCTs or systematic reviews of RCTs. Of 28 relevant RCTs and SRs, 21 were accessible within seconds. treatments for 29% were justified by convincing non-experimental evidence

Evidence from RCTs (53%) 36% had Cardiovascular diagnoses: Ischaemic heart disease 17% Heart failure 6% Arrhythmia 2% Thromboembolism 3% Cerebrovascular 8%

Evidence from RCTs (53%) 7% had taken poison 5% received chemotherapy or analgesia for cancer 3 % had gastrointestinal disorders 2% had obstructive airways disease

Convincing non-experimental evidence (29%) Infections 15% Cardiac disorders 7% Miscellany (non-compliance, drug reactions, bowel or bladder neck obstruction, dehydration, micturition syncope) 7%

Interventions without substantial evidence (18%) Specific symptomatic and supportive care for mild poisoning, non-cardiac chest pain, viral (non-herpetic) meningitis, terminal CNS disease, confusion, and food poisoning.

Better Outcomes for Patients When EBM Is Practised E-B practise vs. Outcome in stroke (US): When cared for by E-B neurologists, patients were 44% more likely to receive warfarin, and much more likely to be placed in a stroke care unit, And were 22% less likely to die in the next 90 days. (Mitchell et al: stroke 1996;27:1937-43)

Centres for Evidence-Based Surgery E-B General/Vascular Unit in Liverpool: 95% received evidence-based Rx 24% Level 1 71% Level 2 E-B Paediatric Unit in Liverpool: 77% received evidence-based Rx 11% Level 1 66% Level 2

Worse Outcomes for Patients When EBM Is Not Practised: In a city-wide study of E-B practise vs. Outcome in carotid stenosis: Generated E-B indications for endarterectomy and reviewed 291 pts. Found the surgical indications: Appropriate in 33% Questionable in 49% Inappropriate in 18%

Worse Outcomes for Patients When EBM Is Not Practised Stroke or death within the next 30 days: Expected (if left alone): 0.5% Expected (if properly selected and operated): 1.5% Observed among operated patients (2/3 operated for questionable or inappropriate reasons): >5% Wong et al. Stroke 1997;28: 891-8.

Evidence-Based Ambulatory Paediatrics 54% of manoeuvres were evidence-based (“experts” had predicted <20%) 77% of diagnostic manoeuvres 67% of treatments 59% of health promotion

Centres for Evidence-Based Psychiatry In-Patients (Oxford) 67% treated on the basis of RCTs Out-Patient >80% received evidence-based Rx

Evidence-Based General Practice 122 consecutive consultations in a suburban (Leeds, UK) practice. 81% evidence-based: 31% based on RCTs or overviews 50% based on convincing non-experimental evidence 19% without substantial evidence (Gill et al, BMJ 1996;312:819-21)

Can we get evidence to the bedside? Need it within seconds if it is to be incorporated into busy clinical rounds Our initial attempts to bring the best evidence to a busy clinical team caring for 200+ admissions per month

Searching for Evidence in the Month Before the Cart: Expected searches = 98 Identified searching needs = 72 Only 19 searches (26%) carried out.

Contents of the Cart: Infra-red simultaneous stethoscope with 12 remote receivers. Physical diagnosis text book and reprints (JAMA Rational Clinical Exam). Notebook computer, computer projector, and pop-out screen. Rapid printer.

Contents of the Cart (cont): Library Round-Trip = 7 min 125 summaries (1-3 pp) of evidence previously appraised and summarised by Side A teams (in the form of “Redbook” entries or Critically-Appraised Topics : “CATs”). Access Time to the “bottom line” = 12 sec.

Contents of the Cart (cont): Library Round-Trip = 7 min CD of Best Evidence Access Time to the “bottom line” = 26 sec. CD of WinSPIRS (5-year clinical subsets) Access Time to useful abstract = 90 sec. (so used for filling Educational Rx after rounds) CD of the Cochrane Library (used for filling Educational Rx after rounds)

Usefulness of the Cart: 81% of searches were for evidence that could affect diagnostic and/or treatment decisions. 90% of these searches were successful in finding useful evidence. *

52% confirmed diagnostic and/or management decisions Of the successful searches (from the perspective of the most junior responsible team member): 52% confirmed diagnostic and/or management decisions 23% led to changes in existing decisions 25% led to additional decisions

Searching for Evidence in a 3-day period after the Cart: Expected searches = 10 Identified searching needs = 41 Only 5 searches (12%) carried out.

Can we get evidence to the bedside? Yes, and it will improve patient care. But can we provide it in a less cumbersome form?

EBM and Purchasing In harmony: Ê When we clinicians stop doing things that are useless or harmful ËWhen we use just-as-good but less expensive treatments, carers, and sites for care.

What we could save in Oxford by switching from: LASIX ê frusemide: £ 90,000 simvastatin ê cerivastatin: £ 500,000 TENORMIN ê atenolol: £ 700,000 diclofenac ê ibuprofen: £ 1,000,000 Total: £ 2,290,000 how many hips would these savings purchase?

EBM and Purchasing Still in harmony: Ì When we spend now to save later.

EBM and Purchasing In grudging collaboration: Í Waiting lists, once we understand the opportunity costs of shortening them: it’s not about money it’s about what else we won’t be able to do if we shorten them

EBM and Purchasing In conflict: Î When we identify so strongly with a dying patient’s short-term goals that we use resources that we know would “add more QALYs” if used for other patients.