Getting evidence into practice Fiona Godlee Editor, BMJ International Clinical Librarian Conference Birmingham 13 June 2011

Why are health professionals slow to adopt evidence-based practice? The story behind preventing neonatal distress syndrome in premature babies

Surfactant treatmentPrenatal steroid treatment Perception of mechanismCorrects a surfactant deficiency disease Ill-defined effect on developing lung tissue Timing of effectMinutesDays Impact on prescriberViews effect directly (has to stand by ventilator) Sees effect as statistic in annual report Perception of side effectsPerceived as minimal Clinicians ’ and patients ’ anxiety disproportionate to actual risk Conflict between two patients No (paediatrician ’ s patient will benefit directly) Yes (obstetrician ’ s patient will not benefit directly) Pharmaceutical industry interest High (patented product; huge potential revenue) Low (product out of patent; small potential revenue) Trial technology “ New ” (developed in late 1980s) “ Old ” (developed in early 1970s) Widespread involvement of clinicians in trials YesNo Factors influencing implementation of evidence to prevent neonatal respiratory distress syndrome (Dr V Van Someren, personal communication)

What is Evidence Based Medicine? "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” David Sackett, et al. BMJ 312, no (1996)

What is Evidence Based Medicine? “ the integration of best research evidence with clinical expertise and patient values." David Sackett, et al. Evidence-Based Medicine: How to Practice and Teach EBM (New York: Churchill Livingstone, 2000), 1.

What is Evidence Based Medicine? Patient preferences EvidenceClinical experience

What do we know about doctors’ information needs? Smith R. BMJ Information needs do arise regularly when doctors see patients Questions are most likely to be about treatment, particularly drugs. Questions are often complex and multidimensional The need for information is often much more than a question about medical knowledge. Doctors are looking for guidance, psychological support, affirmation, commiseration, sympathy, judgement, and feedback.

What do we know about doctors’ information needs? Smith R. BMJ Most of the questions generated in consultations go unanswered Doctors are most likely to seek answers to their questions from other doctors Most of the questions can be answered - but it is time consuming and expensive to do so Doctors seem to be overwhelmed by the information provided for them

The information paradox “Doctors are overwhelmed with information yet cannot find the information they need” Dr Muir Gray Director of the UK’s National Library of Medicine

The poet’s view “Where is the wisdom we have lost in knowledge? And where is the knowledge we have lost in information?” T S Eliot

Many necessary stages between research and practice Are doctors aware of the evidence? Do they accept it? Is it targeted correctly at their patients? Is the necessary change in practice doable? Is the information recalled at the right moment? (does the doctor remember what to do?) Does the patient agree with the doctor’s recommendation? Does it actually happen?

Many “leaks” between research & practice Aware Accept Target Doable Recall Agree Done Valid Research Glasziou, Haynes, ACP Journal Club 2005

Many “Leaks” from research & practice Aware Accept Target Doable Recall Agree Done Valid Research Even if 80% is achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21 Glasziou, Haynes, ACP Journal Club 2005

“The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade” 1 1. Tikki Pang,Muir Gray,Tim Evans. A 15th grand challenge for global public health. The Lancet - 28 January 2006 ( Vol. 367, Issue 9507, Pages ) DOI: /S (06)

2. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992;268(2): Crowley, P. Prophylactic corticosteroids for preterm labour. The Cochrane Library 2000, Issue 1 (CDSR) Update software.. Evidence into Practice It took 200 years before the Royal Navy routinely used lemon juice to prevent scurvy. First study The first RCT that showed the benefit of thrombolytic therapy was in acute MI late 1950s – not in routine use until 1990s 2 International guidelines first recommended antenatal corticosteroid use in preterm labour 22 years after first evidence 3 On average it takes 17 years for 14% of clinical research to become routine practice 4 1. Mosteller, F. Innovation and evaluation. Science 1981,211,881– Westfall, J. M., Mold, J., & Fagnan, L. (2007). Practice based research - "Blue Highways" on the NIH roadmap. JAMA, 297(4), p. 403.

The burden of evidence is significant …although figures vary 35,000 biomedical journal articles published annually 150,000 articles / month 120,000 RCT/year 500,000 articles are indexed in PubMed every year

Patient Safety Adverse event rate in UK hospitals as high as 10.8% 1 190,000 deaths from adverse events in US annually 2 Cost to the NHS £500m annually Caused by slips, lapses, mistakes and non-uniform or poorly evidenced care Results in increased mortality, morbidity and a higher cost of care 1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ (Clinical research ed.). 2001;322(7285): HealthGrades Quality Study. Patient Safety in American Hospitals;

What can we do? Errors and mistakes Poor quality healthcare Waste Variations in practice Poor patient experience The adoption of interventions with low value Failure to get new evidence into practice The application of what we know can prevent and minimise the seven main healthcare problems:

Steps to the solution as proposed in Generating evidence from research Synthesising the evidence Creating evidence based clinical policies Applying the policies 1. Brian Haynes, Andrew Haines. Education and debate: Getting research findings into practice: Barriers and bridges to evidence based clinical practice. BMJ 1998;317:

Data Information Know About Know How Action

Integrating evidence to help organisations: Deliver high quality, safe and more efficient healthcare. For better patient outcomes.

Resources to support CPD, appraisal, re- validation and exam preparation. Over 30 titles supporting research across multiple clinical specialties. Group Content and services for healthcare organisations Evidence based products to support clinicians in decision making Over 30 titles supporting research across multiple clinical specialties Resources to support CPD, appraisal, revalidation and exam preparation

Systematic reviews of 3300 interventions First published in 1999 Reaches more than a million clinicians worldwide in seven languages Updated monthly

Evidence, expert opinion and guidelines Designed to fit the medical model Assessment, diagnosis, treatment, management Web interface designed to be used at the Point of Care

COPD

Can also be integrated into an Electronic Patient Record This allows clinicians to answer their clinical questions while using their clinical systems There is evidence to support the effectiveness of this approach

Successful Decision Support BMJ 2005, Kawamoto et el, systematic review of CDSS 1 Included 70 studies, 6000 clinicians acting as study subjects treating 130,000 patients 75% of interventions succeeded when the decision support was provided to clinicians automatically in the clinical workflow Systems that were integrated into order entry systems were significantly more likely to succeed than stand alone systems 1. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ (Clinical research ed.). 2005;330(7494):765. Available at:

The 4 critical predictors of clinical decision support success Table 1 - Features of CDSS associated with improved clinical practice

Order sets designed for use in electronic orders systems Based on clinical evidence and organised into care protocols Our content covers up to 80% of acute admissions Evidence based reduction in mortality, cost and complication rate

The Problem of Acute Chest Pain is recorded in the patient record We are now in the orders section of Mr Hamilton’s electronic health record

A list of Action Sets is displayed relevant to Acute Chest Pain

Nursing requests Medication and i.v. fluid requests Including dose instructions

Pathology tests Radiology and other tests Specialist Referrals

Some other things we could talk about How good is the evidence? How important is open access, and what can librarians do to support it?