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

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

3. Centre for Evidence-Based Medicine 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

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

5. Centre for Evidence-Based Medicine Evidence from RCTs (53%) l 36% had Cardiovascular diagnoses: »Ischaemic heart disease 17% »Heart failure 6% »Arrhythmia 2% »Thromboembolism 3% »Cerebrovascular 8%

6. Centre for Evidence-Based Medicine Evidence from RCTs (53%) l 7% had taken poison l 5% received chemotherapy or analgesia for cancer l 3 % had gastrointestinal disorders l 2% had obstructive airways disease

7. Centre for Evidence-Based Medicine Convincing non-experimental evidence (29%) l Infections15% l Cardiac disorders 7% l Miscellany (non-compliance, drug reactions, bowel or bladder neck obstruction, dehydration, micturition syncope) 7%

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

9. Centre for Evidence-Based Medicine Better Outcomes for Patients When EBM Is Practised l E-B practise vs. Outcome in stroke (US): l 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, l And were 22% less likely to die in the next 90 days. (Mitchell et al: stroke 1996;27:1937-43)

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

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

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

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

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

15. Centre for Evidence-Based Medicine Evidence-Based General Practice 122 consecutive consultations in a suburban (Leeds, UK) practice. l 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)

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

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

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

21. Centre for Evidence-Based Medicine Contents of the Cart (cont) : Library Round-Trip = 7 min l 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.

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

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

28. Centre for Evidence-Based Medicine Of the successful searches (from the perspective of the most junior responsible team member): l 52% confirmed diagnostic and/or management decisions l 23% led to changes in existing decisions l 25% led to additional decisions

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

30. Centre for Evidence-Based Medicine Can we get evidence to the bedside? l Yes, and it will improve patient care. l But can we provide it in a less cumbersome form?

32. Centre for Evidence-Based Medicine 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.

33. Centre for Evidence-Based Medicine 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 l how many hips would these savings purchase?

34. Centre for Evidence-Based Medicine EBM and Purchasing Still in harmony: Ì When we spend now to save later.

35. Centre for Evidence-Based Medicine 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

36. Centre for Evidence-Based Medicine 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.