From guidelines to shared decision making

Question 1

What does evidence based practice include?

Answer 1

1. Best available evidence
2. Dr.s own clinical expertise
3. Pt’s ICE

Question 2

What is the 5 step approach to EBP?

Answer 2

1. Ask focused q’s - specific
2. Find the most robust evidence to answer it - high quality
3. Critical appraisal skills to review the evidence
4. Apply the findings to the realities of clinical practice and needs of the individual pt
5. Review the first 4 steps and consider changes for the next time (clinical audit)

Question 3

When is EBM used in the context of clinical practice?

Answer 3

1. Making a diagnosis
2. Deciding on further investigations (which may alter the management)
3. Deciding on treatment or manageent
4. Addressing pts ICE (must be considered throughout all of EBM)

Question 4

Examples of secondary sources

Answer 4

1. Guidelines - NICE, SIGN, US national guidelines
2. Evidence summaries - Clinical Evidence (BMJ), CKS (clinical knowledge summaries)
3. SRs - Cochrane Library

Question 5

How to search for best evidence?

Answer 5

Clinical guidelines (NHS evidence) -? Evidence summaries -> SRs of the evidence -> primary research lit in bibliographic databases (Medline) -> consider asking info specialist to help with search design

Question 6

How do we critically appraise clinical guidelines?

Answer 6

For clinical guidelines we often use the AGREE II tool

Question 7

What are the 4 issues in application of results into clinical practice?

Answer 7

1. Define the popn - were the pts like yours
2. Define the intervention - was it appropriate?
3. Understand the strengths and limitations of study/ review : consider biases
4. Interpret and apply to your patients - sample size, summary statistic used, probability or confidence of the result

Question 8

What sorts of questions can be answered in an audit/ service evaluation?

Answer 8

1. Did we follow guidelines?
2. Did the pt comply?
3. How did the pt feel about it
4. How can we improve next time

Question 9

What are the challenges of EBP for clinicians?

Answer 9

1. Availability of relevant evidence (e.g. great deal of guidelines for MS are based on low quality evidence/ expert consensus)
2. Time and ability to interpret evidence appropriately (Vast amount of evidence) - we need summaries and guidelines
3. The translation of knowledge/ evidence into clinical practice - evidence is not the same as a clinical practice recommendation

Question 10

What does I2 measure?

Answer 10

Measures the degree of inconsistency across primary studies in a meta-analysis that is not accountable by chance

• Used to QUANTIFY inconsistency across studies and assess the impact of heterogeneity on the meta-analysis
• Describes the % variability in effect estimates due to heterogeneity NOT chance

Question 11

What might cause statistical heterogeneity (factors that influence the I2 value)?

Answer 11

1. Clinical diff between studies (e.g. diffs in definition of ARM/ diabetes, diffs in treatment of diabetes, diffs in study popns - age, ethnicity, gender, diffs in severity of disease)
2. Methodological diffs between studies - diffs in trial design, diffs in risk of bias in studies, diffs in methods for identifying disease
3. Unknown study characteristics