Dr Sue Wells Senior lecturer in Clinical Epidemiology, Health Innovation & Quality Improvement School of Population Health University of Auckland

1. HINZ Education WorkshopEvidence-based Practice Dr Sue Wells Senior lecturer: Clinical Epidemiology, Health Innovation & Quality Improvement School of Population Health

2. Outline- game of 2 halves Take the health statistic challenge What is evidence-based practice? What skills do you need? Acknowledge Rod Jackson, Gill Robb- EBP SOPH Evidence suggests that we can reduce heart attacks and strokes in New Zealand by half The PREDICT collaboration: the use of informatics to put evidence into practice

3. Drinking coffee, hard exercise, and nose blowing are everyday activities most likely to raise BP and cause a special kind of stroke ....together account for nearly ¼ of all cases in which a blood vessel bursts in the brain (aneurysm)

4. Take the health statistic challenge Making sense of Health Statistics Questionnaire Outcomes Group, VA White River Junction, Vermont, USA Affiliated Dartmouth Medical School www.vaoutcomes.org/downloads/medical_data_test.pdf

6. 1. Which would best help you to determine how much a person could benefit from Gritagrel? (Circle one) a. How often people experience side effects b. The chance of stroke for people who do not take Gritagrel c. How many people take Gritagrel d. How recently Gritagrel was developed

7. 2. Which would best help you to decide whether you will benefit from Gritagrel? (Circle one) a. How many people were in the study b. Age and sex of people in the study c. Whether a doctor confirmed that people had strokes d. Who paid for the study

8. 3. Which additional piece of information would be the best evidence that Gritagrelhelped people? (Circle one) a. Gritagrel lowered antioxidant levels b. Fewer people died for any reason in the Gritagrel group than in the placebo group c. Many doctors prescribe it d. Fewer people died from strokes in the Gritagrel group than the placebo group

9. Your doctor says there is a 10% risk of dying from pneumonia.4. Which information best helps you understand whether this risk applies to you? (circle one) a. Most people who die from pneumonia are 75 years or older b. More than 110,000 people get pneumonia each year c. Pneumonia is one of the most common reasons for hospitalization d. About 15,000 people die from pneumonia each year

10. 5. To better understand how much of a threat pneumonia is to your health,which information is most helpful? a. How much money is spent on pneumonia research b. Whether pneumonia is more common in the US than Europe c. Your chance of dying of other important diseases d. Celebrities who have had pneumonia

11. A new study finds that there were 30 deaths among people who eat broccoli regularly compared to 100 deaths among people who don't eat broccoli at all.6. According to this study, which statement best describes how eating broccoli relates to death? a. Lowers the risk of death b. Doesn't change the risk of death c. Raises the risk of death d. Can't tell from this information

12. Mrs. Smith is told she has a 1 in 296 chance of dying from cancer and a 1 in 407 chance of dying from a stroke.8. Which is bigger, Mrs. Smith’s chance of dying from a stroke or cancer? a. Stroke b. Cancer c. Chances are the same

13. About 51,000 Americans will be diagnosed with melanoma (the most serious skin cancer) this year.10. What is your best guess about an American's chance of being diagnosed with melanoma in the next year? a. 51,000 b. 51,000 divided by the number of Americans c. Don’t know how to figure this out

14. Mrs. Jones is told she has a 28 in 1,000 chance of dying from cancer and a 59 in 1,000 chance of dying from a stroke.Mrs. Jones's doctor now tells her that a new pill, STROKE, will lower her chance of dying from stroke by 50%. Another pill, CANCER will lower her chance of dying from cancer by 50%. She can only take 1 pill. Assuming the 2 pills are equally safe and cost the same, which do you suggest she take if her goal is to lower her chance of dying? a. STROKE pill b. CANCER pill c. Either pill is okay

15. Mrs. Jones is told she has a 28 in 1,000 chance of dying from cancer and a 59 in 1,000 chance of dying from a stroke. 12. Mrs. Jones decides to take the CANCER pill (reduce risk 50%). Now, what is her chance ofdying from cancer? a. 0 in 1,000 b. 7 in 1,000 c. 14 in 1,000 d. 21 in 1,000

16. Please read the following news story about Dr. Womba's study. Promising new drug hailed* Washington, DC -- Researchers announced the results of a long awaited study of Argentex, a drug designed to prevent prostate cancer. In the study, 1000 men age 45 to 75 were randomly assigned to take either Argentex or a sugar pill called a placebo. The men were followed for 4 years. Only 3 of the men taking Argentex developed prostate cancer. Lead scientist Bernard Womba described the findings as “extremely promising” and predicted the drug would be in wide use shortly. *Not a real drug

17. 13. Which question would you most like to ask Dr. Womba? a. Who paid for the study? b. Has Argentex been shown to work in animals? c. What was the average age of the men in the study? d. How many men taking the sugar pill developed prostate cancer?

18. In a new study, people either took pill X or placebo (a sugar pill).3% of people taking placebo died; 1% of people taking pill X died.15. Which statement is correct about how pill X changes the chance of death? a. 2 more deaths per 100 people b. 1 more death per 100 people c. 1 fewer death per 100 people d. 2 fewer deaths per 100 people

19. In a new study, people either took pill X or placebo (a sugar pill).3% of people taking placebo died; 1% of people taking pill X died.14. Which statement is correct about how pill X changes the chance of death? a. Lowers by 67% b. Lowers by 33% c. Raises by 33% d. Raises by 67%

20. What is Evidence-based Practice 2mins- talk to those beside you and come up with your ideas of what it is

21. Sicily Statement “Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources” This statement was conceived by the delegates of the second international conference of Evidence-Based Health Care Teachers and Developers held in Sicily in September 2003

22. ‘Traditional’ Evidence Based Practice (EBP) Anatomy Physiology Pathology Biochemistry Psychology etc.

23. ‘Modern’ EBP emphasises ‘current’ clinical epidemiological evidence of outcomes

24. Clinical Epidemiological* evidence The accuracy of diagnostic tests The power of prognostic markers The effectiveness of interventions Therapy Screening Prevention * the study of the frequency of outcomes in groups of patients

25. Clinical evidence increasing so rapidly that we all need EBP skills to keep up-to-date MEDLINE 2006 1,600 articles / day approx 100 new trials published every day Bastian, Glasziou, Chalmers, ( PLoS 2009)

26. Less that 10% of published evidence is worth reading About 1/3 of evidence eventually refuted or attenuated

27. The first 4 steps of EBP 1. Ask a focused question. 2. Access (systematically search for) epidemiological evidence to help answer question. 3. Appraise evidence found for its validity, effect size, precision (ideally all the relevant evidence) 4. Apply the evidence: a. amalgamate the valid evidence with other relevant information (patient/community values, clinical/health issues, & policy context) and make an evidence-based decision; and b. Act (implement) the decision in practice

28. About 1/2 of relevant evidence is not implemented

29. The 5th step of EBP Audit your practice: check your actual practice against best (evidence-based) practice i.e. the gap between your evidence-based decisions and your actions

30. Step 1. Ask a focused question 1 Participants(patient group,problem,setting) How would I describe a group of patients like mine? 2. Exposure(cause,factor, treatment, disease) 3. Comparison(compared to what?) 4. Outcome (what does this exposure affect? what do I hope to avoid (hospital admission) or achieve (survival)? 5. Time (over what time period is it reasonable to expect an effect? = 5 parts of an epidemiological study

31. Scenario You are a doctor who is conducting heart health checks for adults over 35 yrs in your practice. You are interested in a family history of premature heart disease and whether this might increase the risk of a person having a future heart attack Convert this into a PECOT question P (population/problem) E (exposure) C (comparator) O (outcome) T (over what time frame)

32. Reframe question into the 5-PECOT parts (P) What group of people, with what problem, in what setting? In adults over 35 years (E) What exposure am I considering? Does having a family history of premature heart disease (C) what am I comparing the exposure to? No family history (O) What does this exposure affect, what do I hope to avoid (hospital admission) or achieve (survival) affect the risk of a heart attack (T) Over what time period is it reasonable to expect an effect? over the next 5 years

33. Common Questions Question type Does this person have a disease/condition? What causes it? What should I do about it? What things about them or the disease determine whether they have a good/bad outlook? How common is the problem? What are the issues around these problems? What do people think about it? Diagnosis Aetiology & Risk factors Intervention/Rx Prognosis Prevalence & Incidence Meaning , perspectives, psychosocial context

34. Intervention/treatment Aetiology & Risk factors Diagnosis Prognosis & incidence Prevalence Experiences & meaning Which study design will best answer my question? Question type Randomised controlled trial Cohort or case control study Cross-sectional study Cohort study Cross-sectional study Qualitative study In each case, a systematic review of all available studies is better than a individual study

35. Family history question What type of question is this? What is the best study design to answer this question?

36. Step 2. Access the Evidence ~600,000 new articles/yr Brian Haynes R Evid Based Med 2006;11:162-164 ©2006 by BMJ Publishing Group Ltd

37. the GATE picture: a framework for EBP Graphic Approach To EBP Prof Rod Jackson’s

38. PECOT: the 5 parts of every epidemiological study P Participants Exposure Group Comparison Group E C Outcomes O Time T All epidemiological studies can be hung on the GATE frame

39. Cohort Study : family hx & risk of CVD event Population Men and women 35-75yrs without previous CVD Family Hx No Family Hx Time Outcomes yes MI, angina, stroke/TIA, no

40. Step 3. Appraise the evidence A tool for documenting the steps of EBP www.epiq.co.nz

41. EBP Steps 4 and 5 Ask a focused question. Access (systematically search for) epidemiological evidence to help answer question. 3. Appraise evidence AND then meta-analyse (systematically review) ALL relevant valid evidence. 4. Apply the best evidence: amalgamate the valid evidence with other relevant information to make a good decision; and b. ACT on your decision 5. AUDIT your practice (i.e. check your actual practice – ‘actions’ - against ‘best’ evidence-based practice)

43. X-factor: making evidence-based decisions Evidence including clinical epidemiology Clinical / health considerations Patient / community preferences Policy issues expertise: ‘putting it all together’ the art of practice

44. How can busy people do EBP?

45. 1. use evidence-based “electronic decision support systems”

46. 2. use evidence-based guidelines (& EB text bks?)

47. 3. use Systematic Reviews MEDLINE 2006/day 1,600 articles 95 trials 4 reviews* *Cochrane Database of Systematic Reviews (SR) per day 1 new SR 1 updated SR It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials. Bastian, Glasziou, Chalmers, (accepted for PLoS 2009)

48. Outline- second half Take the health statistic literacy challenge What is evidence-based practice? What skills do you need? Evidence suggests that we can reduce heart attacks and strokes in New Zealand by half The PREDICT collaboration: the use of informatics to put evidence into practice

49. NZ CVD guidelines 2003

50. NZGG CVD guidelines in a nutshell Plus adjustments for ethnicity, fam Hx, diabetes, >15% or prior CVD event < 10% 10-15% Intensive CVD risk management- patient specific lifestyle advice + drug therapy CVD general advice only Specific lifestyle assessment and advice Select people for risk assessment

51. NZGG CVD guidelines in a nutshell If we did this we could prevent/delay more than 50% of the CVD events in the next 5 years

52. Problems

53. Problems with risk assessment tool Framingham CVD equation -based on ~5200 patients starting originally in 1948 through 1960s and 70s in Framingham MA validated for New Zealanders as a whole population accuracy unknown for Māori, Pacific and Indian accuracy unknown for those with a family history limited number of people with diabetes developed for those aged 30-74yrs

54. How often do you use CVD risk charts?(GPs n=500 response rate 83%) Arroll et al. NZ Family Physician 2002:29:177-83

55. PREDICT-CVD Evaluation Study 2004: Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8

56. Treatment gaps in 1º care in NZ Rafter et al NZMJ 2005 Electronic records of 25,384 men over 45 yrs & women over 55 yrs visiting GP in 2000 Dunedin RNZCGP research data base 28% 25% 18%

57. TM 1998-2002 a web-based clinical decision support system

58. Evidence-based care for populations Anonymised linkage to CVD outcomes, drug dispensing & laboratory results Evidence-based care for individuals

59. Acknowledgements- PREDICT Research team- Rod Jackson, Tania Riddell, Andrew Kerr, Romana Pylypchuk, Roger Marshall, Cam Kyle, Elizabeth Robinson, Sue Crengle, Dale Bramley, Tim Kenealy, Raina Elley, Shanthi Ameratunga, Jeff Harrison, Paul Drury, Dudley Gentles General practitioners, practice nurses and patients: ProCare Network North, Auckland and Manukau, HealthWest, Te Tai Tokerau, Manaia, Kaipara Care, TihewaMauriora and Whangaroa PHOs. PREDICT developed by a collaboration of clinical epidemiologists at the University of Auckland, IT specialists at Enigma Publishing Ltd, clinicians and members of primary health care organisations, New Zealand Guidelines Group, National Heart Foundation, Diabetes New Zealand, Diabetes Auckland, several district health boards and the Ministry of Health. PMS companies- MedTech, My Practice, Profile Funding: The PREDICT research project has support by HRC grants 03/183 and 08/121 from the Health Research Council.

61. Break down the complexity of guidelines into tailored management for a patient

62. PREDICT in PHOs Recruitment > 200,000 May 2011

63. Impact of electronic decision support in 1o care Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8

64. Impact of electronic decision support in 1o care Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8

65. Impact on documented CVD risk assessment estimate * * * Wells et al. Eur J CardiovascPrev Rehab 2008; 15:173–178

66. 50% CVD events occur in small % of population High risk CVD events Sue Wells PhD Auckland 2009

67. But we need to improve our risk prediction CVD events Predicted risk

68. Communicating risk I give you six months or 600 miles

69. CVD risk = abstract concept Probability of having a symptomatic CVD event in next 5 or 10 years

70. Your CVD risk is 15% If you stop smoking you can go from yellow to green! out of 100 people like you 15 are predicted to have a heart attack or stroke in the next 5 years out of 100 people like you 85 won’t have an event in the next 5 years Communicating CVD Risk- 1990s-2000s

71. A problem with short-term CVD risk communication: case history 35 yr old Clarke Kent, smoker, BP 150/80mmHg, TC/HDL 5.7, no diabetes, sedentary, abdominal obesity

72. 5-yr CVD risk is 5% = mild But we know that with these risk factors longer-term risk must be high. Problem – false reassurance

73. Telling CVD risk story in another way http://www.heartfoundation.org.nz/index.asp?pageID=2145881453

74. Acknowledgements National Heart Foundation Enigma Publishing Ltd Our team Andrew Kerr, Stewart Eadie, Chris Wiltshire, Andy Biggs, Andy McLachlan, Rod Jackson

75. Telling the story

76. Telling the story: Relative risk

77. Telling the story: Arterial Age or Heart Age

78. Telling the story: long term risk

79. Telling the story: Risk modification

80. consumer version 2010 http://www.knowyournumbers.co.nz/your-heart-age-forecast.aspx

81. Outline- game of 2 halves Take the health statistic challenge What is evidence-based practice? What skills do you need? The PREDICT collaboration: the use of informatics to put evidence into practice Thank you!