Evidence-based health care: A look into the future McMaster - PowerPoint PPT Presentation

Evidence-based health care: A look into the future  McMaster perspective  leaders - past, present, future  new first principle of EBM  implications for evidence assessment  implications for searching  information management  shared decision-making

Thrombolytic Therapy Textbook/Review 0.5 1.0 2.0 Cumulative Recommendations Year RCTs Pts Not Mentioned Experimental Rare/Never 1 23 Routine Specific 1960 2 65 1965 3 149 21 5 4 316 1970 7 1793 1 10 1 2 10 2544 P<.01 11 2651 15 3311 2 8 17 3929 22 5452 7 23 5767 8 1980 1 12 27 6125 P<.001 8 4 30 6346 M 1 1985 33 6571 M 1 3 7 43 21 059 54 22 051 P<.00001 M 5 2 2 1 65 47 185 67 47 531 M 15 8 1 1990 70 48 154 6 1 M Odds Ratio (Log Scale) Favours Treatment Favours Control

First principle  systematic summaries of the best available evidence should guide patient management decisions

GRADE  system to guide interpretation of systematic reviews to inform clinical guidelines and clinical decisions  system for developing recommendations

70+ Organizations 2008 2010 2005 2006 2007 2009 2011 5

GRADE uptake

First principle: Hierarchy of Evidence for Therapy Randomized Trials Observational studies patient-important outcomes Basic research test tube, animal, human physiology Clinical experience

Beyond the old hierarchy: Guides to confidence in estimates

Further advances in GRADE: coming up  application to systematic reviews of prognosis  overall prognosis of population  identification of risk factors  clinical prediction rules  application to systematic reviews of diagnosis  confidence in estimates  utility – treat as an intervention

Beta blockers in non-cardiac surgery Summary of Findings Quality Assessment Relative Absolute risk Quality Effect difference Number of (95% CI) Risk of Publication Outcome participants Consistency Directness Precision Bias Bias (studies) Myocardial 10,125 No serious No serious No serious No serious Not 0.71 1.5% fewer High infarction (9) limitations imitations limitations limitations detected (0.57 to 0.86) (0.7% fewer to 2.1% fewer) 0.5% more 10,205 No serious Possiblly No serious Not Moderate 1.23 Mortality Imprecise (0.1% fewer (0.98 – 1.55) (7) limitations inconsistent limitations detected or low to 1.3% more) 10,889 No serious No serious No serious No serious Not 2.21 0.5% more Stroke High (1.37 – 3.55) (5) limitaions limitations limitations limitations detected (0.2% more to 1.3% more0

Clinicians need pre-appraised evidence Clinicians need guidance on applying that evidence

Evidence-Based Journals Critical Appraisal Filters ~3,500 articles/y 30,000 articles/y meet appraisal and content criteria from 120 journals (93% ‘noise’ reduction)

McMaster PLUS Project ~20 articles/yr for clinicians (99.96% ~3,500 articles/y noise reduction) meet critical appraisal and ~5-50 articles/y for content criteria authors of evidence- based guidelines and reviews Health Knowledge Refinery

What is the problem? Lacking trustworthiness of guidelines - GRADE Inefficient guideline authoring, adaptation and dynamic updating Inefficient guideline dissemination to clinicians at the point of care Suboptimal presentation formats of guideline content Inconsistent and under-developed systems for integration in EMRs

STEP 1 develops: - Authoring tool template Electronic SNAP-IT GRADE GUIDELINE - Electronic outputs authoring tool DECIDE - Optimal formats - Integration in EMR Individual Descriptive Evidence - Adaptation PICO studies tables profiles Database - Decision aids structured content Recommendations Key information Rationale XML language Electronic outputs Decision aids for patients Web + App and clinicians Integrated in the EMR Adaptation National/ local or EBM Textbooks

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Third principle: evidence insufficient  always tradeoffs  many decisions value and preference sensitive  low risk atrial fibrillation  anticoagulants or no anticoagulants  screening  breast and colon cancer  primary prevention  aspirin, statins, bisphosphonates  cancer toxic chemotherapy

GRADE response: Strong and Weak Recommendations  variability in patient preference  strong, almost all same choice (> 90%)  weak, choice varies appreciably  interaction with patient  strong, just inform patient  weak, ensure choice reflects values

Values and preferences  at point of care  decision aids to ensure decisions consistent with individual patient values and preferences

Combination of opportunities Interactive DA GRADE : on iPads Weak recs are ideally For the clinical • framed for SDM encounter Info tailored to • patients needs Technology Enhancing Adaptive EBM & SDM To Local conversations circumstances Semi-Automated Production Evolution of decision aids for the clinical Continous Update encounter When evidence modified

Conclusion: Look into future  dissemination of GRADE  GRADE principles  GRADE evidence summaries  searching and evidence access  guidelines and pre-appraised evidence  evidence improved presentation  guidelines/evidence summaries on smart phones, EMR  push services  Shared decision making  increasingly central: joint conference 2015  decision aids, including electronic from guidelines