Content Evidence-based Geriatric Medicine Patricia P. Barry, MD, MPH Review of evidence-based medicine (EBM) and evidence-based practice (EBP) Use of guidelines in evidence-based practice Relevance of EBM to the practice of geriatric medicine Usefulness of EBM in developing countries Evidence-based Medicine is: Evidence-based Medicine (EBM) Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. Clinical Judgement Patient Preference David Sackett Best Evidence What is the Practice of EBM? Where there is evidence of benefit and value, do it. Where there is evidence of no benefit, harm, or poor value, don t do it. When there is insufficient evidence to know for sure, be conservative. David Eddy Why is EBM Needed? Decay of clinician knowledge over time Human cognitive biases Inefficient transfer of knowledge to practice Organizational need to decide between effective and ineffective therapies 1
Knowledge Decay Unanswered Questions Knowledge Decay Information Explosion Primary care physicians have 3 to 7 questions per every 10 patients They usually don t look for the answers When they do the sources may not be Ely: BMJ, 319(7206):358-361 evidence-based >30,000 new citations added to Medline every month Volume of medical information doubles every 19 years The Inevitable Consequence: Knowledge Decay On average, the clinically-important knowledge of physicians deteriorates rapidly after completion of training. Evidence-based Practice (EBP) EBM is focused on individual practice EBP is an organizational issue requiring: Organizations Able to generate evidence Flexibility to incorporate evidence Individuals and teams Able to find and appraise evidence Open to apply evidence to patient care Muir Gray, 1997 What does evidence-based mean? A comprehensive, systematic, open-minded review of all the evidence Evidence determines the conclusion (not vice-versa) Not the citation of papers supporting a preformed conclusion (and rejection of those that don t) Not the use of evidence when it is positive and judgment when it is negative Yew, 2003 What is good evidence? Results from most appropriate study design Hierarchy of evidence Exclusion of bias Directly or indirectly demonstrates treatment effect on health outcomes Clinically meaningful results (NNT) Not lab values or other intermediate outcomes Is applicable to the patient or population In this case, older adults 2
Applying Treatment Studies to Older Adults (Leipzig, 2003) Patient-disease interactions Increasing prevalence of disease Disease differences Multifactorial disorders Patient differences Increased heterogeneity Treatment differences Socioeconomic factors Patient treatment interactions Pharmakokinetics, pharmacodynamics, and comorbidities Applying Diagnosis Studies to Older Adults Diagnosis studies Diagnostic tests Differential diagnosis Screening tests Clinical prediction rules (Leipzig, 2003) Prevalence and competing diagnoses may be different in older adults Positive predictive values may increase Sensitivity, likelihood ratio, pretest probability may differ in older adults How to Practice EBM Develop answerable questions Locate the best evidence Critically appraise the evidence Apply the results in practice Evaluate performance From Sackett, 2000 How to Support the Practice of EBM Provide high level organizational commitment Train clinicians and provide point of care evidence-based information Provide evidence-linked guidelines and support their implementation Educate patients to expect evidence-based interventions Provide access to system measures of evidence-based practice and outcomes Yew, 2003 Supporting EBP Role of Clinical Practice Guidelines Gap Quality of Care Health Status Satisfaction Cost / Utilization Clinical Practice Guidelines Clinical guidelines are systematically developed statements to assist practitioners and patients in choosing appropriate healthcare for specific conditions. Current Practice & Outcomes Optimal Practice & Outcomes The Institute of Medicine 3
Clinical Practice Guidelines Key Words Systematically - using evidence vs. consensus Assist - to provide resources, not barriers Practitioners & patients - shared decision-making Choosing - by education and synthesis of evidence, not rules or standards Attributes of Good Guidelines Realistic guidance Well-defined population Evidence-based Clear Flexible Exceptions described Measurable Implementable Current Hierarchy of Guidelines Explicit evidence-based guidelines Based on health outcomes Uses systematic analysis of evidence (grading) Consensus-based or subjective judgment Expert opinion Bias is common No development process evident May be driven by self-interest of specialty groups Evidence-based Geriatric Medicine: Limits of the Evidence Older adults are often underrepresented in randomized controlled trials of interventions for important conditions. (Senni, 1998; Nguyen, 2003) Advanced age, comorbidity, cognitive impairment, and frailty may be exclusionary criteria for studies. Pathophysiology of disease may be different in older adults. (Krishnan, 1997; Katz, 1996) Complex interventions are often required, but are difficult to evaluate. (Med Res Council, 2000; Reuben, 2002) Patricia P. Barry, MD, MPH Arlene S. Bierman, MD, MS Rosanne M. Leipzig, MD, PhD Rebecca A. Silliman, MD, PhD Building the Evidence: Study Design Randomized controlled trials can be successful despite challenges: Treatment of depression in subjects with many comorbidities (Robinson, 2000; Lyketsos, 2000) Interventions to prevent functional decline (Wagner, 1994; Inouye, 2000; Tinetti, 2002) Building the Evidence: Study Design Observational studies useful for: Generating hypotheses Examining clinical practices Evaluating one-time events Limitations Selection bias for exposure Potential confounders 4
Building the Evidence: Study Design Observational Studies - administrative and survey data Large sample sizes Statistical power Many variables Observational Studies new sources of data Quality improvement information (Schneider, 2001; Bierman, 2001) Building the Evidence: Analytical Techniques Quantitative meta-analysis requires simple and standard intervention across studies may not be suitable for complex interventions (Greenhalgh, 1998) Qualitative literature synthesis more useful for complex geriatric interventions (Wagner, 1996) Medical Practice Most practicing physicians in the US and Latin America have had no formal training in geriatric medicine. Evidence-based information can provide the necessary knowledge base. Change in practice is essential to ensure that older adults receive age-appropriate, evidence-based medical care. Medical Practice Evidence-based information is useful when it can be incorporated into a self-directed learning process Provision of written materials alone is unlikely to change physician practice (Davis, 1995, 1999) Traditional didactic Continuing Medical Education is also unlikely to be effective in changing practice (Davis, 1995, 1999) Medical Practice Successful interventions for practice change involve: Assessment of educational need Multiple, interactive interventions High levels of practitioner commitment Provision of adequate time Patient-centered system changes Quality improvement approaches Outcomes of practice change or health status Health Behaviors Determinants of evidence-based patient behavior change include: Evidence-based, age appropriate information Professional communication and counseling Patient-centered tools and system supports Public health, community-based interventions (Center for the Advancement of Health, 2000; Task Force on Community Preventive Services, 2002) (Davis, 1995; Mazmanian, 2001; McColl, 1998; IOM, 2001) 5
Evidence-based Geriatric Practice Build the evidence base Prioritize and fund the research Create incentives Utilize a variety of study designs and analysis Translate evidence into practice Provide multiple, interactive educational interventions for professionals Implement health system changes Improve health behaviors of older adults with individual and environmental interventions EBM in Developing Countries: Is it Needed? Limited resources Reduce unneeded health expenses Limited capacity for drug regulation Reduce inappropriate medication use Limited capacity for CME Reduce influence of marketing EBM in Developing Countries: What are the Obstacles? Limited access to medical literature databases Invest in computers Limited access to library facilities Develop networks Applicability of interventions to local settings Pathophysiology Patient factors, including comorbidity Patient compliance Provider compliance Risk of adverse outcomes Teaching EBM in Developing Countries: What are the Obstacles? Inexperience in small-group learning More faculty, more facilitation skills needed Interactive vs. lecture format Develop core group of facilitators Lack of time to attend workshops Modify curriculum to essentials Lack of role models for practicing EBM Develop core group of practitioners Utilize practice settings Ask the right questions Summary EBM required to address multiple challenges of geriatric medical knowledge and practice EBM draws together the most valid evidence along with judgment and preferences EBP is feasible in developing countries The challenge for health systems is to produce environments supportive of EBP 6