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EBM research experiences in Amsterdam(and the rest of the world)
EASOM 2008Amsterdam
Jan Hoving, Rob Kok, Jos Verbeek, Frederieke Schaafsma, g, , , ,Paul Smits en Frank van Dijk
Coronel Institute
BackgroundBackground
Current research on EBMCurrent research on EBM
• Many questions answered (and …. many not answered)
New research projects on EBM at Coronel institute
• PhD project: application of EBM in insurance medicine (randomizedPhD project: application of EBM in insurance medicine (randomized controlled trial)
• MDA Project: comparison of information from medical databases /• MDA Project: comparison of information from medical databases / websites
Coronel Institute
Challenge effectiveness of EBMChallenge ‐ effectiveness of EBM ( Coomerasamy et al., 2004, BMJ)
• Changing behaviour is the real challenge:Changing behaviour is the real challenge:
– Some evidence for positive effect of EBM on behaviour of professionals if given as ‘integrated’ teaching (vs standalone) in particular on:given as integrated teaching (vs standalone), in particular on:
• Reading habits
• Choice of information resources
• Changes in management of patient
• Guidelines
• No evidence on improvement of patients’ health outcomes
Coronel Institute
New PhD project: EBM in insurance medicineNew PhD project: EBM in insurance medicine
• Design: cluster randomized controlled trial (RCT)g ( )
• Subjects: insurance physicians with few skills in EBM
• Interventions:
intervention group: 4 day course EBM + monthly tutorials (2 hrs / 6 months)– intervention group: 4 day course EBM + monthly tutorials (2 hrs / 6 months)
– Control group: business as usual
• Outcomes: knowledge, skills, quality of evidence (vignettes), use of evidence at work, work satisfaction physicians
Coronel Institute
Challenge level of EBM ‘functioning’
Should insurance physicians be:
Challenge – level of EBM functioning
Should insurance physicians be:
‐ users of EBM ?
‐ do‐ers of EBM ?‐ do‐ers of EBM ?
Should level of participation be:
‐ EBM for all physicians?
just a few ‘expert EBM’ physicians?‐ just a few expert EBM physicians?
Minimum level of EBM expertise?
Coronel Institute
Challenge – instruments evaluation EBM educationChallenge instruments evaluation EBM education
Few instruments with reasonable validity : more testing needed ( l l b l f b l ) f(validity, reliability, feasibility), on more domains of EBM (knowledge, skills, behaviour) and on different educational l l / d ( / d )levels/needs (users / do‐ers) (Shaneyfield et al., 2006, JAMA)
‘Level 1’ Instruments: Fresno test, Berlin questionnaire, some more
Coronel Institute
Challenge – different sources of information
Which electronic information sources (databases) could we use?
Challenge different sources of information
Which electronic information sources (databases) could we use?
• Role of (pre‐appraised) aggregated evidence? (systematic review, evidence based guideline, evidence based summary, synopsis )
• Role of original studies ? (cohort study, RCT, case‐control study)
Coronel Institute
MDA Project: comparison of information from
• Design: questionnaire
medical databases / websitesDesign: questionnaire
• Subjects: insurance physicians/ EBM experts
• Material:
10 case scenario’s with medical question: different diseases complexity– 10 case scenario’s with medical question: different diseases, complexity
– For each scenario: information from 6 different medical information di l di bilit d i (MDA) U T D t Cli i l E idsources: medical disability advisor (MDA), Up‐To‐Date, Clinical Evidence,
Guidelines, Pubmed / Trip database / Sumsearch, Cochrane
• Outcome : questionnaire scoring relevance, feasibility, quality/validity of evidence
Coronel Institute
MDA project: example of case scenario
Patient : 53 yr old male nurse on orthopedic ward diagnosedPatient : 53 yr old male nurse on orthopedic ward diagnosed with rheumatoid arthritis 4 years ago, limited in manual work (hands), on sick leave
Physician: Progression of RA disease process over time?
Patient’s profile favourable/unfavourable in view of RTW as a nurse?
Any (supporting) evidence in literature?
=> Medical question on prognosis, so we are interested in ‐ the course of RA (+ on work participation) t e cou se of ( o o pa t c pat o )‐ any prognostic factors which put this nurse at higher/lower risk for (non)RTW
Coronel Institute
Coronel Institute
Coronel Institute
Coronel Institute
Coronel Institute
Coronel InstituteExcellent resource … but not for prognostic questions!
Coronel Institute
32 hit i “ i ” filt32 hits using “review” filter
Coronel Institute
ConclusionConclusion
Challenges are good.
We need to:
- design effectiveness studies that evaluate change of behaviour- have a clear focus on whether we want users or do-ers of EBM- further test /develop outcomes to evaluate EBM (education) - evaluate / critically assess different sources of medical
information
Coronel Institute
