ebayesmet conference october 2011 e-learning evidence-based medicine katrien oude rengerink academic...
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EBayesMet conference October 2011
e-LearningEvidence-based Medicine
Katrien Oude Rengerink
Academic Medical CenterDept. of Obstetrics and Gynaecology
The Netherlands
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Contents
What is Evidence-based Medicine? Why e-learning modules EBM? e-learning basic principles EBM e-learning modules Teach-the-Teacher EBM
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What is EBM?
Dave Sackett BMJ 1996: “Good doctors use individual clinical expertise, the best available external evidence as well as patient preferences, and neither alone is enough.”
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Reduction Number Needed to Read
120+ journals scanned• 50,000 articles
Is it valid? (<5%)• Intervention: RCT• Prognosis: inception cohort• Etc
Is it relevant?• 6-12 GPs & specialists asked:
Relevant? Newsworthy?
< 0.5% selected
www.evidence-basedmedicine.com
Number Needed to Read
is 200+
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Why EBM?
Exponential growth knowledge Integration research into clinical practice slow
evidence summaries important
skills for knowledge translation important
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5 steps of EBM
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Theory of the Stork vs Theory of Sexual Reproduction
R2 0.49, p<0.05
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Evidence supporting Theory of Stork
Storks exist Unexplained features fetal development Sexual intercourse without delivery Correlation birth rate - stork population Storks not seen in hospitals: apparently medical
interventions may replace storks
EBM: hierarchy in evidence sources
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Organisation of evidence
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Parachute use to prevent death: systematic review of RCTs
Parachutes used to prevent death and major injury due to gravitational challenge
Free fall studies: no 100% mortality No RCT: basis use purely observational. Apparent
efficacy potentially explained by a ‘healthy’ cohort effect. No evidence do not use intervention
Some effects not need RCT
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Why e-learning EBM?
Clinical professionals value EBM important, but slow integration and application in practice
Huge variation EBM content and education Europe Interactive, clinically integrated education best way
learning and applying EBM
Current available courses useful, but: - minimum integration clinical practice- low flexibility
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Leonardo IAn European e-learning course in
Evidence Based Medicine
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Partners
UK • University of Birmingham/Birmingham Womens’ Hospital• CASP International
Germany - Agency for Quality in Medicine Poland - CASPolska Spain - CASPe Hungary - TUDOR Italy - Universita Cattolica del Sacro Cuore Switserland - Basel Institute for Clinical Epidemiology The Netherlands - AMC
Independent steering commitee
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Aim
Familiarise participants with EBM basics to help incorporate evidence from systematic reviews on therapeutic interventions into daily clinical practice
Harmonise EBM teaching across Europe
Short, individual e-learning sessions On-the-job training
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Course content
1. Defining clinical questions
2. Searching the evidence
3. Appraisal of the systematic review
a. Validity of RCTs
b. relative risk and 2x2 table
4. Applying evidence to patient
5. Implementation of evidence into practice
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Instruments for evaluating education in EBM
4 EBP domains:
1. Knowledge
2. Skills
3. Attitude
4. Behavior• enacting EBP steps in practice• permorning evidence-based clinical manoevers• affecting patient outcomes
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Course evaluation
101 participants from Switserland, Germany, Hungary, Spain, UK
Pre- and postcourse assessment• Knowledge/skills: modelled Berlin Questionnaire• Attitudes: questionnaire by Taylor L. et al.
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Results
Across all countries, knowledge scores improved from pre- to post-course for all five modules (p<0.001) (paired Wilcoxon signed ranks test)
After completing course participants felt more confident that they can assess research evidence
E-learning at least equally effective as regular teaching
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Leonardo II
Evidence Based Medicine: Training the Trainers across the healthcare sector
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Background
During Leonardo I & Sicily EBM conference: need support teaching EBM in practice • low level EBM teaching in clinical practice possibly
due to lack of confidence to teach EBM in workplace
Complementary to existing EBM programmes: exploit learning opportunities in clinical setting
Leonardo II
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Partners
England (lead): • University of Birmingham/Birmingham Women’s Hospital• J&B Associates
Italy – Universita Cattolica del Sacro Cuore
Poland - CASPolska
Hungary - TUDOR
Switserland - Basel institute of clinical epidemiology
Netherlands – AMC
Germany – AzQ
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Aim
Train trainers to teach EBM through on-the-job training, by demonstration of applied EBM, to encourage clinically relevant teaching of EBM in post-graduate education
Develop European standard in EBM education
Target: clinical teachers who teach EBM in clinical practice to postgraduates
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Course contents
Based on teaching opportunities modules developed for 6 clinical settings:• Learner-centered (e-learning)• Problem-based• Video clip incorporated• Applicable in Europe
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Teaching opportunities in clinical practice
Learning Opportunities
5 EBM stepsFormulating questions
Searching for
evidence
Critical appraisal
Integrating evidence
with clinical
scenario
Bringing change to practice
Ward round +++ (+) + ++ +
Journal club + + +++ + +Clinical teaching and assessment
++ (+) ++ +++ +
Outpatient clinic +++ (+) ++ ++ +
Formal clinical meeting
+++ (+) + ++ +
Audit ++ (+) ++ + +++
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Example: Teaching and learning EBM during ward rounds
Outline: Learning objectives Pre-requisites to undertake the module Learning opportunities EBM steps Example Video clip (3 min) Teaching and learning lesson Conclusion
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Course evaluation
5 countries: about 10 clinical teachers who teach EBM to postgraduates per country piloted
Pre- and postcourse assessment using ‘Basel questionnaire’
e-learning course on how to teach EBM in various settings is feasible and effective.
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Barriers EBM teaching
120 clinical EBM teachers from 11 countries completed questionnaire regarding barriers for EBM teaching
Barriers: • lack of time in busy practice
• lack of requirements for EBM skills
• pyramid hierarchy in health care management structure.
Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.
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Availability
Free available in:
English German French Polish
Hungarian
Accessible through: www.ebm-unity.org
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References
1. Sackett, BMJ 1996 EBM what is it and what isn’t it?
2. Höfer T, Przyrembel H, Verleger S. New evidence for the Theory of the Stork. Paediatric and perinatal epidemiology. 2004(18):88-92.
3. Smith GCS, Pell JP. Parachute use to prevent dath and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003.
4. Khan AT, Mehr MN, Gaynor AM, Bowcock M, Khan KS. Is general inpatient obstetrics and gynaecology evidence-based? A survey of practice with critical review of methodological issues. BMC Women’s Health 2006(6):5.
5. Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidence-based medicine. BMC Med Educ 2006:15(6):59.
6. Coppus SFPJ, Emperanza JI, hadley J et al. A clinically integrated curriculum in Evidence-based medicine for just-in-time learning through on-the-job training: The EU-EBM project. BMC Medical Education 2007(7):46.
7. Shaneyfelt T, Baum KD. Instruments for evaluating education in evidence-based practice: a systematic review. JAMA 2006;296(9):1116-1127.
8. Kulier R, Hadley J, Weinbrenner S et al. Harmonising Evidence-based medicine teaching: a study of the outomes of e-learning in five European countries. BMC Medical Education 2008(8):27.
9. Taranganitam S, Barnfield G et al. Teaching trainers to incorporate evidence-based medicine (EBM) teaching in clinical practice: the EU-EBM project.
10. Oude Rengerink K, Thangaratinam S. How can we teach EBM in clinical practice? An analysis of barriers to implementation of on-the-job EBM teaching and learning.
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Thanks to
Leonardo IRegina KulierJulie HadleySusanne WeinbrennerBerrit MeyerroseTamas DecsiAndrea HorvathEva NagyJose EmparanzaSjors CoppusTheodoris ArvantisAmanda BurlsJuan CabelloMarcin KaczorGianni ZanreiKaren PiererKatarzyna Stawiarz Regina KunzBen Willem MolKhalid Khan
Steering committee
Leonardo IIShakila Thangaratinam Gemma Barnfield Theodoros ArvanitisSusanne WeinbrennerKhalid Khan Berit Meyerrose Andrea Horvath Gianni Zanrei Regina Kunz Katja Suter Jacek WalczakAnna Kaleta Javier ZamoraHarry Gee Ben Willem Mol Maciej NogasBernard BurnandChantal Arditi