EBHC Bulletin Trinity Term 2015

May 26, 2015

Professional Development at Oxford University

EBHC Bulletin

for Evidence-Based Health Care Programme Alumni and Students

A world class programme that equips individuals

to transform health care with evidence-based methods

In the Trinity Term 2015 Bulletin …

Lead Article

Evidence Live 2015: Plenty of food for thought

Dr Annette Plüddemann, interim Course Director for the MSc in Evidence-Based Health Care and co-ordinator of the Evidence-Based Diagnosis and Screening module

Upcoming Events

‘Fat or sugar: What does the evidence tell us about the priorities for weight control?’  Susan Jebb PhD, OBE.  Professor of Diet and Population Health, Nuffield Department of Primary Care Health Sciences. University of Oxford. 1 June 2015, Oxford

The Multiple Evidential Roles of Clinical Case Reports.

Professor Brian Hurwitz. 17 June 2015. Oxford


Teaching Evidence-Based Medicine 14 – 17 September 2015, St Hughs College, Oxford

Evidence Live! 2016 22 – 24 June 2016

Peer Update

Aaron Lai (Msc Alumni)  From Ignorance to Enlightenment, my personal journal to EBHC

Felipe Martinez  (MSc AlumniStopping Delirium in The Intensive Care Unit

Amy Price (DPhil student and MSc Alumni) Using Evidence Based Health Care in Every Day Life

Events Catch-up

Evidence Live! 2015

The James Lind Library Launch

EBHC Programme Module talks …  podcasts from Professor Trisha Greenhalgh, Professor Carl Heneghan, Barbara Farrell and  Helen Ashdown

Recent Publications

by the Nuffield Department of Primary Health Care Sciences

Programme Update and News

Translating knowledge across hemispheres

Upcoming Modules

Lead article

Evidence Live 2015: Plenty of food for thought

Dr Annette Plüddemann, interim Course Director MSc in Evidence-Based Health Care

Evidence Live 2015 took place at the Oxford University Examination Schools on two surprisingly sunny days in April.  There were lots of fantastic talks from a range of speakers providing plenty of food for thought and lively debate.  Here’s a summary of what I took away from the conference:

“The right evidence for this patient”

Or as Trish Greenhalgh put it, “Is the management of this patient in these circumstances an appropriate (“real”) or inappropriate (“rubbish”) application of the principles of EBM?”.  Iona Heath echoed this sentiment, “Evidence from science is essential, but not sufficient when dealing with individual patients” We therefore need to practice patient-focused individualisation of the evidence, and that means we need more work on the external validity of studies.  By doing so we may find that for some things we don’t need much more evidence and that, as Trish put it, “more research isn’t needed”.  Richard Peto spoke out against excessive and spurious subgroup analyses, stating that “virtually all subgroup analyses are rubbish”. We should be wary of their findings, particularly when the treatment effect is small. It also means that all clinicians need to be able to appraise evidence.  To help with this, Rod Jackson has developed the GATE tool for critical appraisal, which – if you haven’t heard about it- is worth looking in to (www.epiq.co.za). It can be used for any study design; in fact Rod offered £100 to anyone who could come up with a study design where the GATE framework could not be used….

“We have changed the world”

A session on the All Trials campaign with Ben Goldacre, Carl Heneghan, Iain Chalmers and Sile Lane (Sense about Science) opened with this extraordinary statement.  To date, about 540 organisations and 83 000 people have signed up to the AllTrials campaign; if you haven’t already, I would encourage you to do so as well.  Partly in response to pressure from the campaign – and coincidentally on the day this session was held –  the WHO published a Statement on Public Disclosure of Clinical Trials Results . It contained the following strong statements: (1) results from clinical trials should be publicly reported within 12 months of the trial’s end; (2) results from previously unpublished trials should be made publicly available; and (3) calls on organisations and governments to implement measures to achieve this.  Carl presented work he is involved in, auditing the registration and publication of clinical trials undertaken in Oxford as part of the NIHR Biomedical Research Centre and Unit. He called this “getting our house in order” and challenged delegates to go back to their institutions and to do the same too.

“Dangerous ideas”

Delegates were challenged to come with a “dangerous idea” – an idea that was daring, because it actually might work! Some very interesting suggestions came up here, have a look  for yourself on the BMJ youtube channel and do let us know about your own “dangerous ideas” for EBM.

And lastly, I have to briefly mention diagnostic studies.  Patrick Bossuyt likened mastering the 2×2 table to Judo…Is it really that tough? But beyond the numbers, he reminded us that, “diagnosis is not an end in itself; the ultimate value is the difference in health outcomes resulting from the test”.

Overall, compared to the previous Evidence Live conference held in 2013, there was a shift away from merely focusing on issues such as study flaws and lack of access to trial information towards thinking about how to implement evidence into practice for the benefit of individual patients.  Planning is already underway for the next Evidence Live which will be held in Oxford in June 2016.  We do hope to see you there!

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Upcoming Events

EBHC Programme Module talks …

‘Fat or sugar: What does the evidence tell us about the priorities for weight control?’ Susan Jebb PhD, OBE, Professor of Diet and Population Health

Nuffield Department of Primary Care Health Sciences, University of Oxford.

1 June 2015, Rewley House, 1 Wellington Square, Oxford, UK

Register HERE for free tickets

Susan Jebb is a nutrition scientist who has spent more than 25 years studying the links between what we eat and the effect on our weight and risk of cardiovascular disease. Her research includes a mix of observational analyses from prospective cohorts, experimental studies and both controlled and more pragmatic dietary intervention studies.

In this talk she will consider how evidence from these diverse sources informs dietary recommendations. Drawing on her experience as a scientific advisor to the Department of Health on obesity and food policy and a raft of public engagement activities, including the recent Horizon series “What’s the right diet for you?” she will also consider how the scientific evidence is translated into policy and practice.

The Multiple Evidential Roles of Clinical Case Reports.

Professor Brian Hurwitz. 17 June 2015. Rewley House, 1 Wellington Square, Oxford, UK

Register HERE for free tickets

Brian Hurwitz is D’Oyly Carte Professor of Medicine and the Arts in the Department of English.  He is a medical practitioner affiliated to the Division of Health and Social Care Research, King’s College London, directs the Centre for the Humanities and Health and is a member of the Steering Advisory Board of the Centre for Life-Writing Research at King’s.

Collectively clinical case reports constitute a huge repository of medical experience. This talk will scrutinise their shape, salient features, and the nature of the hindsight from which they are composed, filtered for coherence, and turned into second order accounts of encounters, observations and reasoning about a patient or series of patients. It asks what case reports are good for and what kinds of knowledge they embody.

Harms in healthcare.  22-26 June 20215, Oxford

The Centre for Evidence Based Medicine and the Centre for Governance and Transparency will present a unique insight on the  individual and institutional self-interests in research, combined with increased global competition that are currently leading to substantial harms in healthcare.

Deb Cohen’s investigative work has highlighted that new drugs approved by regulators often withhold important information on harms and corrupt practices are harming patients around the globe.

Ben Goldacre believes medicine is broken. “And genuinely believes that if patients and the public ever fully understand what has been done to them – what doctors, academics and regulators have permitted – they will be angry.”

Jeff Aronson has spent a lifetime researching adverse drug reactions, and perceives there is considerable room for improvement in our understanding

Whilst, Carl Heneghan has shown that for the drug Tamiflu, 500 £million has been wasted.

For more information and to reserve a place visit the Centre for Evidence Based Medicine web pages.

Teaching Evidence-Based Medicine 14-17 September 2015, St Hughs College, Oxford

Teaching Evidence-Based Medicine is designed for all health care professionals, who have some knowledge of critical appraisal and experience in practicing evidence-based health care, and who want to explore issues around teaching.

More info on the Centre of Evidence-Based Medicine website

Evidence Live! 2016 22-24 June 2016.

Find out more from the Centre of Evidence-Based Medicine webpages

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Peer Update

If you would like to feature in this section, please contact cpdhealth@conted.ox.ac.uk

Send a contribution to the EBHC Bulletin
From Ignorance to Enlightenment, my personal journal to EBHCAaron LaiPlease allow me to paraphrase a statement I read years ago: some places give you a career, but Oxford gives you a life.  Even though “life changing experience” is such an overused cliché, I can still firmly assert that Oxford does change my life.
Oxford has already changed my life once when I did my sociology degree.  The second coming to Oxford for the M.Sc. in EBHC changed my life again.  As someone with no experience at all in healthcare, I am always indebted to the bold tutors who granted me a chance and took the risk to accept me.  This was the starting point of my two-year journey.I was pleasantly surprised to find that the uniqueness of the Oxonian way had not been diminished by the part-time nature of this degree: we were encouraged to experiment and to challenge the subject areas rather than simply absorbing information.  All weekly assignments were not marked and thus they would not affect the final grade.  This unusual method allowed us to try different “risky” approaches.  We collaborated and discussed across countries and time zones.  Since I came from a different background, my arguments were sometime considered as “unconventional”.  Nevertheless, I benefited a lot from the discussions with my supportive classmates and tutors.  The classmates were wonderful yet it could be quite intimidating — one time in a class of twelve people, we had eight doctors, six health specialists, four Ph.D., and two with more than one Ph.D.  This diverse mix of people enriched our in-class discussions and this also enabled us to pick up great friendships with people from other areas and even countries.Mathematically speaking, anything jumps from zero is an infinite growth.  My growing knowledge in evidence-based healthcare brought along the following fruits.

  • Completed three research projects with one funded by the Hong Kong government on genetic discrimination. One research was published in the Bioethics.
  • Won the first prize of a prescribing strategy competition hosted by Innocentive.
  • Invited by the Direct Marketing Association to be a guest blogger to discuss health analytics.
  • Published in the Journal of Clinical Trials on early stoppage of clinical trials.
  • Published in the Parson Journal of Information Mapping on health data visualization.
  • Published a reply in BMJ.
  • Published an article on London cholera and epidemiology theory in the Significance, the official joint magazine of the Royal Statistical Society and the American Statistical Association.
  • Presented in the Preventing Overdiagnosis Conference on mammography screening.
  • Served as a reviewer for the American Journal of Managed Care and the Journal of the American Medical Informatics Association.

It is simply impossible for me to accomplish those without the wonderful education here.  I now have a much deeper understanding on the importance of evidence as well as how to evaluate the research of others.  As the world is moving toward an evidence-based healthcare system, especially after the Obamacare in the US, I am incredibly fortunate to learn from the pioneers in the place that started the whole field.

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Stopping Delirium inThe Intensive Care UnitFelipe Martinez

A few months ago, I had the opportunity to develop a programme in an Intensive Care Unit (ICU) to help prevent delirium among critically-ill adults. This was perceived as a very common condition among our patients, but no formal data had been gathered to date. The challenge wasn’t easy, but I had the invaluable support of my Unit’s Chief, colleages, nurses and staff at my centre. Hopes were high.

We chose to approach this as a formal research project at my hospital’s ICU, which is an 8-bed facility aimed at providing care for naval personnel and their relatives. An interrupted time series (“before & after”) study was started, with its first phase aimed at providing our unit’s baseline statistics, which were unavailable at the time. Our first analyses showed some interesting results: Delirium roughly developed among 40% of our admitted patients, and was significantly associated with prolonged hospital stays, failure to wean from the ventilator, mortality and self-removal of invasive medical devices, including central venous catheters, nasogastric and orotracheal tubes.  All of these outcomes were considered highly relevant by our team, and everyone agreed that delirium was a relevant risk factor that needed to be controlled.That’s when the evidence came in. I had recently finished my dissertation, a systematic review on how to prevent delirium using non-pharmacological, multicomponent interventions. Briefly, these strategies are methods  aimed at avoiding risk factors that commonly contribute to the development of this condition. Several randomised trials had already shown their effectiveness among inpatients, including the critically-ill (You can find the full-text here). Using this information, we developed a tailored multicomponent intervention that suited our Unit’s needs and expectations. Several meetings were held, in which everyone was invited to participate and share their views and experiences with delirium. After a few weeks we developed a 10-item intervention whose components were based on current evidence, but also took ideas from these meetings into consideration.It’s been a few months since our programme started, and we have already applied our strategy to 130 critically-ill patients. Our results have been more than satisfactory so far. The absolute risk to develop delirium has dropped by 15%, which roughly translates in that we avoid one case of delirium per 7 admissions. Furthermore, significant drops in rates of self-removals have also been seen, as a reduction in the mean time on mechanical ventilation. This is likely to result in cost reductions for our Unit, and I plan to conduct formal calculations soon!

I believe that the reason behind our success stems from the proper translation of evidence into practice, which couldn’t be achieved without the constant commitement of everyone involved in the care of our patients. Adherence rates to our programme are always over 90%, which shows how motivated my team is towards preventing incident delirium.

So, what’s the next step? I would love to develop similar strategies for other wards in our hospital. Getting support from the Board of Directors is certainly going to be key to achieve this goal, but I trust that our numbers will speak for themselves.

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Using Evidence Based Health Care in Every Day Life.  Amy PriceWhat is Evidence?

I came to EBHC through the Center for Evidence Based Medicine. At that time I was still reeling from being terminated as the executive director of a spinal advocacy organization  after a disagreement about ethics in regards to direct to consumer stem cell “treatments”.  The company was later the recipient of FDA injunctions. Sometimes the end leads to a new destiny but at that time being dismissed and later sued rocked my world. It was my first job after a significant brain injury.

I didn’t know the stem cell company was in violation of FDA law. Because the organization was led by doctors, epidemiologists and lawyers, I assumed they would do right. My background was in world missions and psychology. I had no training in how to assess research evidence or Bad Science. I knew nothing about evidence but that was about to change.Where Do I Go From Here?”Life may not be the party we hoped for, but while we are here we might as well dance.”

(Author Unknown, from Dear Bertha)

I was struggling to understand and reconcile research that claimed to supply breakthroughs for those without options, shared inflated safety results and came to extravagant conclusions with methods that could not deliver what the papers promised. I saw how non-FDA approved interventions can bring harm to vulnerable people. I wanted to help and not harm.

Anchored By Evidence

The job of the human being [in the digital age] is to become skilled at locating relevant valid data for their needs.  In the sphere of medicine, the required skill is to be able to relate the knowledge generated by the study of groups of patients or populations to that lonely and anxious individual who has come to seek help”  (Sir Muir Gray, 2001)

I searched.  On the CEBM website I found a series of articles on the How to Read a Paper series by Professor Trish Greenhalgh and this helped clarify my direction. What really sold me were the wonderful mind changing podcasts Interpreting Results-Stats in Small Doses  by Professor Amanda Burls and The Information Revolution by Sir Muir Grey.  I wanted more so that I could never again be used as a gateway for junk science.  I applied to Oxford and I was accepted.

Learning Through Teaching

From the first week of the first module in Evidence Based Health Care I found ways to share my new knowledge. I helped clinicians and the public find research and interpret the results. As I learned, I taught others about critical appraisal, numbers needed to treat, the differences between incidence and prevalence and how to read the headlines. Helping others like my neighbors and colleagues with informed shared decision making became a daily event. I enjoyed my time as a Masters student at Oxford and made friends I will treasure for a lifetime.

I am privileged to attend Oxford as a DPHIL student at Kellogg College after successfully completing the MSc.  It was not easy but it was important. Some things are worth fighting past the barriers of our limitations.

Beyond the Barriers

“What lies behind us and what lies before us are small matters compared to what lies within us. And when we bring what is within us out into the world, miracles happen.” (Henry Stanley Haskins)

My DPHIL project is PLOT-IT Public Led Online Trials-Infrastructure and Tools. The plan is to involve the public in multiple aspects of clinical trials from prioritizing research questions to giving feedback about trial design. This serves a double purpose where the public can learn about research in an interactive way while we can research the interface between interaction and methodology to guide the development of best practice for online trials. The Question: Online trials. What Works?  We welcome collaboration. Visit us at http://ithinkwell.org

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Events Catch-up

Evidence Live! 2015.  View highlights of this years event on YouTube.

The James Lind Library Launch May 2015

The James Lind Library has been developed to illustrate the evolution of fair tests of treatments in health care. It contains essays introducing and explaining the key features of fair tests of treatments; images of key passages from 1000 documents, from antiquity to the present; and over 200 commissioned articles commenting on this wealth of material.’

‘The James Lind Library was initially launched in 2003 by the Royal College of Physicians of Edinburgh. Twelve years later it has undergone a radical redesign and its scope has been extended to incorporate material illustrating the evolution of evidence-based health care.’

Module Talks podcasts

There are a series of podcasts available to you through the Centre for Evidence Based Medicine podcast series

These podcasts come from talks that have been held as part of the Postgraduate programme in Evidence-Based Health Care.

There are a wide range of podcasts from past courses available for you to listen to and we will be adding new podcasts as and when they become available.

Tamiflu: An update on 6 years of evidence gathering by Professor Carl Heneghan – 21 May 2015, Oxford. Podcast will be available shortly.

Carl has been the author and principal investigator on the Cochrane reviews on Tamiflu in adults and children and for 6 years he has worked alongside an international Cochrane group to obtain the missing unpublished evidence. This work has proved controversial in questioning the £500 million spent by the UK stockpiling the drug and has led to parliamentary appearances and substantial news coverage. The talk will detail the journey to obtain the evidence, the new methods including the use of clinical study reports and the effect of the drug once all the evidence became available.  Further details about the talk can be found here

Managing large scale international clinical trials 

Managing clinical trials, of whatever size and complexity, requires efficient trial management. Barbara Farrell is a trial manager with an interest in the efficient conduct of randomised controlled trials and the training and development of trial managers.

Barbara Farrell, Nuffield Department of Population Health. 29th April 2015

Storytelling in diabetes: a mixed-methods study

The patient as storyteller and the story as ‘self management’

Trish Greenhalgh 07 Apr 2015.

Research impact: the new jargon for knowledge to action

If we are going to take impact seriously, we need to be clear about the philosophical assumptions underpinning different kinds of research and also the different kinds of links between research, practice and policy.

Trish Greenhalgh 26 Mar 2015

The Campaign for Real EBM Evidence Based Medicine

Professor Trish Greenhalgh gives a talk on the crisis facing evidence based medicine and offers a solution for its rennaissance within healthcare.

Trish Greenhalgh 24 Mar 2015

‘From inspiration to publication: bumps along the road’

Helen Ashdown from the Introduction to Study Design and Research Methods course 1 Dec 2104

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Programme Update and News

Translating knowledge across hemispheres by Dr Sharon Mickan

Working in the MSc programme in Evidence-Based Health Care in Oxford over the last 4 years has galvanised my interest in and passion for knowledge translation: that is using research evidence to enhance clinical practice. While most researchers expect that disseminating good research through high impact publications and international conferences will change practice, many clinicians and managers know that evidence alone is insufficient for clinical improvement! Therefore, it is important that we document and share what is known about these complex processes. The MSc module “Knowledge into Action” does just that and many students have proceeded to use research evidence to improve their own practices.

However, I have recently taken on a significant personal challenge in moving to a new conjoint position between Gold Coast Health and Griffith University in Australia. A new 750 bed hospital has been built literally beside a university that educates a broad range of health care professionals. I am now in a position to develop and share practical strategies to support clinicians to understand, use and participate in research; with the eventual aim to enhance patient care. To get started, I offered bursaries to two members of my new team, to attend the “Knowledge into Action” module in Oxford. I expect that with a shared understanding of the complex processes involved in knowledge translation, we can build strategies to pilot and document ways to use research evidence to improve clinical practice. Together with Jill Mahoney and Rachel Wenke, we will collate resources and our own learning experiences to promote success throughout our local health service. Keep posted for future stories…

Rachel Wenke, Sharon Mickan and Jill Mahoney at Rewley House in Oxford

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Upcoming Modules

Introduction to Study Design & Research Methods

1-5 June 2015

Choosing and designing the most appropriate study to address your clinical research problem is paramount in generating the best evidence

The History and Philosophy of Evidence-Based

Health Care

15-19 June 2015

Why and how did evidence-based medicine arise, and why should you accept it?

Qualitative Research Methods

29th June – 3 July 2015

Exploring qualitative research through interviews

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