![Evidence based practice
You have a dry eye patient and you want to prescribe artificial tears containing sodium
hyaluronate? Which preparation should you choose and which dosing regime will lead to
the best clinical outcome?
Ocular lubricants are largely regarded as safe, although there are some reported side effects, most notably
blurred vision, variable levels of ocular discomfort and foreign body sensation [16]. There are relatively
few randomized controlled trials (RCTs) that have compared the relative superiority of a particular OTC
product to others for DED therapy [17]. A recent Cochrane systematic review, which sought to evaluate the
effect of OTC tear supplement products for treating DED, included 43 randomized controlled trials that had
compared artificial tear formulations to no treatment, or placebo [16]. The primary outcome measure was
patient-reported symptoms. The authors reported that the overall quality of evidence was low for the
various tear supplement formulations compared in the review, and concluded that while artificial tears
may be effective for treating DED, there was still a need for future research to enable robust conclusions
to be drawn about the effectiveness of individual OTC artificial tear formulations.
Jones, L., Downie, L.E., Korb, D., Benitez-del-Castillo, J.M., Dana, R., Deng, S.X., Dong, P.N., Geerling, G., Hida, R.Y., Liu, Y. and Seo, K.Y.,
2017. TFOS DEWS II management and therapy report. The ocular surface, 15(3), pp.575-628.](https://image.slidesharecdn.com/lecture3embeddingevidencebasedpracticegculearn-250316115807-c893643f/85/Lecture-3-Embedding-Evidence-Based-Practice-GCU-Learn-pdf-39-320.jpg)
![Evidence based practice
You have a dry eye patient and you want to prescribe artificial tears containing
sodium hyaluronate? Which preparation should you choose and which dosing
regime will lead to the best clinical outcome?
As the range of commercial products that contain sodium hyaluronate increases, a
growing number of Level 1 and 2 clinical studies have been published that
demonstrate good tolerability and the ability to improve dry eye symptoms [35
42].
Jones, L., Downie, L.E., Korb, D., Benitez-del-Castillo, J.M., Dana, R., Deng, S.X., Dong, P.N., Geerling, G., Hida, R.Y., Liu, Y. and
Seo, K.Y., 2017. TFOS DEWS II management and therapy report. The ocular surface, 15(3), pp.575-628.](https://image.slidesharecdn.com/lecture3embeddingevidencebasedpracticegculearn-250316115807-c893643f/85/Lecture-3-Embedding-Evidence-Based-Practice-GCU-Learn-pdf-40-320.jpg)
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Lecture 3 Embedding Evidence Based Practice GCU Learn.pdf
- 1. Laura Sweeney Laura.sweeney@gcu.ac.uk Embedding Evidence Based Practice into Your Clinical Decision Making Process Myopia Management
- 2. Learning Objectives Understands how to use the clinical signs and symptoms alongside the clinical evidence base in order to manage patients safely and in line with the current evidence available Is able to evaluate the quality of the current clinical evidence available
- 3. Clinical Decision Making Highly complex cognitive process which has aspects of both problem solving and decision making in order to reach a diagnosis Using Evidence based practice will improve your diagnostic ability and your clinical decision making process leading to the best clinical outcomes for patients
- 4. Aspects of Clinical Decision Making Critical Thinking Problem Solving Clinical Decision Making
- 5. Aspects of Clinical Decision Making Identify the problem Gather and analyse the data Identify the solutions/alternatives Select an action Analyse the action Problem Solving
- 6. Aspects of Clinical Decision Making Identify the problem What is the key reason for visit? Gather and analyse the data Gather appropriate information both from patient responses during history and symptoms and choose appropriate tests based in the presenting complaint. Combine data from your history and examination Generate a list of differential diagnosis Identify the solutions/alternatives Decide upon a provisional (working diagnosis) Select an action Create an appropriate management strategy based on the available evidence both intrinsic and extrinsic Analyse the action Reflect upon your management strategy Problem Solving
- 7. Clinical Decision Making Problem Solving Strategies Diagnosis by hypothesis testing Generating a limited number of hypotheses early in the diagnostic process and using these hypotheses to guide subsequent data collection. Each hypothesis will predict what the additional findings will be Pattern Recognition/Categorisation Clinician matches features of the current case to a specific instance of a condition that they have seen before, or they match it to a protoype More common in experienced clinicians who may only fall back on hypothesis testing in complex cases
- 8. Clinical Decision Making Problem Solving Strategies Diagnosis by hypothesis testing Generating a limited number of hypotheses early in the diagnostic process and using these hypotheses to guide subsequent data collection. Each hypothesis will predict what the additional findings will be Pattern Recognition/Categorisation Clinician matches features of the current case to a specific instance of a condition that they have seen before, or they match it to a protoype More common in experienced clinicians who may only fall back on hypothesis testing in complex cases
- 9. Clinical Problem Solving and Diagnostic Decision Making Errors in Estimation of probability Availability - overestimation of memorable events and underestimation of routine, ordinary events Representativeness considering all hypotheses equally when more prevalent conditions are more likely to be the final diagnosis Other Errors Information which presents later in a case likely to be weighted more highly Tendency to interpret findings as consistent with a single hypothesis Neglecting facts inconsistent with a favoured hypothesis Over emphasizing positive findings and underemphasizing negative findings
- 10. A good place to take a break
- 11. Evidence based practice The basic concept of evidence-based medicine proposes to make health related decisions based on a synthesis of internal and external evidence. Internal evidence is composed of knowledge acquired through formal education and training, general experience accumulated from daily practice, and specific experience gained from an individual clinician-patient relationship. External evidence is accessible information from research. It is the explicit use of valid external evidence (eg, randomised controlled trials) combined with the prevailing internal evidence that defines a clinical decision as evidence-based. Porzsolt, F., Ohletz, A., Thim, A., Gardner, D., Ruatti, H., Meier, H., Schlotz-Gorton, N. and Schrott, L., 2003. Evidence-based decision makingthe six step approach. BMJ Evidence-Based Medicine, 8(6), pp.165-166.
- 12. Evidence based practice Porzsolt, F., Ohletz, A., Thim, A., Gardner, D., Ruatti, H., Meier, H., Schlotz-Gorton, N. and Schrott, L., 2003. Evidence-based decision makingthe six step approach. BMJ Evidence-Based Medicine, 8(6), pp.165-166.
- 13. What separates us from Gwyneth Paltrow and Tom Brady? We promote behaviours associated with the maintenance of good eye health We will support members in providing the best care they can for patients Tom Brady and Gwyenth Paltrow both promote and showcase practices which improve health Peer Reviewed Evidence!
- 14. What separates us from Gwyneth Paltrow and Tom Brady? We promote behaviours associated with the maintenance of good eye health We will support members in providing the best care they can for patients Tom Brady and Gwyenth Paltrow both promote and showcase practices which improve health Peer Reviewed Evidence! Not following evidence based practice can leave practitioners vulnerable to GOC fitness to practice proceedings
- 15. What separates us from Gwyneth Paltrow and Tom Brady? We promote behaviours associated with the maintenance of good eye health We will support members in providing the best care they can for patients Tom Brady and Gwyneth Paltrow both promote and showcase practices which improve health Peer Reviewed Evidence!
- 16. What separates us from Gwyneth Paltrow and Tom Brady? We promote behaviours associated with the maintenance of good eye health We will support members in providing the best care they can for patients Tom Brady and Gwyneth Paltrow both promote and showcase practices which improve health Peer Reviewed Evidence!
- 18. Evidence based practice Key to evidence based practice is your ability to evaluate the evidence base during clinical decision making Evidence based practice is not just relevant to myopia management- every clinical decision you make should be based on the available evidence Guidelines are evidence based CMGs NICE guidelines SIGN guidelines
- 19. Evidence based practice Hierarchy of evidence https://www.cebm.net/2014/04/study-designs/
- 20. Evidence based practice Hierarchy of evidence https://www.cebm.net/2014/04/study-designs/
- 21. Evidence based practice Hierarchy of evidence
- 22. Evidence based practice Hierarchy of evidence Editorials and Expert Opinion May take the form of information found in textbooks, can help with your basic understanding of a topic and may help you become familiar with the terms associated with it Mechanistic Studies Explore the mechanism of action of an intervention, test for adverse events in healthy populations or contribute to knowledge of the mechanisms of disease processes
- 23. Evidence based practice Hierarchy of evidence Case Studies and Case Reports Observational Descriptive study design- detailed qualitative description of a condition given by an expert observer (clinician) Cross-Sectional Design/Surveys Observational Descriptive Design - used to generate prevalence data and to help inform health interventions for that disease process
- 24. Evidence based practice Hierarchy of evidence Case Control Studies Evaluates the relationship between disease and exposure by observing patients who have the same disease or outcome Cohort Study A longitudinal study of a group of people who share a characteristic e.g. age and gathers cross sectional data at set intervals throughout the study and compares the data in the group between those with a particular condition or intervention and those who did not develop a particular condition or were not exposed to the intervention
- 25. Evidence based practice Hierarchy of evidence Randomised Control Trials Experimental Analytical design - A trial in which subjects are randomly assigned to one of two groups: one (the experimental group) receiving the intervention that is being tested, and the other (the comparison group or control) receiving an alternative (conventional) treatment . To determine efficacy of treatment in an unbiased way.
- 26. Evidence based practice Hierarchy of evidence Systematic Reviews and Meta-analysis of RCTs Collate available evidence on a specific and clearly defined topic in order to draw unbiased conclusions
- 27. Evidence based practice Hierarchy of evidence
- 28. A good place to take a break
- 29. GRADE system Proposed as an effective way to evaluate evidence Used by College CMGs, NICE guidelines etc. Certainty What it means Very low The true effect is probably markedly different from the estimated effect Low The true effect might be markedly different from the estimated effect Moderate The authors believe that the true effect is probably close to the estimated effect High The authors have a lot of confidence that the true effect is similar to the estimated effect Certainty can be rated down for: Certainty can be rated up for: Risk of bias Imprecision Inconsistency Indirectness Publication bias Large magnitude of effect Dose-response gradient All residual confounding would decrease magnitude of effect (in situations with an effect)
- 30. Evidence based practice College Clinical Management Guidelines uses GRADE system to classify the quality of evidence which underpins their recommended pharmacological and non pharmacological interventions
- 31. Evidence based practice Hierarchy of evidence Levels of Evidence - Used by Scottish Intercollegiate Guideline Network (SIGN) and National Institute for Health Care Excellence (NICE)
- 32. Evidence based practice Hierarchy of evidence OCEBM Levels of Evidence Working Group. "The Oxford 2011 Levels of Evidence". Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson
- 33. Evidence based practice Does lowering intraocular pressure reduce glaucoma disease progression? OCEBM Levels of Evidence Working Group. "The Oxford 2011 Levels of Evidence". Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson
- 34. Evidence based practice Does lowering intraocular pressure reduce glaucoma disease progression?
- 35. Evidence based practice Does lowering intraocular pressure reduce glaucoma disease progression?
- 36. Evidence based practice Does prescribing antibiotics decrease the time course of bacterial conjunctivitis?
- 37. Evidence based practice Does prescribing antibiotics decrease the time course of bacterial conjunctivitis? Jefferis J, Perera R, Everitt H, van Weert H, Rietveld R, Glasziou P, Rose P. Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Br J Gen Pract. 2011;61(590):e542-8 Public Health England. Guidance on Infection Control in Schools and other Childcare Settings. March 2017 http://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_co ntrol_in%20schools_poster.pdf Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Syst Rev. 2012;9:CD001211
- 38. Evidence based practice Does prescribing antibiotics decrease the time course of bacterial conjunctivitis? Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Syst Rev. 2012;9:CD001211 Although acute bacterial conjunctivitis is frequently self limiting, the findings from this updated systematic review suggest that the use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission in comparison to the use of placebo. Use of antibiotic eye drops should therefore be considered in order to speed the resolution of symptoms and infection College Clinical Management Guideline reflects this finding
- 39. Evidence based practice You have a dry eye patient and you want to prescribe artificial tears containing sodium hyaluronate? Which preparation should you choose and which dosing regime will lead to the best clinical outcome? Ocular lubricants are largely regarded as safe, although there are some reported side effects, most notably blurred vision, variable levels of ocular discomfort and foreign body sensation [16]. There are relatively few randomized controlled trials (RCTs) that have compared the relative superiority of a particular OTC product to others for DED therapy [17]. A recent Cochrane systematic review, which sought to evaluate the effect of OTC tear supplement products for treating DED, included 43 randomized controlled trials that had compared artificial tear formulations to no treatment, or placebo [16]. The primary outcome measure was patient-reported symptoms. The authors reported that the overall quality of evidence was low for the various tear supplement formulations compared in the review, and concluded that while artificial tears may be effective for treating DED, there was still a need for future research to enable robust conclusions to be drawn about the effectiveness of individual OTC artificial tear formulations. Jones, L., Downie, L.E., Korb, D., Benitez-del-Castillo, J.M., Dana, R., Deng, S.X., Dong, P.N., Geerling, G., Hida, R.Y., Liu, Y. and Seo, K.Y., 2017. TFOS DEWS II management and therapy report. The ocular surface, 15(3), pp.575-628.
- 40. Evidence based practice You have a dry eye patient and you want to prescribe artificial tears containing sodium hyaluronate? Which preparation should you choose and which dosing regime will lead to the best clinical outcome? As the range of commercial products that contain sodium hyaluronate increases, a growing number of Level 1 and 2 clinical studies have been published that demonstrate good tolerability and the ability to improve dry eye symptoms [35 42]. Jones, L., Downie, L.E., Korb, D., Benitez-del-Castillo, J.M., Dana, R., Deng, S.X., Dong, P.N., Geerling, G., Hida, R.Y., Liu, Y. and Seo, K.Y., 2017. TFOS DEWS II management and therapy report. The ocular surface, 15(3), pp.575-628.
- 41. Activity
- 42. Useful Resources https://guidance.college-optometrists.org/home/ https://www.college-optometrists.org/guidance/using-evidence-in- practice.html OCEBM Levels of Evidence Working Group. "The Oxford 2011 Levels of Evidence". Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/
- 43. Post-lecture activity (40 mins) Read and evaluate the following research paper (available in GCU Learn) He M, Xiang F, Zeng Y, et al. Effect of Time Spent Outdoors at School on the Development of Myopia Among Children in China: A Randomized Clinical Trial. JAMA. 2015;314(11):11421148. doi:10.1001/jama.2015.10803
- 44. Post-lecture activity What is the hierarchy level of the evidence? What are the strengths and limitations of the study? What are the key points that you can apply to the management of your patients in practice? Record your thoughts in the Padlet found in the Post lecture activity folder You will need to keep up to date with myopia research and be able to evaluate and apply the evidence to your practice
- 45. Coming up. Myopic growth and the time spent outdoors