Clinically Speaking

CEP presents Clinically Speaking, a podcast series that unpacks the past, present and future of evidence-based medicine in primary care, hosted by Dr. Jamie Meuser and Christine Papoushek, PharmD. In each episode, we speak with academics, clinical experts and practitioners who are just as passionate as we are about how evidence could and should be used to guide optimal care.

This podcast is available on iTunes. New episodes are released every three weeks on Tuesdays. The next episode will be online on Tuesday, February 19, 2019.

What it takes to produce a good clinical practice guideline

Episode 3

Keeping up with the evidence can be a daily struggle. We often turn to, and depend on, clinical practice guidelines to help make evidence-informed decisions. Dr. Jan Hux, President and CEO of Diabetes Canada, provides her insights on tackling one of the most difficult and complex areas of practice: diabetes.

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Jamie Meuser:  You're listening to "Clinically Speaking," a podcast that explores the past, present, and future of evidence based medicine and primary care, brought to you by the Center for Effective Practice. I'm Jamie Meuser, a family physician practicing home palliative care in Toronto.

Christine Papoushek:  I'm Christine Papoushek, a pharmacist practicing at a family health team in Toronto.

Jamie:  As described by Gordeyev in our first episode, evidence based medicine or EBM for short was originally conceived and taught as an individual practitioner's pursuit to find and appraise evidence to inform their everyday clinical decision making. It became abundantly clear, however, early in the EBM movement, just how impractical that was.

Christine:  Stay on top of new publications and studies relevant to your practice while it's also assessing the quality of said evidence became its own full time job.

In response, we've turned to a more collective approach to EBM through the creation and dissemination of clinical practice guidelines or CPGs. CPGs have become one of the most important tools clinicians use to guide their clinical care decisions.

Jamie:  The prevalence of diabetes in the work of all primary care practitioners makes the Diabetes Canada guidelines a particularly important patient care information tool.

Today, we speak with Dr. Jan Hux, president and CEO of Diabetes Canada, to get a better sense of the CPG development process, who is involved and how they work to make their guidelines useful for a broad audience of practitioners.

I'm pleased to welcome Jan Hux whose president of Diabetes Canada. We're going to talk today about the construction project that is the Diabetes Canada Clinical Practice Guideline. Can you give us a bit of an idea of the process of pulling a massive endeavor like that guideline together?

Dr. Jan Hux:  Sure. We actually start with the consumer. Do a needs assessment and really get a sense of what are the needs? What are the questions? Where are the gaps in knowledge? Where do healthcare providers feel they need support in their decision making and in the care they deliver?

I guess the next step would be to generate our team of volunteers, endocrinologists, primary care practitioners, both physicians and nurse practitioners, pharmacists, dietitians, nurse educators as well as patients. Then from that, generate the questions that are going to be relevant to drive the content of the guidelines.

Those questions are then given to a literature searching service that's run through McMaster University. They do the literature search for us which is a non insubstantial task. When we did the 2018 guidelines, there were over 200,000 articles that could be potentially relevant for practice of diabetes care that were identified.

Then the job becomes separating the wheat from the chaff, identifying what the messages were from the good articles, and then resolving the apparent contradictions. Even LA audiences is familiar with the notion that one week, coffee causes cancer and the next week, it cures heart disease.

We see that, of course, in the diabetes literature, so resolving contradictions, then distilling that down to recommendations, publishing the book, peer reviewing it, and then disseminating.

Jamie:  You talked about pulling together a team of people to help construct this guideline. What kind of expertise is necessary to do a high quality guideline in 2018?

Dr. Hux:  I think a range of expertise. Since we have, I believe, 38 chapters in this guideline, each chapter having its own team. We may not have the bench strength in some of the technical areas, methodology, and statistics.

We actually have a two phase process. For each chapter, the people with that content expertise review the literature and bring forth recommendations.

Then it goes under separate evidence review where the people with more clinical epidemiology expertise, statistical ability will go through and make sure that every one of the recommendations is actually supported at the level of strength that its reported at.

The skills that would be needed would be the direct clinical care, the application of evidence. That's why we feel it's important to have patients involved in our panels and then both a primary care and specialist care perspective so that we want guidelines that are durable across the setting in which they're used.

Jamie:  You talked about the massive number of studies. How do you select the evidence that you choose to use and not to use?

Dr. Hux:  That's a great question. You end up with over 200,000 because you want to keep your filters very wide at the beginning. You find that a bunch of them are most studies, or studies that aren't likely to be relevant in practice, or studies that are in a very specialized setting that we're not confident is generalizable.

Beyond that, we want to look for, "Are they actually providing the light on the question we were asking?" Then as I said looking at the quality of the study so we can get the wheat from the chaff and trying to resolve the conflicts.

Both studies may be completely accurate, but the population in which they're studied or the duration of the intervention or the intensity of the intervention may have led to a different outcome in the study.

Jamie:  It's certainly one of the trends in primary care in the hospital that allows the involvement of patients to a much greater degree in participating in and often directing their own care. You've talked about involving patients in the construction of this past guideline. I think that began a few guidelines ago.

What have you found out about what's the right part of the process to involve patients? How do you do that effectively?

Dr. Hux:  I'm becoming convinced there's no wrong spot for the patients to be, that we need to create a welcoming space. We need to empower them to bring their unique perspective. They can bring value anywhere. The challenge is to create a space that welcomes them.

Sometimes, that involves some training and education ahead of time so that they have the background they need. Then it's chairing the panels well so that their voice is recognized and called on.

Jamie:  You alluded to this, but I wonder if you can be explicit about who the audience or audiences are for the guideline that you're producing.

Dr. Hux:  The answer to that question is our audience is evolving. In the past, we had been fairly content to preach to the choir that the people who came together to produce the guidelines were people whose primary practice was diabetes.

Even though some of them, for instance, might be a general internist or geriatrician or a family doc, they had oriented their practice toward diabetes. It was worth it to them to invest a fair amount of time in informing themselves of the latest evidence.

We've realized that if we only focus on people whose primary practice is diabetes, many of them will be relatively up to date on this literature anyway.

The unmet need is in the generalist audience, the people who have a much broader demand on their attention, who need to know everything from immunization schedules for infants through to screening for dementia in the elderly and have a narrow capacity to take up diabetes information.

Curating the information and packaging it to be useful in primary care has become a real emphasis in the 2018 iteration of the guidelines.

Jamie:  We've talked about creating guidelines. I guess the end point of that will be recommendations for how care should be organized or prioritized. Any thoughts around formatting how that content gets presented to the various audiences and distributed to them?

Dr. Hux:  Yeah, I think that it became clear to me in my med school class of 252 people at UT that one size does not fit all. There were clearly students who sat in the front row and meticulously wrote down everything the professor said.

There were others who never attended a lecture. There were people who bought and read all of "Harrison's Principles of Internal Medicine." There were those who bought the skinniest internal medicine textbook in the bookstore. I think...

Jamie:  They're all called doctor. [laughs]

Dr. Hux:  They are all called doctor. To think that one tool is going to meet the need of all providers is naive. We need to have a range of things. There will be some people who will take great comfort in the 218 page tome, and other books we'll only find it useful as a doorstop.

We need to not be shirty about the fact that people have different preferences. Electronic tools, paper based tools, book based tools, web based tools. We need a range of tools. We also need a range of depth. There are some personalities that need the story behind the story before they're confident in making the decision.

There are others who just, "Give me the bottom line. Tell me what to do." Trying to have a smorgasbord for people to eat where they want and what they want is going to be the best approach.

Jamie:  What kind of strategies have you used or have you contemplated for simplification?

Dr. Hux:  The most important thing is have the end users on the panels. After the guidelines are produced, they go into the hands of our dissemination and implementation group. This time, we have two co chairs, one of whom is a family doc. We felt that was extremely important to have a range of primary care providers around the table who are actively informing.

Again, if they choose to give a ton of volunteer time to have diabetes guideline, they still may not be representative of the general population, but at least they are pushing us in that direction.

If we can get a guideline that only contains 40 percent, or 30 percent of the content of the main guideline but is 80 percent applicable rather than 100 percent of the guideline is 2 percent applicable, we're further ahead.

Jamie:  Have you considered doing that? Have you considered putting out a version of the guideline with emphases that are appropriate to the audience?

Dr. Hux:  Yeah. We're talking about a variety of schemes, none of which are set on yet but would include picking only the chapters that are likely to be relevant to most providers, i.e., primary care, and updating them annually, and focusing much more on practical actionable recommendations even in areas where there's not a ton of evidence.

Often, those are the areas where providers need even more help. It's the expert, "Here's what I would do in my practice. There's no evidence, but it seems to work," because they've seen a thousand patients like that, and you're on your second or third one.

Jamie:  Save the easiest question for the end. Guidelines, clearly, are very intense and complex endeavors, requiring our suspect substantial resources to pull that off. Where should the resources come from?

Dr. Hux:  That's a great question. For many organizations and for us in the past, the obvious answer has been the pharmaceutical industry because they have a vested interest in seeing particularly new products that are bringing to market pushed out and education around their appropriate use being provided.

There's equally, if one wants to be evidence based, good evidence that shows that guidelines where industry has been involved in the development at an uncontrolled level due to the biased guidelines and would promote inappropriate overutilization.

We've taken the step to not use any corporate funding for the development of our guidelines this time and even prior to that, really worked very hard to build that Chinese wall so that our funders had no access to the guidelines until they were printed.

Then that leaves the question, "Who should?" Governments aren't keen to fund this kind of work. They would be seen to have a conflict of interest as well.

At Diabetes Canada, we're in the luxury space of being the only health charity that is both the professional section who would rightly lead a guideline process and health charity that might have the resources to fund that. We use general donations because the guidelines are critical to our mission to fund that.

[background music]

Christine:  Thank you for listening to this episode of Clinically Speaking. It was produced and edited by Pippy Scott Meuser at the Center for Effective Practice.

Jamie:  Special thanks to our guest this episode, Jan Hux, for taking time out of her busy schedule to talk with us.

Christine:  We'd love to hear from you. If there's a specific topic you'd like us to cover, please feel free to send us an email at info@cep.health, or come and find us on Twitter @CEPhealth.

Jamie:  Don't forget to subscribe on iTunes, our website, or however else you get your podcasts.

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Making clinical practice guidelines more useful for everyday practice

Episode 2

Dr. Mike Allan, a family physician and academic from Alberta, heads an initiative that takes a very different approach to producing clinical guidance for decision making, specifically by targeting primary care practitioners at all stages of the process.

[background music]

Dr. Jamie Meuser:  You're listening to "Clinically Speaking," a podcast that explores the past, present, and future of evidence based medicine in primary care, brought to you by the Center for Effective Practice. I'm Jamie Meuser, a family physician practicing home palliative care in Toronto.

Christine Papoushek:  And I'm Christine Papoushek, a pharmacist practicing at a family health team in Toronto.

Dr. Meuser:  By far, the most read and referred to article in "Canadian Family Physician," the official journal of the College of Family Physicians of Canada, is the simplified lipid guidelines. Published in 2015, volume 61, issue 10 for those who haven't read it, by Dr. Mike Allan and his team at the Alberta College of Family Physicians and the University of Alberta.

The simplified lipid guidelines strayed from the traditional CPD development process in an attempt to achieve a more useful, more practical and a more relevant guideline for its users.

Christine:  Ironically, very few clinical practice guidelines are developed with much or significant input from primary care providers, the chief users of them. The simplified lipid guideline flipped this on its head. They stacked the development group to ensure that the resulting guideline was focused, relevant, and easy to implement for their target audience, primary care providers.

Dr. Meuser:  By focusing the output to a more narrow audience and by explicitly addressing questions relevant to them, this guideline has the potential to be more useful as a tool for supporting clinical decision making, and will hopefully set a precedent for the development of future guidelines.

Christine:  We had the pleasure to speak with Mike about the work that he's been doing, what's to come, and how we can work towards making EBM more meaningful for primary care providers.

Dr. Meuser:  Today, we're welcoming Dr. Mike Allan. Mike's a family physician in Edmonton, founder and leader of the evidence based medicine group at University of Alberta. Mike's been active in CPD in Alberta, BC and well beyond, and in particular has been a primary contributor to the Tools for Practice evidence based medicine group at University of Alberta.

Mike is also a contributor and co host for the "BS Medicine Podcasts." You might want to take a listen to that. These are superb podcasts and lots of them. How many now?

Dr. Mike Allan:  300 and something? I believe so. [laughs]

Dr. Meuser:  Really? Holy mackerel!

[laughter]

Dr. Meuser:  Wow!

Dr. Allan:  It's robust. [laughs]

Dr. Meuser:  Lots of background there and really a focus on particular clinical topics similar to the Tools for Practice or write ups that you've gotten, brief reviews of evidence on particular clinical topics.

Probably more recently and more germanely to our discussion today, Mike is the principal author of what they've called, "Simplified Guidelines," the two that have so far been on lipids and on cannabis. You have been invited, first and foremost, because of the interests that we share with you and commitments that we have to evidence as a cornerstone for the practice of primary care.

Why don't we start by having you describe the various roles you've got currently around clinical practice guideline creation dissemination?

Dr. Allan:  Well, right now, I'm at the University of Alberta. I'm a professor there in the Department of Family Medicine. The section that we're in within the department is called Evidence Based Medicine.

We call ourselves the peer group, and that comes from the very foundation of evidence based medicine. Patients is the "P", Experience is the first "E", Evidence is the second "E". Then Research because of what we do. Also, we didn't want to call ourselves the "PEE" group.

[laughter]

Dr. Allan:  There was a problem with that.

Dr. Meuser:  Thank God for research, eh?

Dr. Allan:  Thank God research came along. Tina and I and Mike Culver, we co lead that group. Scott's a part of our group, Scott Garrison, and then all sorts of other people.

Then I also am the incoming director of programs and practice support at the College of Family Physicians of Canada and hoping to continue all of this kind of work there. That's the intention. Then, of course, I have a clinical practice, like many of us. Those are the hats I wear.

Within CPD and guidelines, I noticed early that CPD wasn't being delivered for primary care, by primary care. I did a research study with Doug Klein that showed that. Then a bunch of us did research study asking that of guidelines.

We realized we were 17 percent of the total contributors to our own guidelines. That made me motivated to get more involved in guidelines. On top of the Tools for Practice and best science medicine, I became quite passionate about trying to develop guidelines with a more primary care focus.

Dr. Meuser:  You talked about being a researcher and creates some of the knowledge that goes into the package into guidelines, developer guidelines, so part of the packaging process and then a consumer, a user?

Dr. Allan:  Yes, that's right.

Dr. Meuser:  From those various points of view, how important do you think practice guidelines are to clinical decision making for Canadian family physicians, for Canadian patients?

Dr. Allan:  Because their very name is guidelines, they're guides, they're not strict rules to be enforced. That needs to be stressed for everyone because we all have patients that are exceptions or that don't fit into the constraints of a guideline.

Accepting that, and being comfortable with that, I think guidelines still have a role. They fill a series of voids. One is sometimes we don't have research. Sometimes we don't really know what direction.

Having a guidance document to help direct care, give suggestions in care can be very helpful. We know family doctors couldn't possibly keep up with reading to stay up to date. The best estimate is that would take pretty close to 20 hours a day.

What are we going to do instead? Well, guidelines have a potential role to fill there in summarizing the evidence in key areas of practice. They fill a bunch of potential roles for us, and they can be very helpful in practice.

We just have to make sure that they don't dominate our decision making or restrict us in any way to take care of people. We have to make sure that they're done the right way and by the right people.

Dr. Meuser:  We've got a guideline for just about everything these days.

Dr. Allan:  Hopefully, just one for everything, but we don't. We have way more than that.

Dr. Meuser:  No shortage of guidance, I would say. All those guidelines came from somewhere. Someone thought they were a good idea. Someone, in fact, put resources into making that good idea come true.

Based on what you've experienced through your career, talk about what forces have driven the current model of clinical practice guideline creation and dissemination.

Dr. Allan:  There're a lot of forces. Some of them are good, neutral, and some of them are less than good. [laughs] A good one is just what we talked about. There's a need out there and a lot of clinicians appreciate having a guideline to turn to to help them in managing their patients. My only fear there is how rigid they are in that recommendation.

There's other reasons that guidelines have come to be and become such a big part of what we do, and that is some people feel ownership of certain conditions. We, in primary care, we see all the conditions. We don't really care about diabetes unless our patient has diabetes.

There's different viewpoints where they only care about that patient because they have the condition they care about. It's kind of a reverse thinking. When you have control of a condition, you want to write the rules for that condition.

That's one of the motivators that goes behind guidelines is there's a sense of wanting to control it. Within a field, if I was an endocrinologist, for example, getting a seat at the table of the Canadian Diabetes Association and being an author of part of that guideline would be considered a bit of a feather in the cap.

I would want to be at that table if I could. There's a motivation from that perspective. I would consider that more of a neutral thing. Then there's certainly is influence within industry and that kind of thing to direct guideline base care to enhance a certain bottom line.

Dr. Meuser:  Can you give us any thoughts about the kinds of differences in the process that you would see as contributing to usefulness?

Dr. Allan:  There's a group called the Institute of Medicine. They wrote a document called Guidelines We Can Trust. It's supposed to be a guidance document itself for the writing of guidelines.

It follows some very basic principles. One is the lack of conflict of interest, so to avoid any conflict of interest, if at all possible. One of the pieces that falls out from that that we often forget about is something called predisposition bias. That's where you already have a belief system in place.

I would say that you also need to tread quite carefully there. If I'm a researcher and all I've done in my entire career is research apolipoprotein B, you put me on a guideline I am going to advocate heavily for testing for apolipoprotein B. If I was in the diabetes and I studied glucagon, I'd want that in the guideline somehow.

Many people will focus on what's happening with industry funding. Also, as important, I would say is this. It's been shown in a study by Oxman and Guyatt, that the more specialized you become in an area, the less likely you are to be objective about new research that comes along.

The next thing is being evidence based as much as possible. Where they're not, I think we need more flexibility and less rigidity.

Then the last thing, I think, or not the last thing. The second last thing is if we accept that primary care is providing the majority of care, and I think that's inarguable. Then we need more primary care on these guidelines. The best estimate is just for all of care in Canada, all of healthcare in Canada, we're delivering 65, 67 percent of all of the care.

For guidelines targeting primary care, we need to be at that table. We need to be the majority of that table, not to exclude our colleagues and pharmacology, or pharmacy, or nurse practitioners, or nurses, or our specialist colleagues. We need to be the leads and the leaders of that guideline, not the other way around.

The last piece is simple. Primary care is very, very busy. The research shows, again and again, that we're swamped with all that we're supposed to do. If we were to take care of chronic disease and preventive medicine alone, it would take around 18 hours every day.

Because we've ended up in a situation where specialty societies continually parse off their niche and don't worry about what is the broader picture of what's affecting our population and our patients, we end up with a burdensome amount of things that are recommended for us in primary care. I think the better approach for us is to simplify that.

Why don't we spend more time doing the actual shared decision making with our patients? Listening to their stories, listening to their concerns and addressing those. Rather than, I've got to get through this huge checklist of preventative care maneuvers and this periodic health exam today.

I've got to squeeze it into your complaint about your ankle today so I'd like to skim along and talk about the PSA which is going to take 10 minutes.

Instead of doing that, I'd like to see us simplify things a lot more where we can. I'm not saying where things are complex, we just abandon that complexity, but where they are simpler, where they could be simple, why don't we gravitate in that direction? Rather than always looking to make things more complex and difficult.

Dr. Meuser:  Can you give us any thoughts about how you would organize or prioritize the care recommendations that come out of a guideline? In some ways, some would say that two dozen recommendations without prioritization attached to them is almost useless. It doesn't help me in my decision making very much if I got to focus on two dozen things, because I never will.

Dr. Allan:  Exactly. Within the actual framework of recommendations, the goal is to keep it to 10. You can't always because there's too many, but some will obviously bubble up to the top. Those are the ones with better evidence. Those are the ones the committee would feel are essential to practice.

Then that would be something we would obviously focus on and bring more front and center into the guideline write up.

Dr. Meuser:  Any thoughts about how format can influence uptake in successful guideline?

Dr. Allan:  Absolutely. If you look at our guidelines, there's three pieces to the guideline.

The first is the evidence review. That's a massive document, generally. I don't think anyone is going to read that, or I certainly hope they don't. Unless they're super keen on finding out what we did and have maybe distrust for what we did or maybe are just really keen on pursuing a certain area of research.

The next step is the guideline itself. That is something between a 5 and a 10 page document, at most. That might be read by more than a few people, but it certainly won't be read by everybody. They're going to want to read a summarized version. Because some people still like all of the key recommendations on a single page, we provide that as well.

Then we have something we call a one pager. We create that as an algorithm so that it's as simple as possible for docs to use in primary care.

Dr. Meuser:  If this, then that.

Dr. Allan:  We try and make it as straightforward as possible. If you looked at the cannabinoid guideline, the evidence section was very, very big. Then we got it down, in the end, to an algorithm that's less than half a page in size.

The goal of the one pager is not only to provide the algorithm but to provide the tools that allow a clinician to do everything that's needed, key from the guideline.

If you look at our lipid one, we have an algorithm for deciding on who should have a discussion about treatment and the relative strengths of that discussion. Someone over a 20 percent risk, we strongly recommend that a discussion should occur.

On the flip side of it, because we recommended moderate or low potency and those kind of things, we say what those are. We say what the expected benefits would be from randomized controlled trials and the cost of the agents, those kind of things so that that decision making process is as easy as possible.

Dr. Meuser:  You've nicely described the simplified means. Did you worry at all when you coined the simplified term that it would reinforce the hidden curricular around family docs being lesser beings than the others?

Dr. Allan:  It's interesting. You're the second person today to bring that up to me. This is the first time I've ever heard that.

Dr. Meuser:  Is that so?

Dr. Allan:  Yeah. I did not even begin to perceive that. I saw guidelines as broken, in part because of their complexity. The guideline itself, I'm not talking about the evidence section, but the guideline itself, 200 pages. It's just too cumbersome for us in primary care.

I've always thought that simple is better and that speaks to our tools for practice in lots of what we do. If you can say something in 10 words or a hundred words, why would you say it in a hundred? I actually thought it was quite a cunning marketing ploy. Now I see that...

Dr. Meuser:  [laughs] .

Dr. Allan:  ...like most of my great ideas, it has faults. [laughs]

Dr. Meuser:  In fact, I think the elements you described are all compelling around handing people the most useful tool possible. You're right. The most useful tool in some way is the one where how to use it is obvious.

Mike, we'll be talking with the Canadian Diabetes Association about the guideline. It's clearly an important one for driving care in family physicians' offices across the country. Any specific comments on the CDA guideline?

Dr. Allan:  The CDA guideline has some of the things that I've mentioned earlier, the challenges that are present in guidelines. There's no doubt that some of that exists. Anyone who is listening could probably piece that together, but they do have a very difficult task.

Maybe, you've noticed that the simplified group hasn't embraced doing a diabetic guideline, and maybe that's because they're afraid of it.

[laughter]

Dr. Allan:  It's such a huge topic. Certainly, if we were to do it, we wouldn't include Type 1 diabetes, which they do. We would cover a lot less topics than they do. They try and hit every little target. I don't mean that target like A1C target. They try and hit every area of...

Dr. Meuser:  A minor relevance to the treatment.

Dr. Allan:  There'll be a whole section on photocoagulation and eye disease related to diabetes. There'll be a section on neuropathy. That is just not possible for something like our group and probably not possible to do a true evidence based guideline as I described.

If you had 10 questions, just for the eyes. If it takes us, with a whole team of people working around the clock, five months minimum to get 10 questions done. Can you imagine when we're talking about something else? There's challenges there that are quite big.

I personally wouldn't want to be trying to decide right now what's the second line therapy in diabetes. I would not want to be confronted with that. It's a very charged and challenging debate right now.

If you're truly evidence based, you would have to pick the ones with hard outcomes. That means you're picking expensive drugs. That means you're making a lot of people angry. It's a bit of a quagmire that I'm quite happy to let them [laughs] get stuck in and try and wade their way out of.

Dr. Meuser:  What strikes me that unlike you, they've got to send their guidelines out to a broad audience, not a narrow audience. It's more than family physicians that they're interested in.

Dr. Allan:  For sure.

Dr. Meuser:  In fact, that might change everything if you decided to only provide guidelines for questions that are going to be of value or interest to primary care.

[crosstalk]

Dr. Meuser:  You talked about...in your cannabinoid guidelines    having patients involved in the process.

Dr. Allan:  In the actual committee.

Dr. Meuser:  Can you talk a bit about how it changed the conversation in the room?

Dr. Allan:  Unfortunately, we had two, but one had to drop out for personal reasons. We were left with one, and then we still included the peer review of more. Our new guideline that we're working on right now has two.

There's almost a sense with the dynamics that when clinicians are in the room, patients sometimes will feel almost like, "Well, maybe the doctors know better," or, "Maybe, the healthcare providers know better."

We're toying with the idea of in the future actually creating a separate committee to give them a voice that's going to allow them more ability to influence the process. As I mentioned right from the onset, I don't have the right answers yet, but we're still experimenting with how to do this right.

Dr. Meuser:  You've talked a bit about how the patients are involved. How about the when?

Dr. Allan:  I would think it's critical in two parts    the choosing of the questions, but the second piece is at the end. When we do the guidelines, we try and keep things separated. We have a guideline committee. We have the evidence committee. We have a peer review committee.

Only when the guideline's written do they send it out. They take all of the information, and we're sending it out for 50 people.

They take that feedback. They try and see, "Does this have merit? Do I actually understand it when I read the guideline?" They end up doing so much work in the end that they're authors on the guideline, because it changes it substantially.

Then the last piece, the last committee    so this is four committees to do one guideline    the fourth committee is the knowledge translation committee. They're the ones that turn it into something usable for patients and clinicians, and we have patients on that. That does make a difference. Again    always learning I think we can strengthen that part a little bit better.

Dr. Meuser:  You talked a little bit about the intersection between electronic medical records and user guidelines. Can we better integrate clinical practice guidelines into the medical recordkeeping that we do?

Dr. Allan:  Keeping that dream alive. I started to research healthcare costs back in my residency over 20 years ago. I looked at the idea of providing cost information to improve prescribing to reduce cost for equivalent drugs.

There were promising studies there indicating that, but if you could find one that showed a reduction in cost, you could find another one that showed no reduction in cost.

This whole thing about medical reminders and embedded information into our EMRs, it still has promise, but we can't let the cart get ahead of the horse. We have to prove that these things are effective before we jump onboard too quickly.

Dr. Meuser:  It takes us a little bit towards the redundifying of care that...

Dr. Allan:  Absolutely.

Dr. Meuser:  ... you cited at the beginning as a downside to guideline based care.

Dr. Allan:  A real risk. We have some things to figure out before we integrate some of these into care. We have to make sure that they don't make our life more complicated rather than less.

Dr. Meuser:  We'll finish with the $64 million question. It really is. Good guidelines    I'm sure you know better than most are not cheap.

Dr. Allan:  No.

Dr. Meuser:  You don't do them for nothing. If they are an essential tool for high quality care, who should pay?

Dr. Allan:  Actually, it should be a shared payment. Universities have a role to play. Governments have a role to play. I don't actually think societies have as big a role to play, but you've probably guessed, I would gravitate away from that kind of guideline writing because of the system that it's built on.

We should be having a different approach. It should be kind of a shared model. We have academics who have time. It can't be just academics doing it. That has a lot of danger because they lose sight of some of the key elements of the way practice really is.

Our guidelines spend a ton of time choosing those family doctors    rural, making sure they're not academics, all of these kind of things. The actual leadership of it in that kind of role, that takes someone who can carve out time. Academics have that time to carve out. That, but having excellent representation from the community.

Dr. Meuser:  Sounds like    for all the reasons you've cited    who does it, how it's done, is probably more important than who pays for it. Who pays for it becomes a question you can settle when the rest of those questions are well taken care of.

Dr. Allan:  I agree. I'd love to see, if anyone from government is listening and you want to send us millions of dollars, we would take it. [laughs] Or some non profit organization.

Dr. Meuser:  Well, they're all listening.

[laughter]

Dr. Allan:  They all are, I'm sure. It's tough, because I think everyone has a strong belief system. The system that's built right now is built around the traditional model that we have. For our government colleagues to just suddenly abandon that approach and switch would be very, very challenging for them. I'm hopeful that we can start to show them that there's a hunger within primary care.

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Christine:  Thank you for listening to this episode of Clinically Speaking. It was produced and edited by Pippy Scott Meuser at the Center for Effective Practice.

Dr. Meuser:  Special thanks to our guest this episode, Mike Allen, for taking time out of his busy schedule to talk with us.

Christine:  If you're interested in learning more about the Center for Effective Practice, please visit our website at cep.health. Don't forget to subscribe on iTunes, our website, or wherever else you get your podcasts.

What has shaped evidence-based medicine?

Episode 1

Dr. Gord Guyatt, one of the founders of the evidence-based medicine movement, provides an overview of the forces and factors that stimulated the birth of evidence based medicine and have influenced its development.

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Dr. Jamie Meuser:  You're listening to "Clinically Speaking," a podcast that explores the past, present and future of evidence based medicine in primary care, brought to you by the Center for Effective Practice. I'm Jamie Meuser, a family physician practicing home palliative care in Toronto.

Christine Papoushek:  I'm Christine Papoushek, a pharmacist practicing at a family health team in Toronto.

It only made sense for us to start this pursuit to unpack evidence based medicine with one of its earliest and most effective champions, Dr. Gord Guyatt.

Dr. Meuser:  While at McMaster University, Gord spearheaded the initial idea of evidence based medicine and further developed this concept with Landmark Publications and the "Journal of the American Medical Association."

His series of more than 34 articles, collected into to the "Users' Guide to the Medical Literature," has provided the basis of EBM curricula in medical schools and residency programs nationally and internationally.

Today, EBM continues to be a method for appraising applying evidence, but also a movement that characterizes how we understand optimal approaches to medical practice in the modern age.

Christine:  Gord's contribution to the profession cannot be overstated. We are grateful that he could take time to speak with us today. He candidly shares his perspective on the early days of EBM, the motivation behind it, the surprising wins, and the unforeseen shortcomings of the approach.

We delve into how EBM has evolved since the challenges of bringing EBM into everyday practice, the hijacking by the pharmaceutical industry and the hopes that have been realized. He also shares his visions for the opportunities that lie ahead for EBM. Stick around.

Dr. Meuser:  Gord, just as a bit of background, you've got a long history, a substantial reservoir of expertise and a clear passion for evidence based medicine. You were there, I think it's safe to say, at the very beginning of the time when applying evidence to the clinical decision making we undertake as physicians became much more important, almost de rigueur.

Can you give us a bit of an idea, Gord, what was envisioned and what was intended when you conceived the idea of evidence based medicine as a touchstone of how we practice?

Dr. Gord Guyatt:  I still remember being at the Toronto Western Hospital as a second year resident in internal medicine and being told about how one should read the literature. The advice was, read the introduction and the discussion because of the accurate perception that one wouldn't be able to understand the methods and results.

A vision that Dave Sackett, who is my mentor, began with was, "Clinicians should be able to understand the methods and results, and so be able to distinguish what was trustworthy from what was less trustworthy."

At the start, there were a lot of practices that people were doing for which the evidence was not very satisfactory. In fact, the evidence might be that they were doing more harm than good and lots of other things that people weren't doing for which there was good evidence.

Clinicians should be able to look at the original medical literature, be able to understand what was there and distinguish what was useful from what was not useful. It's evolved quite a bit since that, but I would say that that was the original vision at the start.

Christine:  Gord, in your opinion, what hopes were realized, or what were some of the lasting effects on the medical profession and community more broadly?

Dr. Guyatt:  The big hope is that the medical community in general and associated communities, anywhere from pharmacists to nurses to occupational and physiotherapists, have adopted the vision of the requirements of an evidence based approach that is a critical look at the available evidence should inform clinical decision making.

As a result in North America, certainly, and increasingly in other parts of the world as well, both undergraduate and residency education in medicine, in nursing, and in other affiliated health professionals, the teaching of the concepts of evidence based medicine is seen as a core competency.

The licensing and accreditation of medical programs requires them to demonstrate that they are teaching their trainees these activities.

For people already out in practice, there's this general acceptance to that approach should be used. Many, many, many textbooks are called "Evidence Based Cardiology," "Evidence Based Anesthesia," "Evidence Based Pediatrics," and so on.

Analysis has become a selling point to say, "The practices that we are promulgating or encouraging are, in fact, based on evidence." Then in the electronic medical textbooks that have become extremely popular and, in fact, displaced old medical text, such as "UpToDate" and "DynaMed" sell themselves and, I think, try to be evidence based resources as well.

It's basically been accepted over a period of about 25 years as a fundamental of medical practice.

Christine:  In the 25 years, since and reflecting back on the original impetus behind the approach, can you tell me, have there been any unforeseen outcomes or unintended consequences?

Dr. Guyatt:  Well, it's actually ended up as something quite different, in at least two ways. One thing was that if you look at what we wrote at the beginning, the notion of values and preferences and value and preference sensitive decisions was really not there at all.

It only emerged over the first five years of the evolution of EBM, which it's been exciting to be involved in these 25 years or more now because it does keep evolving. What we realized after a while was that evidence never actually tells you what to do. The reason is that so many of our alternative decisions, the alternatives have both upsides and downsides.

Often those ups and downsides are relatively closely balanced. One paradigmatic situation we often use is atrial fibrillation.

Depending on how you feel about the burden of anticoagulation, and how you feel about the bleeding risks with anticoagulants versus the stroke prevention, two individuals in exactly the same situation based on the same evidence, one might very well say yes, anticoagulation is right for me, and another might say no.

There are many, many, many decisions within medical practice that are value and preference sensitive in this way. We've come to say an ironic principle of evidence based medicine is evidence never tells you what to do. There's always evidence in the context that patient values and preferences.

That's been one major shift from the beginning. The other major shift is the realization that clinicians do not have the time to actually read the medical literature in the way we might have envisioned it first. In fact, to really do it properly takes training, that the basics of knowing about what evidence based practice is about, will not take you there.

As a result, we have much more of the focus on pre appraised resources, systematic reviews, more and more guidelines, and presentation evidence summaries. In keeping now, this is a frontier area, decision aids for the practice encounter where both the patient and the clinician have the evidence summarized for them.

Those two things, the importance of values and preferences and the awareness that clinicians are not going to be doing the typical appraisal of the original literature themselves. They need to appreciate the fundamental principles, but then they need high quality clinical practice guidelines to help them achieve evidence based practice.

Dr. Meuser:  Someone we talked to recently talked about the shift from evidence based medicine being a individual skill that clinicians would exercise, usually through clinical appraisal of articles.

It's evolved from being that, as you said, to being more of an exercise of using a trusted source that has packaged evidence in particular ways. Clinical practice guidelines are probably the very best example. I think that's what you're talking about.

Dr. Guyatt:  That's exactly right. Clinicians still have to be able to understand the output of those.

Dr. Meuser:  In our day, there might be two or three different packages of evidence around a particular topic. Sometimes, in fact, quite often, coming to different conclusions or providing different recommendations for what the right next thing to do with patients would be. Which means that the evidence is not neutral.

It's malleable. It's manipulable. Is that a good thing by and large, would you say so?

Dr. Guyatt:  Great point. Clinicians, they do need to be able to identify a trustworthy guideline. There are some guidelines that are trustworthy and some that are less trustworthy. Guidelines based on well done systematic reviews are much more trustworthy than those that are not so based.

The clinicians, they need to be able to look at the outputs. What we would hope is less the evidence is malleable in that well done systematic reviews would come to more or less similar evidence summaries.

However, the inference is that one makes from that may differ and that goes back again to the underlying values and preferences. For instance, American medical practice is different in many ways from Canadian and definitely Europeans. The Americans put, I would say, a much higher value on small and uncertain benefits from highly costly therapies.

Canadians and Europeans, particularly Canadians, to some extent less, Europeans, in many countries even less so, so that same evidence summary in different environments because of different values and preferences lead to different decisions.

What the clinicians needs to be able to do is identify good evidence summary, understand that evidence summary, and help their patients with value and preference sensitive decision.

What follows is that there are many situations in which with the same evidence the patient presents the same way, but the right decision differs between patients depending on their values and preferences. That mandates shared decision making and shared decision making unequivocally is a challenge.

First of all, the clinician has to be able to present it in a way that the patient will be able to understand. They have to have the time to do this in what is for just about everybody a very time constrained practice. How we can make this as efficient as possible is still a big challenge.

For quite a while, there have been decision needs available, which are essentially information from patients and that can be helpful, but it doesn't really facilitate the shared decision making that we think is crucial or it only facilitates it to a limited extent.

Much more and more now we are experimenting with electronic accounts, or decision made designed to be looked at simultaneous and worked to together and understand together.

We think that that has the potential to revolutionize the process of shared decision making, whether it will or not remains to be seen. We've got a long way to go in terms of making the process of shared decision making efficient enough that it actually becomes a standard part of medical practice for most clinicians.

Dr. Meuser:  You probably have heard, as I have, part or more cynical colleagues make the assertion that evidence based medicine to some extent has been hijacked. Hijacked by commercial interests who have a stake in persuading decision makers that their way of approaching a clinical problem that is in the interests of their product should be followed. Do you think there's anything to that?

Dr. Guyatt:  Absolutely, yes. It is certainly the goal of those who are making money within medicine whether they be for diagnostic procedures or for drugs or for devices. It is the smart people in those areas and there is a lot of them, have recognized that using the language, concepts, and presentations of evidence based medicine is a great way to sell your product.

It's their job to present the evidence in such a way. Often, they somewhat distorted way, but nevertheless done in a way that looks convincing to persuade the practitioners and the patients to use their products. No question that goes on and characterizing it as a hijacking of evidence based medicine is quite appropriate.

The big push back then is encouraging physicians not to follow the guidance from their local pharmaceutical representative, but rather look to unbiased, high quality trustworthy guidelines.

Dr. Meuser:  You've talked a fair bit about engagement of patients in clinical decision making and use of evidence that is aimed simultaneously at the clinician and the patient. Are there any other ways that you see evidence based medicine evolving over the next few years?

Dr. Guyatt:  Conflict of interest is still a problem. The optimal production and dissemination of the evidence summaries in ways that are attractive and compelling to clinicians. The uniform application of well done systematic reviews to provide the information for the guideline.

All of that can be improved, but a lot of organizations are doing pretty well now. What we need to do is just raise the bar for everybody who's producing guidelines so that clinicians, when they go through a guideline, can feel comfortable that it is trustworthy.

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Dr. Meuser:  Gord, you've been really generous and helpful. Thank you again.

Dr. Guyatt:  You're very welcome. It's been a pleasure for me to talk to you.

Christine:  Thank you for listening to this episode of Clinically Speaking. It was produced and edited by Pippi Scott Meuser at the Center for Effective Practice.

Dr. Meuser:  Special thanks to our guests this episode Gord Guyatt for taking time out of his busy schedule to talk with us. If you like what you heard today, we encourage you to share with your friends and colleagues. Your support goes a long way.

Christine:  Don't forget to subscribe on iTunes, our website, or wherever else you get your podcasts.

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Introducing Clinically Speaking

Teaser

Over the next few months, Dr. Jamie Meuser and Christine Papoushek will explore different perspectives on evidence-based medicine (EBM) in primary care - from its origins to what it may look like in the future. Don’t miss an episode, subscribe and join us as we explore some of the most pressing questions and issues in primary care.

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