Carl,

Thanks for highlighting this paper, of relevance to us all.

I would like to challenge the list to further explore the paper and its implications.

If the findings are legitimate, then we should all reconsider our teaching priorities and practices.

In this pragmatic RCT of patients with a recent hospitalization for CHD, the NNT to prevent one death at 10 years is 5 for repeated case-based teaching (realistic cases, based on evidence and integrating issues of ethics, social and economic aspects, and valuing the pros and cons of different options) versus usual care (passive guidelines diffusion, available lectures). The authors mentioned the cases were based on local guidelines released after the publication of the 4S trial of simvastatin for secondary prevention.

Wow! NNT of 5 for death at 10yrs. What else is as powerful as that? 

....Or, on the flip-side, are the results too good to be true? A NNT of 5 far exceeds the NNT for statins for secondary prevention. In 4S, the NNT was 29 to prevent 1 death at 5 years. In LIPID, the NNT was 33 to prevent death at 6 years.

On the one hand, I truly applaud the authors for their vigor in undertaking an analysis of EB-case-based teaching with follow-up for 10 years for the ultimate outcome of interest (all-cause mortality). On the other hand, we need to understand more about whether this large effect size is plausible. And/or, what else might have affected the results.

One thing is certain, we should explore further with the authors on what the cases entailed (perhaps the multiple recommendations could have additively or synergistically resulted in NNT of 5 over a 10y period??). Perhaps most importantly, we should even dare to do similar studies to confirm or refute the findings. 

Many thanks for circulating the paper,

Janet

---------------------
Dr. Janet Martin, PharmD, MSc (HTA&M)
Director, High Impact Technology Evaluation Centre (HiTEC)
Director, Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR)
London Health Science Centre & St. Josephs Health Centre London
Assistant Professor, Department of Anesthesia & Perioperative Medicine
University of Western Ontario
Room B7-200, 339 Windermere Rd
London, Ontario
Canada N5Y 5M3

Tel: 519-685-8500 ext 34482
Fax: 519-663-3031
Email: [log in to unmask]



Sent from wireless handheld device. 
-----Original Message-----
From: carl heneghan <[log in to unmask]>
To: heneghan, carl <[log in to unmask]>
To:  <[log in to unmask]>

Sent: 6/21/2011 4:33:08 AM
Subject: evidence-based training

Dear all

 I thought you'd be interested in this imprtant randomized controlled trial
finding for the rationale for EBM training published in this months edition
of Family Medicine

Case-Based Training of Evidence-Based Clinical Practice in Primary Care and
Decreased Mortality in Patients With Coronary Heart Disease

Anna Kiessling, Moira Lewitt, Peter Henriksson,
Ann Fam Med 2011;9:211-218. doi:10.1370/afm.1248

PURPOSE We investigated the 10-year mortality rates in a trial that tested a
casebased
intervention in primary care aimed at reducing the gap between evidencebased
goals and clinical practice in patients with coronary heart disease (CHD).
METHODS A prospective randomized controlled pragmatic trial was undertaken
in a primary care setting. New evidence-based guidelines, with intensifi ed
lipidlowering
recommendations in CHD, were mailed to all general practitioners in
the region and presented at a lecture in 1995. General practitioners (n =
54) and
patients with CHD (n = 88) were assigned according to their primary health
care
center to 2 balanced groups and randomly allocated to usual care as a
control
or to an active intervention. General practitioners in the intervention
group participated
in repeated case-based training during a 2-year period. Patients whose
CHD was treated by specialists (n = 167) served as an internal specialist
comparison
group. Altogether, 255 consecutive patients were included. Cox regression
analysis was used to detect any survival benefi t of the intervention.
RESULTS At 10 years, 22% of the patients in the intervention group had died
as
compared with 44% in the control group (P = .02), with a hazard ratio of
0.45
(95% confi dence interval, 0.20-0.95). This difference was mainly due to
reduced
cardiovascular mortality in the intervention group (P = .01). In addition,
the mortality
rate of 22% in the intervention group was comparable to the rate of 23%
seen in patients treated by a specialist.
CONCLUSIONS Use of case-based training to implement evidence-based practice
in primary care was associated with decreased mortality at 10 years in
patients
with CHD.

Ann Fam Med 2011;9:211-218. doi:10.1370/afm.1248.
http://www.annfammed.org/cgi/reprint/9/3/211.pdf

Cheers Carl
-- 
Dr Carl Heneghan MA, MRCGP DPhil
Director Centre for Evidence-Based Medicine, University of Oxford

-- 
Dr Carl Heneghan MA, MRCGP DPhil
Director Centre for Evidence-Based Medicine, University of Oxford

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