Evidence-Based Medicine For KSOM Y2

Pamela Corley, MLS, AHIPEileen Eandi, MLSAdrian Follette, MLISEvans Whitaker, MD, MLISNorris Medical Library2003 Zonal Ave.Los Angeles, CA 90089-9130

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We will post the materials for this class to Norris Library website (path to materials is Key resources for: Students Medical Year 2)

Get a “clicker” and two handouts Additional Resources, Evaluation

Outline for today

1. EBM Background

2. EBM Resources

3. Practice with Resources

I use MeSH terms when searching MEDLINE…1. Always

2. Usually

3. Sometimes

4. Occasionally

5. Never

When searching for information related to clinical care, the first place I look is…1. Cochrane database

2. MEDLINE

3. UpToDate

4. Google (Scholar)

5. Other

My understanding of EBM is…1. Excellent

2. Good

3. So-so

4. Could be better

5. I am uninformed

Are you comfortable searching for information in UpToDate?1. Yes

2. No

What is Evidence Based Medicine?

EBM process… begins and ends with the patient weighs three factors to assist with medical

decision making Best available clinical evidence Experience of individual clinician Patient needs/desires/resources

the evidence factor receives the attention,

the other factors are relatively ignored

Best available clinical evidence

Clinician experiencePatient needs,

desires, resources

Patient-Doctor Dyad – Not really changed through time

The point at which effecting Doctor-Patient communication and planning is informed by the best evidence

Three interacting realms of EBM

Definitions of EBM

Vary… EBM is “the conscientious, explicit, and judicious use of current

best evidence in making decisions about the care of individual patients” -- (Sackett, Rosenberg, and Gray, 1996)

“Evidence-based medicine is the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision making in the diagnosis, investigation or management of individual patients.” — (Greenhalgh, 2006)

“EBM encourages a healthy skepticism of every practice in medicine and promotes a culture of inquiry.” -- (Sloane, P.D., Slatt, L.M., Ebell, M.H., Jacques, L.B., Smith, M.A. (2008). Essentials of Family Medicine (5th ed.). Philadelphia : Wolters, pp. 40).

Stages of EBM Process

1. Formulate search2. Perform search3. Assess search results

• relevance (does it apply to my patient?), • validity (are the findings of the articles true?)

4. Apply results5. Reassess patient

You will see variations in the above depending on the author and the field in which they work

Step-by-step EBM1. Formulate search

Scenario: Wintertime, yet another of your patients has come in for antibiotics for a common cold. Once again you have explained that he will get well on his own.

The 32 y.o. junior exec has been sick with a cold for 3 days. Symptoms are sore throat, cough, discolored nasal drainage, mild aching, and fatigue. He says he never gets well from these types of illnesses without antibiotics…

He resists putting on a gown or taking off his shirt for the exam. He took a call during your visit and is busy reading email on his Blackberry. You find the blue flashing from his ear distracting.

He stomps out when you explain you will not prescribe antibiotics at this point. He tells you he will not be back and that he is heading down the block to the walk-in clinic for his antibiotics.

What do you do at this point?

1. Shake it off and see you next patient.

2. Realize he might be right that he only gets well with antibiotics.

3. Call him back and give him antibiotics.

4. Review EB treatment of colds.

5. Rip his Bluetooth off his ear and stomp on it!

Step-by-step EBM1. Formulate

search (Part 2)

Identify information need

Define clinical question

Define searchable clinical question (SCQ)

Identify concepts within SCQ to use as search concepts

Identify: Shaken by this hostile encounter, you decide to review the literature of antibiotics for common cold.

Define CQ: For healthy adult males with a 3-day history of cold symptoms and purulent rhinorrhea, do antibiotics speed recovery and improve symptoms?

Define SCQ: Do antibiotics effectively treat the common cold?

Concepts: Common cold/URI/purulent rhinitis/acute rhinosinusitis, antibiotics, treatment outcomes.

Notice the confusing/overlapping naming:•Common cold•Upper Respiratory Infection•Purulent rhinitis•Acute rhinosinusitis

Do you OR them all together?

2. Search

The traditional emphasis of information literacy instruction for health sciences students

Good search skills insure you find what you want and not more or less…

Choose appropriate sources for your search – background vs. foreground question?

Search: Interlude 1

2. Search (cont.) Background Sources

ACP Pier Essential Evidence UpToDate Clinical Evidence text books

Foreground Sources Ovid MEDLINE PubMed@USC Ovid EBM Databases

Cochrane Database of Systematic Reviews ACP Journal Club, DARE (Database of Abstracts of Reviews of Evidence)

TRIP (tripdatabase.com)

3. Assess/Appraise Retrieved results are evaluated for relevance

and validity (“Critical appraisal”) As a non-epidemiologist/biostatistician I do

not pretend to be an expert on this piece Using model of Trisha Greenhalgh, MD

clinicians can make a first pass at assessment of a variety of study types which does not require extensive mathematics background

Link to original Greenhalgh articles in Student portal

4. Apply results…

…to your patient, while factoring in clinician experience and patient desires.

5. Reassess patient…

… after application of results. Observe effect of intervention, results of

diagnostic maneuver, etc. Reformulate EBM process if necessary

The Sacred Objects of EBM

• The Pyramid

• PICO

Evidence Pyramid

Source: http://library.downstate.edu/EBM2/2100.htm

The best evidence also is the least available!!

Evidence Pyramid

Systematic reviews, meta analyses, and randomized control trials minimize researcher bias (see handout).

Many topics in medicine do not have research evidence in the top pyramid layers.

A clinician is forced to “make do” with the best available information.

At times you must operate with little high-quality research-based information.

PICOAssists formulation of the clinical question.

Grown from the EBM movement of the last 15 years.

Common types of clinical questions: therapy, diagnosis, prognosis, harm

PICO works best for diagnosis and therapy, not as well for questions of prognosis and harm.

P Population, Patient, or Problem

I Intervention or Exposure

C Comparison (optional)

O Outcomes

Examples of EBM questions by question type

Question type

Population Intervention/

Exposure Outcome

Best Feasible

Study Design

Suitable Databases

Best Single MEDLINE Search

Term for Appropriate Study

Type Diagnosis In patients

with lung cancer

What is the test performance of CT scan

For detecting mediastinal metastatic disease

Cross sectional analytical study

Best Evidence, UpToDate, MEDLINE

Sensitivity as a MeSH or key or title word

Treatment In patients with HTN and DMII

Does a target BP of 80 compared to a DBP target of 90

Lower risk of stroke, MI, cardiovascular death, and all-cause mortality

RCT or systematic review of RCTs

Cochrane, Best Evidence, UpToDate, MEDLINE

Meta-analysis or Clinical trial or Randomized Control Trial as “publication types”

Prognosis In young men with atypical chest pain

Sent home from the ER, in the next 72 hours

Suffer appreciable rates of unstable angina, heart failure or arrhythmia, MI or sudden death

Cohort study

Best Evidence, UpToDate, MEDLINE

Explode cohort studies as MeSH term

Harm In men Does vasectomy

Cause testicular cancer

Cohort study, population- based case- control trial

Best Evidence, UpToDate, MEDLINE

“Risk” as MeSH or as title or keyword

Adapted from: Guyatt, G., Rennie, D. (eds.). 2002. User’s guides to the medical literature. NY: JAMA, p. 43.

Types of Clinical Questions

“Background” General information

about a disorder Book might be best

“Foreground” Specific knowledge

about a disorder Articles usually best

i.e., the type of clinical question determines the best resource to use

Back to previous slide

Problems in locating information Asking the right question

Think before you type Decide what really matters, remove extraneous details

Choosing the right information resource Match the tool to the job…

Avoid tendency to rely on a favorite resource (Google, UpToDate) -- journal articles or a book might be better for a particular question

With experience and practice skill levels improve markedly in both areas

EBM Specific Resources

Ovid EBM Reviews Cochrane Database of Systematic Reviews DARE (Database of Abstracts of Reviews of Effects) ACP Journal Club

Clinical Evidence (BMJ product) Guideline.gov (US government -- free) TRIP (Turning Research Into Practice) SUMSearch (Quirky, will not look at today)

PEDro (PT oriented) OTseeker (OT oriented)

Other General Resources Which Can Be Used For EBM Approach to Care

MEDLINE (Ovid or PubMed) Clinical Information Tools

UpToDate ACP Pier Essential Evidence Plus

Textbooks ACP Medicine Harrison’s (in Access Medicine) Access Medicine, Access Surgery

Tips with these sources

Keep searches simple This is all “key word” searching –

there is no mapping or translation function try synonyms

Hands-on Portion Clinical Evidence (BMJ product) – beta-blocker AND

MI – two aspects acute and secondary prevention Guideline.gov (free) – diagnosis of autism Ovid – ankle sprain

Cochrane Database of Systematic Reviews DARE (Database of Abstracts of Reviews of Effects) ACP Journal Club Use training account for class only.

URL:ovidsp.ovid.com, UN: sci001, PW: medical TRIP (Turning Research Into Practice) – breast

cancer, role of MRI in screening. SUMSearch –same as TRIP

Ovid EBM Databases

Cochrane Database of Systematic Reviews ACP Journal Club Database of Abstracts of Reviews of Evidence.

Use for assignment Use simple search strategies

Migraine Prophylaxis with Feverfew Cochrane Database of Systematic Reviews

search “migraine” search “feverfew” (can do as “migraine and feverfew” also) combine 1 and 2 may use the few available limits

ACP-JC to run same search, “Change database”, “ACP-JC”, “Open

and Re-Execute” DARE

Same as ACP-JC

What are these various sources good for? Quick clinical information - variably evidence-based

UpToDate, ACP Pier, Essential Evidence Quick EBM “textbook” – evidence-based but limited

number of topics Clinical Evidence

EBM Database – more time consuming but more extensive resources searched Cochrane DSR, ACP-JC, DARE

MEDLINE – most time consuming, huge resource, many different publication types, can filter results to emphasize EBM. See handout for filtering information.

Clinical Guidelines – guidelines draw conclusions from primary literature to advise doctors how to behave Guideline.gov

Summary

Evidence-based medicine is a formalized structure for finding and using information in the care of patients

There are a number of useful sources for EBM information

My understanding of EBM is…

0% 0% 0%0%0%

1. Excellent

2. Good

3. So-so

4. Could be better

5. I am uninformed

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