ebm rounds jgh_29_nov2012

"There is nothing like looking, if you want to find something" - asking questions and searching for

answers - the evidence based approach

JGH Psychiatry Rounds 29 Nov 2012Contacts: jill.boruff@mcgill.ca

tconstantinescu@jgh.mcgill.ca

Jill Boruff, Assistant Librarian, McGill UniversityTeodora Constantinescu, Librarian, JGH

Ashley Wazana, MD, JGH

DISCLAIMER

• Haroon M, Phillips R. "There is nothing like looking, if you want to find something" - asking questions and searching for answers - the evidence based approach. Arch Dis Child Educ Pract Ed. 2010 Apr;95(2):34-9. PubMed PMID: 20351149.

• “There is nothing like looking, if you want to find something. You certainly usually find something, if you look, but it is not always quite the something you were after.” J.R.R. Tolkien, The Hobbit

OBJECTIVES

• To structure the clinical question for finding relevant answers

• To select the appropriate information sources

• To know the tools for supporting the practice of EBM in clinical settings

OUTLINE

• Introduction

• Background

• Structuring the Clinical Question & EBM Information Sources

• Information on Mobile Devices

• Discussion

WHY TODAY’S PRESENTATION (1)

CanMeds Objectives: Medical Expert 2. Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice; 2.4. Contribute to the enhancement of quality care and patient safety in their practice, integrating the best available evidence and best practices

JGH : • 2010: EBM 1-Awareness and survey in Child Psych • 2011: EBM 2-Reflections after one year Journal Club in Child Psych

McGill - Centralized teaching:• Sep 2011: Intro to EBM R1• Sep 2012: Intro to EBM R1 (6 hours) • Jan 2013 : EBM R2 (6 hours)

Psychiatry Residency Curriculum Committee:• Need to sustain EBM in clinical settings • McGill teaching hospitals (knowledge, skills, support)

To develop a more reflective, research based practice: • EBM Educational activities at JGH Psychiatry:• Child Psychiatry Research based presentations• Psychiatry Nursing EBM skills building workshops• Skills building workshops for OTs• Residents’ Journal Club

• A successful start in EBP depends on the ability to formulate a clear clinical question

Evidence Based Practice

BRIEF BACKGROUND

PRINCIPLES OF EVIDENCE BASED PRACTICE

1. Practice should be based on best evidence*

2. There is a hierarchy of evidence

3. Evidence alone is not enough

• Clinical expertise

• Patient preferences

Archie Cochrane, CBE FRCP FFCM, (1909 - 1988)

*“Effectiveness and Efficiency: Random Reflections on Health Services” (1972) Source: Cardiff University Library, Cochrane Archive, University Hospital Llandough.

LIMITS OF EBM

• Research related – Sampling, bias, ethics, etc.– Evidence (from non-biomedical sciences)– Many clinical questions have not been researched

• Translating efficacy studies into clinical effectiveness

• Tool related – Evidence based summaries relatively few– Access – Technological changes

• Implementation - Knowledge, Skills, Training- Organizational support and mandate - Time

HIERARCHY OF EVIDENCE

Question Best Evidence

Cost •Cost-effectiveness study

Diagnosis •Diagnostic validation studies•Prospective studies / blind comparison to a gold standard

Etiology/Harm •Cohort study•Case control study

Prognosis •Cohort study•Case control study

Quality of life •Qualitative studiesTherapy •Systematic review of Randomized

Controlled Trials (RCTs)•Single RCT

1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/

EVIDENCE BASED PRACTICE (EBP) – 5 Steps

PATIENT CENTERED

OUTLINE

• Introduction

• Background

• Structuring the Clinical Question & EBM Information Sources

• Information on Mobile Devices

• Discussion

Clinical Scenarios

THE QUESTION & EBM INFORMATION SOURCES

Guyatt G, Rennie D, Cook D. Users' Guides to the Medical Literature : A Manual for Evidence-Based Clinical Practice (2nd Edition). New York, NY, USA: McGraw-Hill Professional Publishing; 2008.

What are the atypical antipsychotic drugs?

Are cognitive-behavioural parenting interventions effective in reducing early-onset child conduct disorder?

(Problem solving)

WHAT IS THE QUESTION ?

BACKGROUND QUESTIONS – INFORMATION SOURCES

Patient Scenario #1

“Ms X is a 34 year old woman brought by her friend for increasing binging and purging behaviors. Patient is diagnosed with bulimia nervosa. She is reluctant to take medication and does not believe in psychotherapy. She is has mixed feelings regarding her eating behaviors and any form of treatment and is afraid to relinquish control. There is no imminent risk. You consider recommending self-help programs as an initial treatment.

Background questions

What is standard treatment for bulimia nervosa?

Others?

Residents and other students might have more (or simple) background questions than you

Patient Scenario #1

“Ms X is a 34 year old woman brought by her friend for increasing binging and purging behaviors. Patient is diagnosed with bulimia nervosa. She is reluctant to take medication and does not believe in psychotherapy. She is has mixed feelings regarding her eating behaviors and any form of treatment and is afraid to relinquish control. There is no imminent risk. You consider recommending self-help programs as an initial treatment.

Figuring out your question with PICO

Patient, population, or problem

Intervention, prognostic factor, or exposure

Comparison or intervention

Outcomes to measure or be achieved

Figuring out your foreground question with PICO

P: Female with bulimia nervosa

I: Self-help program

C: Psychotherapy

O: Improvement of binging and purging behaviours

C: Medication

C: Medication with psychotherapy

Writing a clinical question

In patients with bulimia nervosa, is self-help treatment as effective as psychotherapy in reduction of symptoms?

Systematic Reviews

Randomized Controlled

Trials

Randomized Controlled

Trials

Case-Control studies

Cohort StudiesCohort Studies

Case Reports

Contained in databases like

PubMedPsycInfoEMBASE

Searching the evidence

Question Best Evidence

Cost •Cost-effectiveness study

Diagnosis •Diagnostic validation studies•Prospective studies / blind comparison to a gold standard

Etiology/Harm •Cohort study•Case control study

Prognosis •Cohort study•Case control study

Quality of life •Qualitative studiesTherapy •Systematic review of Randomized Controlled

Trials (RCTs)•Single RCT

1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/

FilteredFiltered

} includes:

• Cochrane Database of Systematic Reviews

• DARE (Database of Abstracts of Reviews of Effects)

Information Sources: some examples

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UnfilteredUnfiltered

Expert Opinion

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Expert Opinion

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Patient Scenario #2

• Mr M, 22 yr old, presents with 3 weeks history of ↓ concentration, ↓sleep and poor appetite, agitation, severely depressed mood, feeling hopeless and with thoughts of suicide. He also feels people might be laughing at him on the street. He has a 3 yrs history of marijuana and cocaine use. Inquiry about family history reveals that maternal aunt “was not well” and was known to have “ups and downs” and had been apparently treated with lithium or ECT (?).

• Clinically, what are the risk factors that predict bipolar disorder when a patient presents with first episode of depression?

Background Questions

What is the prognosis of major depression?

What are the risk factors for bipolar I and II ?

Differential diagnosis: manic, mixed, hypomanic episodes?

Figuring out your question with PICO

Patient, population, or problem

Intervention, prognostic / risk factor, or exposure

Comparison or intervention

Outcomes to measure or be achieved

Type of Question / Ideal Type of Study

P : major depression, 22 yr , co-morbid substance abuse

I : predictors

C : none

O : bipolar disorder (conversion)

T : Risk factors studies: Cohort Studies > Case Control > Case Series/Case Report

Writing a clinical question

•In a 22 year old male presenting with first episode (major) depression with co-morbid substance abuse (P) does …..[psychotic episode] [aunt with BD]….. (I) predict conversion to bipolar disorder (O) ?

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CLINICAL EVIDENCE (BMJ) : •Evidence based summaries (by disorder)•Background •Evidence for effectiveness of interventions (GRADE)*•Guidelines •Patient information (UK)

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Expert Opinion

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Scenario #2 : Search in PubMed Clinical Queries or TRIP

Search : depression conversion bipolar risk factors

Gilman SE, Dupuy JM, Perlis RH. Risks for the transition from major depressive disorder to bipolar disorder in the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2012 Jun;73(6):829-36. Epub 2012 Feb 21. PubMed PMID: 22394428.

Question #3

• Is insight a mediator of change in dynamic psychotherapy?

P : patient in psychodynamic therapy I : insight (mediator)C : noneO : improvement (measurement on a

scale)T : effectiveness studies, (longitudinal,

follow-up studies, comparative outcome studies)

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Information Sources: Individual studiesPubMed, PsycINFO

Information Sources: some examplesIndividual studies

PsycINFO: - Behavioral sciences literature- Over 3 million records/citations- Own vocabulary

- E.g. Insight (Psychotherapeutic Process) = index term

PubMed: - Biomedical literature - Over 22 million records/citations- Biomedical Vocabulary (Medical subject headings MeSH)

- E.g. Insight = not an index term (non-MeSH) > search as keyword

- e.g. Search: insight psychodynamic therapy

Scenario #3 : PubMed

Search : insight psychodynamic psychotherapy

Johansson P, Høglend P, Ulberg R, Amlo S, Marble A, Bøgwald KP, Sørbye O, Sjaastad MC, Heyerdahl O. The mediating role of insight for long-term improvements in psychodynamic therapy. J Consult Clin Psychol. 2010 Jun;78(3):438-48.

PubMed PMID: 20515219.

Searching for Individual Studies (“Nuts and Bolts”)

• Identify concepts• Identify information resources to search in • Choose appropriate search terms

– Subject headings (standardized index terms) and/or

– Keywords • Search databases and apply :

– Boolean operators– Truncation, adjacency– Limits: research methodology, population,

language, type of publication etc.

Question #4

• Do antipsychotics work on the core symptoms of delirium, or do they just work as sedatives (for agitation) and to treat psychosis in delirium?

P: patients with delirium I : antipsychotics C : none O : core symptoms of delirium (disorientation,

fluctuating levels of consciousness, sleep wake cycle

disturbance)T : outcome studies

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Information Sources: Individual studies EMBASE

Embase is an international biomedical and pharmacological database, especially strong in its coverage of drug and pharmaceutical research from 1947 to present day. Over 27 million records: covers all MEDLINE citation and 5 million non-Medline.

EMBASE

SUMMARY: Searching

Determined by: • Purpose of your search

– Clinical decision making vs.– Literature review

• Importance of your question – Does patient’s well being depend on this answer? – Does question appear often in practice or not?

• Background knowledge of the searcher• Time you have

SUMMARY : Asking structured unambiguous questions

• To clarify need : – what you know, what you do not know – what you REALLY need to know

• To locate evidence :– Choice of information source – Identify search terms

• To keep search on track

In CONCLUSION

• You own the question and the answer !

• If you have spent 15 minutes and haven’t found the answer, ask a librarian!

OUTLINE

• Introduction

• Background

• The Question & EBM Information Sources

• Mobile Devices

• Discussion

MOBILE DEVICES

Some technical information

Mobile-optimized sites versus regular web pages.

Downloadable applications versus web pages

Setting up VPN—not always necessary

Tour of the mobile subject guide

m.library.mcgill.ca/healthsciguide/

CONCLUSION: Support for EBM in Practice

Frameworks: • EBP Process (5 steps)• PICO framework (question) • Evidence Pyramid

EBM Resources (website) :• Dr Henry Kravitz Psychiatry Website http://www.jgh.ca/en/icfplibrary• Clinical Decision Making (Evidence Based Practice)

http://www.jgh.ca/en/icfpebmresources• Using Mobile Devices to Access McGill Resources

http://www.jgh.ca/en/icfp-use-mobile-devices

Handouts (JGH):FindingGoodAnswers_Psychiatry.docEBM resources summary Psychiatry 2012.doc

DISCUSSION: How do we support EBM at JGH?

Some suggestions: • Start with a clear clinical question• Search for an evidence based answer • Engage the whole team in the EBM problem

solving– Nurses, OTs, psychologists, students, librarian

• Use the EBM tools: – ICFP Website: http://www.jgh.ca/en/icfplibrary

QUESTIONS?

tconstantinescu@jgh.mcgill.caJill.boruff@mcgill.ca

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