selecting the best evidence-based medicine resources
DESCRIPTION
Selecting the Best Evidence-Based Medicine Resources. Daniel J. Van Durme, MD Chairman, Dept. Family Medicine and Rural Health Nancy Clark, MEd Director of Medical Informatics Education. Objectives. What is EBM? Formulate a clinical question - PowerPoint PPT PresentationTRANSCRIPT
FSU College of Medicine 1
Selecting the Best Evidence-Based Medicine Resources
Daniel J. Van Durme, MDChairman, Dept. Family Medicine and Rural Health
Nancy Clark, MEdDirector of Medical Informatics Education
FSU College of Medicine 2
Objectives What is EBM? Formulate a clinical question Apply levels of evidence to decision making
process including patient concerns What are the major EBM databases Search for evidence based information
Using EBM hunting tools
FSU College of Medicine 3
Handouts and Resources EBM Tutorial online
www.med.fsu.edu/informatics/EBMTutorial.asp EBM Resources handout Clinical Question Worksheet Cases Slawson article on EBM
New Resource EBM Teaching Materials
FSU College of Medicine 4
FSU College of Medicine 5
What is EBM? Evidence based medicine (EBM) was
originally defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
(Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS.
Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-2)
6
What is EBM? The revised and improved definition of evidence-
based medicine is “the integration of the best research evidence with clinical expertise and patient values”
It reflects a systematic approach to clinical problem solving.
(Sackett DL, Strauss SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2nd Ed. London: Churchill-Livingstone,2000)
7
What EBM skills do all practicing clinicians really need? Among other skills:
Information mastery: finding the best evidence for every day practice
Have at fingertips “just in time’ information at point of care for clinical decision making web based and/or PDA
Evaluate expert-based information, including colleagues, CME, presentations, reviews and guidelines
Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med. 2005 Jul;80(7):685-9.
FSU College of Medicine 8
Advanced EBM SkillsOnly a small percentage of clinicians need to be able to do the
following Critical Appraisal and Interpretation of Research on:
Therapies, Diagnostic Tests, Prognosis Critical Evaluation and Interpretation of:
Systematic Reviews, Including Meta-analysis, Decision Analysis, Practice Guidelines, Pharmaceutical Advertising, Including Pharmaceutical Representatives
Assigning Levels of Evidence to Research Findings Teaching Level 1 Skills Produce written Communication of Research Findings
Physicians Patients (Slawson, et al)
FSU College of Medicine 9
Lifelong Learning Old method: read a few journal articles per
week Reality: Primary care docs would need over
17 hrs/day just to review reasonable and pertinent material
Even in one narrow specialty would need 6+hrs/wk Practicing docs (all specialties) average 1-1.5
hrs/wk
Lifelong Learning from Day to Day Encounters
Reading the articles that happen to cross the desk does not help MY PATIENTS TODAY
Finding evidence based optimal care for my patients today helps them AND helps me to stay current in my field and be an efficient and effective lifelong learner
FSU College of Medicine 10
FSU College of Medicine 11
The EBM Process
“The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning in which caring for one's own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues.”(Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship education. Am J Med. 1997 May;102(5):427-32.)
FSU College of Medicine 12
The EBM ProcessThe patient 1. Start with the patient -- a clinical problem or question
arises out of the care of the patient
The question 2. Construct a well built clinical question derived from the case
The resource 3. Select the appropriate resource(s) and conduct a search
The evaluation 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)
The patient 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice
Self-evaluation 6. Evaluate your performance with this patient
FSU College of Medicine 13
Constructing A Clinical QuestionP
patient
I intervention
C comparison
O outcome
Who? What?Alternative
Intervention?Outcomes
“How would I describe a group of patients similar to this particular patient?”
”Which treatment, test or other intervention?”
“Compared to what other treatment, test, or perhaps compared to doing nothing”
What is the patient oriented outcome – better prognosis? Higher rate of cure? Etc.?”
FSU College of Medicine 14
ExamplesP I C O
Kids with acute otitis media -2-4 y/o
AntibioticsNo treatment except
acetaminophen for pain/fever
No pain after two days?
Adult with microhematuria
IVP CT scanDiagnostic accuracy (Predictive value or
likelihood ratio)
Adult patients <70 TIA No TIARates of CVA within 90 days
Healthy adolescentsRoutine
scoliosis screen
No screening – evaluate only if problems
Pain, disability, need for intervention
FSU College of Medicine 15
Types of Questions Best Answered by EBM Resource Therapy Question
In patients with migraine headaches without auras, is Depakote more effective than Inderal for prophylaxis of headaches?
Prognosis Question In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis
with MRI as predictive of healing as an audible pulse on Doppler examination?
Diagnosis Question In geriatric patients with suspected carotid stenosis, is duplex
ultrasound as good as magnetic resonance angiography in detecting significant carotid stenosis?
Harm Question For pregnant patients, does the consumption of large amounts of
coffee, (compared to non-coffee drinkers) increase the rate of spontaneous abortion?
FSU College of Medicine 16
Question Worksheet P - Who? I - What? C- Alternatively? Outcome?
Type of Question Therapy Prognosis Diagnosis Harm/Etiology
Using the worksheet provided, construct a Using the worksheet provided, construct a clinical question from your own practice.clinical question from your own practice.
Assessing Validity Definitions
Level of Evidence (LOE): usually one study Strength of Recommendation (SOR):
recommendation based on multiple studies A value of the confidence in the
recommendation based on the quality of research
Assigned by experts using specific criteria17
Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. Feb 1 2004;69(3):548-556.
FSU College of Medicine 18
Levels of Evidence
Level 1: Systematic Review (with meta-analysis) of Randomized Clinical Trials
Level 2: Cohort Studies Level 3: Case-Control Studies Level 4: Case-series Level 5: Expert Opinion
Centre for Evidence-Based Medicine, Oxford
FSU College of Medicine 19
Strength of Recommendation Taxonomy
A: There is good research-based evidence to support the recommendation.
B: There is fair research-based evidence to support the recommendation.
C: The recommendation is based on expert opinion and panel consensus.
X: There is evidence of harm from this intervention.
FSU College of Medicine 20
Bottom Line on LOE or SOR Level 1 A Highest level Level 2 Level 3 B Level 4 Level 5 C Lowest Level
But still evidence
FSU College of Medicine 21
Evidence Based Medicine Databases (Foraging Tools)
People who do the heavy lifting for you.
22
EBM Foraging ToolsA high-quality foraging tool employs a
transparent process that Systematically searches and reviews literature Identify useful, valuable, “quality” research Synthesizes into “bottom line” recommendation
Patient oriented outcomes (POEM); not disease-oriented outcomes (DOE)
Assign level of evidence How to apply recommendations?(Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be
teaching information management instead? Acad Med. Jul 2005;80(7):685-689.)
FSU College of Medicine 23
Major EBM Databases (Foraging Tools) Cochrane Clinical Evidence DARE ACP Journal Club InfoPOEMS Evidence Based _____ USPSTF National Guidelines
Clearinghouse
FSU College of Medicine 24
Cochrane LibraryCochrane Library
The current resource with the highest methodological rigor
For each clinical question, all of the English literature meticulously searched for randomized trials
Large systematic reviews with valid methods + collaborative effort by Review Groups
Conclusions are based on all the evidence from valid randomized trials (treatment and harm questions)
FSU College of Medicine 25
Cochrane Library
Full text at Cochrane Library at Wiley Abstracts in InfoRetriever Limitations
limited to English only addresses questions amenable to
randomized trials most of medicine has not been studied
enough to allow for conclusions $235/year or abstracts only free
www.cochrane.org
26
FSU College of Medicine 27
ACP Journal Club About 140 internal medicine journals systematically
surveyed Highest-validity articles abstracted Structured abstracts to guide critical appraisal Clinical commentary Web site acpjc.org Also published in Annals of IM Alerts available
FSU College of Medicine 28
ACP Journal Club Limitations
Limited pediatrics individual article summaries may not account for the “big
picture” may have to read multiple items No “control” over what is covered $78/year ?
29
FSU College of Medicine 31
InfoPOEMS Patient Oriented Evidence that Matters Journal of Family Practice and other specialty journals Systematic surveillance of 100 journals Reviews of recent research articles Effect patient concerns – morbidity, mortality, quality of
life Included in Essential Evidence Plus (formerly InfoRetriever)
Daily e-mail updates available
POEMS
32
Evidence Based Practice Summaries: structured search, critical
appraisal, authoritative recommendations, clinical perspective, and rigorous peer review
FPIN.org – Family Physicians Inquiries Network
Appear in PEPID
FSU College of Medicine 33
FSU College of Medicine 34
FSU College of Medicine 35
Guidelines.gov Stored at National Guidelines Clearinghouse Agency for Healthcare Research and Quality 1600 Guidelines may be
Explicit evidence-based Evidence-based Research-based (highly referenced) “expert consensus”
Multiple guidelines on one condition
FSU College of Medicine 36
US Preventive Services Task Force First convened by the U.S. Public Health Service in 1984 Since 1998 Agency for Healthcare Research and Quality Leading independent panel of private-sector experts in
prevention and primary care Conducts rigorous, impartial assessments of the scientific
evidence for effectiveness of broad range of clinical preventive services, including screening, counseling, and preventive medications
Its recommendations considered "gold standard" for clinical preventive services
FSU College of Medicine 37
USPSTF Tool Free PDA and online tool (ePSS) Enter age, gender Get recommendations Filter level of recommendations http://epss.ahrq.gov/PDA/
FSU College of Medicine 38
Hunting Tools
Most Bang for Your Buck
39
Drilling Down for Information
Grandage KK, Slawson DC, Shaughnessy AF. When less is more: a practical approach to searching for evidence-based answers. J Med Libr Assoc. 2002 Jul;90(3):298-304.
FSU College of Medicine 40
EBM Hunting ToolsA high-quality Hunting tool employs a transparent
process that Searches multiple EBM databases (several
foraging tools) Organizes results to make them easy to find Provides levels of evidence (Slawson, et al)
FSU College of Medicine 41
EBM Pyramid
5, C
MEDLINE
InfoRetrieverDynaMed
Major EBM Hunting Tools
Tools Cochrane ACP Journal
Club
Guide-lines
US-PSTF
LOE
Essential Evidence + Dynamed Clinical Evidence ACP Pier (Web only) PEPID
FSU College of Medicine 42
Web
an
d P
DA
Summaries
Summaries
Summaries
FSU College of Medicine 43
Clinical Evidence Includes >250 conditions Summaries of evidence Specific clinical questions: treatment and prevention Makes specific recommendations States when there is a lack of evidence Book Free from United Health Foundation Web and PDA versions available
FSU College of Medicine 44
Clinical Evidence
Do Clinical Evidence Case
FSU College of Medicine 45
FSU College of Medicine 46
Essential Evidence Plus (EE+) POEMS -- JFP
>104 journals surveyed Over 3500 article synopses Link out to PubMed
Cochrane abstracts Selected evidence-based guidelines Basic drug info Clinical calculators/prediction rules
New Content Essential Evidence summaries
Organized like disease quick reference Bottom Line at top Links to InfoPOEMs, Cochranes Links to calculators and algorythms, images Uses SORT for level of evidence
FSU College of Medicine 47
FSU College of Medicine 48
EE+ Features Essential Evidence (replaces 5MCC) EBM Guidelines Pearls –PDA; Favorites on Desktop Levels of Evidence explained ICD-9 and E/M coding tools Immunization Guide USPSTF Guidelines Derm Expert
FSU College of Medicine 49
Symbols
New 8/09
FSU College of Medicine 50
Essential Evidence Plus Comes in web, desktop and PDA versions Daily POEMS are available in mp3 podcast version Limitations
individual article summaries may not account for the “big picture”
may have to read multiple items $79/year
Do EE+ Case
FSU College of Medicine 51
PEPID FPIN summaries included in CRC module Drug and disease reference, interaction tool Clinical rotation aids for students with basic
principles Lab manual, calculators, images Compares favorably with Epocrates, 5MCC PDA and Online $199 for individual subscription
FSU College of Medicine 52
Using PEPID
FSU College of Medicine 53
Links to Evidence Based Summaries
FSU College of Medicine 54
FSU College of Medicine 55
DynaMed
Designed as entry point to information Textbooks and Medline not efficient Intuitive clinical organization Brief summarized information presented Links out to articles and reviews if more
details needed ICD-9 codes and links to patient information
handouts
FSU College of Medicine 56
DynaMed Sources
Systematic surveillance of 18 primary journals – e.g. BMJ, JAMA, Lancet, NEJM, Pediatrics
12 major EBM resources – e.g. ACP Journal Club, Cochrane Library, InfoPOEMs, Alternative Therapies,
4 drug info sources – e.g. The Medical Letter, FDA MedWatch
57
DynaMed Organization of Results Description (including ICD-9
Codes) Description, Also called,
ICD-9 Codes, Types, Organs Involved, Who Is Most Affected, Incidence/Prevalence
Causes and Risk Factors Causes, Pathogenesis,
Likely risk factors, Possible risk factors
Complications and Associated Conditions
History CC, HPI, Meds, PMH, FH,
SH, ROS Physical
Skin, HEENT, Neck, Extremities, Neuro, Pelvic
Diagnosis Making the diagnosis, Rule
out, Tests to order, Blood tests, Urine studies, Imaging studies, Pathology tests, Other diagnostic testing
Prognosis Treatment
Treatment Overview, Diet, Activity, Counseling, Medications, Surgery, Consultation and referral, Other management, Follow-up
Prevention and Screening References (including Reviews
and Guidelines) Patient Information
FSU College of Medicine 58
DynaMed Limitations
variable quality if not Cochrane or review areas with a lot of research can get hard to
navigate. Lot of information-slower to wade through
Hard to navigate on PDA $200/year or effort
Do DynaMed Case
Use CTRL-F to Find words in articles
FSU College of Medicine 59
ACP PIER PIER: The Physicians' Information and Education
Resource. Available online at ACP and PDA ($69/yr) Modules on Disease, Screening and prevention,
complementary medicine, procedures, quality measures and drug resource (Clinical Pharmacology)
Provide A-B-C levels of evidence Excellent Tables summarize recommendations
FSU College of Medicine 60
Do ACP PIER Case
FSU College of Medicine 61
FSU College of Medicine 62
Searching All Resources at Once
WebFeatIn development,
but getting better all the time.Web Only
SummaryNeed Resource
Treatment of common diagnosis Clinical Evidence
Need to create a presentation on a topic DynaMed
Answers to clinical questions, use a clinical decision support calculator, ICD-9 code
Essential Evidence Plus
Tabular summaries of diagnoses, treatment, and follow-up of chronic or acute illness
ACP PIER
Broad and basic overview for med students organized by rotation
PEPID63
CTRL-F
FSU College of Medicine 64
Find the Answer to Your Question
Group exercise