september 16, 2010 larissa j. lucas, md senior deputy editor, dynamed
TRANSCRIPT
September 16, 2010Larissa J. Lucas, MD
Senior Deputy Editor, DynaMed
DisclosureSenior Deputy Editor,
DynaMed, EBSCO Publishing, Ipswich, MAClinical Instructor in Medicine
Harvard Medical School, Boston, MA
Evidence Based Medicineconscientious, explicit, and judicious use of
current best evidence in making decisions about the care of individual patients
integrating individual clinical expertise with the best available external clinical evidence from systematic research
Sackett DL BMJ. 1996 Jan 13;312(7023):71-2
Clinical Expertise and Patient Preference
Haynes RB ACP J Club. 2002 Mar-Apr;136(2):A11-4.
Evidence Based Decision Making
Tilburt JC. J Eval Clin Pract. 2008 Oct;14(5):721-5
Why we need EBM toolsBarriers to answering clinical questions
Ebell MH. Am Fam Physician. 2009 Feb 15;79(4):293
TimeDoubtCultureAccess
Rising health care costsQuality of careIndustry sponsored studies (BMJ. 2007 Dec 8;335(7631):1202)
Answering clinical questions112 primary care
physicians3,511 visits with 635
questions22.8% questions were
investigated14% of questions
investigated not answered
time to answer questions 2 minutes during
consultation 32 minutes after
consultation
Ann Fam Med. 2007 Jul-Aug;5(4):345-52.
48 primary care physicians1,062 questions55% questions
investigateddoubt that answer
existed for 11% questions
resource failure in 26%41% of answers were
found easily31% found with difficulty
J Am Med Inform Assoc. 2005 Mar-Apr;12(2):217-24
How to ask a questionCochrane systematic
review4 trials
PICO training PubMed searching
training Information seeking
training Question formulation
training
Short-term benefitsImproved searching
timeImproved question
qualityImproved
satisfaction with searching
Increased correct answers
Cochrane Database Syst Rev. 2010 May 12;5:CD007335.
Existing toolsTextbooks and handbooksPubMedGuidelinesGoogleNews servicesSubscription online databases
Types of ToolsAlerting “foraging”
Prompts clinicians to ask questionsFiltered for relevance and validityTransparent evaluation and appraisal processEvidence ratingDifferentiate between “news” and practice
changing outcomesFinding “hunting”
Finding the answer to a clinical questionTransparent evidence rating criteriaTransparent reproducible methodologyEase of useEase of access
Relevance:Patient Oriented Outcomes
Symptoms Functioning Quality of Life Lifespan
Validity
ValidityUse of appropriate criteria for appraisal
Randomized trialsSystematic reviewsDiagnostic studiesPrognostic studies
Criteria include patient oriented outcomes
Highly Controlled ResearchRandomized Controlled TrialsSystematic Reviews
Physiologic ResearchPreliminary Clinical ResearchCase reportsObservational studies
Uncontrolled Observations
&Conjecture
Effect on Patient-Oriented OutcomesSymptoms (drivers license)Functioning (visual loss)Quality of Life (leg ulcers)Lifespan Effect on Disease MarkersDiabetes (Photocoagulation, GFR, NCV)Arthritis (x-ray, sed rate)Peptic Ulcer (endoscopic ulcer)Effect on Risk Factors for DiseaseImprovement in markers (blood pressure, HBA1C, cholesterol)
SORTA
Validity of Evidence
Re
leva
nce
of O
utc
om
eR
ele
vanc
e o
f Ou
tco
me
SORTB
SORTC
Adapted with permission from Slawson D. Evidence Based Medicine: Don’t We Need Information Management Instead?Evidence Based Medicine: Don’t We Need Information Management Instead?
Defining Evidence-Based for a Clinical ReferenceEvidence-Based = conclusions based on best available evidence
1. Systematically identifying all applicable evidence
2. Systematically selecting the best available evidence from that identified
3. Systematically evaluating the selected evidence (critical appraisal)
4. Objectively reporting the relevant findings and quality of the evidence
5. Synthesizing multiple evidence reports
6. Deriving overall conclusions and recommendations from the evidence synthesis
7. Changing the conclusions when new evidence alters the best available evidence
What clinicians needComprehensive
Valid
Systematic
Current
Synthesized
AccessDesktopMobileElectronic Health
Record