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EBM for KSOM Powered By Docstoc
					Evidence-Based Medicine
   Pamela Corley, MLS, AHIP
   Eileen Eandi, MLS
   Adrian Follette, MLIS
   Evans Whitaker, MD, MLIS
   Norris Medical Library
   2003 Zonal Ave.
   Los Angeles, CA 90089-9130
Introductions and Business
     Introduction to Library Personnel
     Fill out evaluation forms at the end of the session.
      We value the feedback…we use it to improve over
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      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
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
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
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
           Three interacting realms of EBM
                              Best available clinical evidence

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

          Patient needs,
                                                                 Clinician experience
         desires, resources

                   Patient-Doctor Dyad – Not really changed through time
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 search
2.       Perform search
3.       Assess search results
     •     relevance (does it apply to my patient?),
     •     validity (are the findings of the articles true?)
4.       Apply results
5.       Reassess patient

         You will see variations in the above depending on
         the author and the field in which they work
  Step-by-step EBM
               Scenario: Wintertime, yet another of your patients has
1. Formulate   come in for antibiotics for a common cold. Once again you
      search   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 EBM
                                 Identify: Shaken by this hostile encounter, you decide
1.     Formulate                 to review the literature of antibiotics for common cold.
                                 Define CQ: For healthy adult males with a 3-day
         (Part 2)                history of cold symptoms and purulent rhinorrhea, do
                                 antibiotics speed recovery and improve symptoms?

     Identify information need   Define SCQ: Do antibiotics effectively treat the
                                 common cold?

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

     Define searchable           Notice the confusing/overlapping naming:
         clinical question                •Common cold
         (SCQ)                            •Upper Respiratory Infection
                                          •Purulent rhinitis
     Identify concepts within             •Acute rhinosinusitis
         SCQ to use as           Do you OR them all together?
         search concepts
2. Search
   The traditional emphasis of information
    literacy instruction for health sciences
   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 (
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
   Link to original Greenhalgh articles in Student
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

Evidence Pyramid
                                                       The best
                                                       also is the

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.
Assists 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

                                                                                         Best Single
                                                                                      MEDLINE Search
Question                  Intervention/                    Feasible      Suitable
            Population                      Outcome                                        Term for
   type                     Exposure                        Study       Databases
                                                                                     Appropriate Study
Diagnosis In patients What is the        For detecting Cross            Best         Sensitivity as a
            with lung     test           mediastinal      sectional     Evidence, MeSH or key or title
            cancer        performance metastatic          analytical    UpToDate, word
                          of CT scan     disease          study         MEDLINE
Treatment In patients Does a target Lower risk of         RCT or        Cochrane, Meta-analysis or
            with HTN      BP of 80       stroke, MI,      systematic Best            Clinical trial or
            and DMII      compared to cardiovascular review of          Evidence, Randomized
                          a DBP target death, and all- RCTs             UpToDate, Control Trial as
                          of 90          cause                          MEDLINE “publication types”
Prognosis In young        Sent home      Suffer           Cohort        Best         Explode cohort
            men with      from the ER, appreciable        study         Evidence, studies as MeSH
            atypical      in the next    rates of                       UpToDate, term
            chest pain 72 hours          unstable                       MEDLINE
                                         angina, heart
                                         failure or
                                         arrhythmia, MI
                                         or sudden
Harm        In men        Does           Cause            Cohort        Best         “Risk” as MeSH or
                          vasectomy      testicular       study,        Evidence, as title or keyword
                                         cancer           population- UpToDate,
                                                          based         MEDLINE
                                                          control trial
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)
 (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
 (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., 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

   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…
1.   Excellent
2.   Good
3.   So-so
4.   Could be better
5.   I am uninformed
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