Intro to Evidence Based Medicine Resources

Intro to Evidence Based Medicine Resources Nancy Clark FSU College of Medicine 4/11/2008 EBM Resources 1 Objectives • Students will – Formulate a clinical question – Identify and utilize EBM online resources to answer their questions • EBM Databases • Guidelines – Apply rules for levels of evidence to make clinical decisions 4/11/2008 EBM Resources 2 Assessment • Triple Jump Exam, 2nd yr 1. Have a simulated patient or paper case 2. Go to your computer, the web or your Palm for pertinent information 3. Present patient and information collected to attending 4/11/2008 EBM Resources 3 The EBM Process 4/11/2008 EBM Resources 4 The EBM Process The patient The question The resource 1. Start with the patient -- a clinical problem or question arises out of the care of the patient 2. Construct a well built clinical question derived from the case 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) 5. Return to the patient -- integrate that evidence with The patient clinical expertise, patient preferences and apply it to practice Self-evaluation 6. Evaluate your performance with this patient 4/11/2008 EBM Resources 5 Types of Questions • Therapy/prevention Question • Prognosis Question • Diagnosis Question • Harm Question 4/11/2008 EBM Resources 6 Elements of a Good Question • • • • Who? What? Alternately? Outcome? • Write the question • Type of question? • Type of Study? 4/11/2008 EBM Resources 7 Summary Type of Question Therapy Diagnosis Etiology/Harm Prognosis Prevention Clinical Exam Cost Suggested best type of Study RCT>cohort > case control > case series Prospective, blind comparison to a gold standard RCT > cohort > case control > case series Cohort study > case control > case series RCT>cohort study > case control > case series Prospective, blind comparison to gold standard Economic analysis http://www.hsl.unc.edu/lm/ebm/Supplements/QuestionSupplement.htm 4/11/2008 EBM Resources 8 Evidence Pyramid Meta-Analysis Systematic Review Randomized Controlled Trial Cohort studies Case Control studies Case Series/Case Reports Animal research 4/11/2008 EBM Resources 9 Levels of Evidence • Level 1: Randomized Clinical Trials • Level 2: Head to Head Trial or Systematic Review of Cohort Studies • Level 3: Case-Control Studies • Level 4: Case-series • Level 5: Expert Opinion 4/11/2008 EBM Resources 10 Levels of Evidence • • • • • Level 1: Highest: Level 2: Level 3: Level 4: Level 5: Lowest—but still evidence 4/11/2008 EBM Resources 11 Purpose-specific resources • • • • • • • CDC Travel Drug information resources Patient Education handouts Diagnostic Testing – ARUP Medical Search engines Textbooks Journals 4/11/2008 EBM Resources 12 EBM Databases Systematic Literature Searches • • • • • • • Cochrane Library (OVID) Clinical Evidence ACP Journal Club (OVID) DARE DynaMed Medical InfoRetriever TRIP Database Systematic Literature Surveillance EMB Search Engine 4/11/2008 EBM Resources 13 Today • • • • • • National Guidelines Clearinghouse (AHRQ) Cochrane ACP Journal Club Dynamed First Consult InfoRetriever 4/11/2008 EBM Resources 14 Guidelines • What is a guideline? • Guidelines may be – – – – – Explicit evidence-based Evidence-based Research-based (highly referenced) Opinion-based ―expert consensus‖ 4/11/2008 EBM Resources 15 Guidelines • National Guideline Clearinghouse • Primary Care Clinical Practice Guidelines • Agency/Association sites – AAFP – APA – AAP 4/11/2008 EBM Resources 16 Cochrane 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 • Conclusions are based on all the evidence from valid randomized trials 4/11/2008 EBM Resources 17 Cochrane Library • Included in OVID subscription • 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 4/11/2008 EBM Resources 18 ACP Journal Club • About 100 journals systematically surveyed • Highest-validity articles abstracted • Structured abstracts to guide critical appraisal • Clinical commentary • Included in our OVID subscription 4/11/2008 EBM Resources 19 ACP Journal Club • Limitations – individual article summaries may not account for the ―big picture‖ – may have to read multiple items – No ―control‖ over what is covered – $78/year ? 4/11/2008 EBM Resources 20 DynaMed • • • • • • Designed as entry point to information Textbooks and Medline not efficient Intuitive clinical organization Brief summarized information presented Links and references if more details needed ICD-9 codes and links to patient information handouts 4/11/2008 EBM Resources 21 DynaMed format • • • • • • • • Description Etiology Increased Risks Associated Conditions Complications History (cc, HPI, etc.) Physical Diagnostic (including Rule out, Tests to order) • • • • • • Prognosis Treatment Prevention Screening References Patient Information 4/11/2008 EBM Resources 22 DynaMed Sources • 18 primary journals – e.g. BMJ, JAMA, Lancet, NEJM, Pediatrics • 12 secondary literature sources – e.g. Alternative Therapies, ACP Journal Club, Cochrane Library, InfoPOEMs • 4 drug info sources – e.g. The Medical Letter, FDA MedWatch 4/11/2008 EBM Resources 23 DynaMed • Limitations – variable quality – areas with a lot of research can get hard to navigate – $200/year or effort 4/11/2008 EBM Resources 24 First Consult/PDxMD • • • • By MDConsult Differential Diagnosis Disease Information Patient Education Handouts 4/11/2008 EBM Resources 25 PDxMD 4/11/2008 EBM Resources 26 Medical InfoRetriever • 104 journals surveyed for Evidence-Based Practice Newsletter • Over 1300 article synopses/ POEMS • Cochrane abstracts • Selected evidence-based guidelines • Basic drug info • Clinical calculators/prediction rules 4/11/2008 EBM Resources 27 Symbols 4/11/2008 EBM Resources 28 InfoRetriever • Comes in web, desktop and PDA versions • Limitations – individual article summaries may not account for the ―big picture‖ – may have to read multiple items – $249/year – Optimized for use with Internet Explorer 5.x or Netscape 6.x 4/11/2008 EBM Resources 29 Hands-On Experience 4/11/2008 EBM Resources 30