1. Evidence-Based Medicine at St. Barnabas Hospital
Hai Jung Helen Rhim, MD, MPH St. Barnabas Hospital, Bronx, NY
Director, Inpatient Pediatrics September 24, 2009

2. Objectives Define Evidence-Based Medicine (EBM)
Discuss the need for and the benefits of EBM
Present the Evidence-based Information Cycle
Introduce the PICO format for clinical questions
Decide what types of studies address the question
Determine which studies are most valid and reliable
Describe the new inpatient EBM curriculum
Practice EBM format with a sample case

3. Questions for the Audience…
Have you ever had a clinical question?
Have you been able to find an answer every time?
Do you have a good & systematic way to find it?
Don’t worry, you’re not alone.

4. It turns out that… Therefore we need a better system…
For every 10 patients seen, clinicians generate 0.7 to 18.5 questions1,2
66% of those questions are investigated but not resolved or never queried at all3,4
But almost all unanswered questions could be answered if only for a better system for searching2
Therefore we need a better system…

5. Evidence Based Medicine
We need…
Evidence Based Medicine

6. What is Evidence-Based Medicine?
EBM is:
"the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients"1
1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2.

7. What is EBM? (cont.) The Practice of EBM is:
“integrating individual clinical expertise with the best available external clinical evidence from systematic research"1
is a method of solving clinical problems that stresses the examination of clinical research rather than relying on intuition and clinical experience alone2
1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2.
2. Guyatt Gordon; Drummond Rennie. Users' guides to the medical literature : a manual for evidence-based clinical practice. Chicago: AMA Press; p.

8. Decision Making in Clinical Practice
EBM is the practice of medicine in which the physician finds, assesses, and implements methods of diagnosis and treatment on the basis of the best available current research, their clinical expertise, and the needs and preferences of the patient. 3
Patient Preference
Research Evidence
Clinical Expertise
3. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

9. Why Do We Need EBM? Need to keep up to date Life long learner
New discoveries everyday
Must stay current with changing therapies
Life long learner
Assessing the medical literature
Curiosity/Self-directed learning
Teaching others
Trainees/Students
Patients
Clinical Questions

10. What are the Benefits of EBM?
Recognizes that it is impossible to know everything
But you need to know how to find the information if and when you need it4
“A detailed and exact knowledge of the outcomes of different interventions, derived from the research, can often save lives”4
“Offers the surest and most objective way to determine and maintain consistently high quality and safety standards in medical practice”5 4. 5.

11. So how do we do it?

12. Evidence-based Information Cycle
The
Five
A’s

13. The 5 A’s
ASSESS clinical or policy problems and identify key issues; ASK well-built questions that can be answered using evidence-based resources; ACQUIRE evidence using selected, pre-appraised resources; APPRAISE the validity, importance and applicability of evidence that has been retrieved; APPLY evidence to clinical or policy problems.

14. Step 1: ASSESS
Identify an issue

15. You are on rounds…
Presenting the H&P on a 3 month old baby who was admitted overnight with RSV+ bronchiolitis. The night float started the patient on oral steroids but is unsure if they are making a difference. You have noticed that not all patients with bronchiolitis get started on oral steroids…You mention this and your attending asks you to see what you can find in the literature in terms of efficacy of oral steroid therapy…

16. Now What???

17. Formulate a clinical question
Step 2: ASK
Formulate a clinical question

18. Formulating a Clinical Question
It is CRITICAL to formulate a specific question so that you don’t end up with 21,354 articles to evaluate!
Makes the search for evidence easier
Identifies the search terms needed to enter into whichever searching service you choose  

19. How do we ask a specific question?
P I C O
is your best friend for quick formulation of a clinical question

20. Formulating a Specific Question
P for population
I for intervention
C for comparison
O for outcome

21. P: Patient Population (Patient/Condition)
How would you describe a group of patients similar to yours?
What are the most important characteristics of the patient?
This may include the primary problem, disease, or co- existing conditions
Sometimes the sex, age or race of a patient might be relevant to the diagnosis or treatment of a disease

22. I: Intervention (Drug, Procedure, Diagnostic Test, Exposure)
Which main intervention, prognostic factor, or exposure are you considering?
What do you want to do for the patient? Prescribe a drug?
Order a test? Order surgery?
What factor may influence the prognosis of the patient? Age? Co-existing problems?
What was the patient exposed to? Lead? Cigarette smoke?

23. C: Comparison
What is the main alternative to compare with the intervention?
Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests?
Your clinical question does not always need a specific comparison

24. O: Outcome
What can you hope to accomplish, measure, improve or affect?
What are you trying to do for the patient? Relieve or eliminate the symptoms?
Reduce the number of adverse events? Improve function or test scores?

25. PICO Worksheet C for comparison O for outcome P for population
I for intervention
C for comparison
O for outcome
PICO, was originally defined by physicians at McMaster University in the early 1990's.

26. Before starting a search…
Write down the answers to these PICO questions
The key elements in the answers will become search terms in your on-line search
The additional information will help you when analyzing the studies you find
Then it helps to form a clinical question from these PICO elements

27. Back to the case…
Presenting the H&P on a 3 month old baby who was admitted overnight with RSV+ bronchiolitis. The night float started the patient on oral steroids but is unsure if they are making a difference. You have noticed that not all patients with bronchiolitis get started on oral steroids…You mention this and your attending asks you to see what you can find in the literature in terms of efficacy of oral steroid therapy…

28. Your question is:
In otherwise healthy infants aged 0-2 years with RSV+ bronchiolitis, does the addition of oral steroid therapy to conventional supportive care decrease the length of hospitalization?

29. Step 3: ACQUIRE
Go to the Literature

30. Go to the Literature AAP.org MEDLINE CAT Banks TRIP Database Cochrane
PubMed
Guidelines.gov

31. The Type of Question
Certain resources are better for particular questions
It will determine which resources you use
It will affect how you use it
It will influence the kind of answer you need
It will change the way you analyze the studies you find

32. Types of Questions Diagnosis
how to select and interpret diagnostic tests
Therapy
how to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them
Prognosis
how to estimate the patient's likely clinical course over time and anticipate likely complications of disease
Harm/Etiology
how to identify causes for disease (including iatrogenic forms)

33. Which Study Design is the Best?
Type of Question
Suggested best type of Study
Therapy
RCT>cohort > case control > case series
Diagnosis
prospective, blind comparison to a gold standard
Etiology/Harm
RCT > cohort > case control > case series
Prognosis
cohort study > case control > case series
Prevention
RCT>cohort study > case control > case series
Clinical Exam
prospective, blind comparison to gold standard
Cost
economic analysis

34. Hierarchy of evidence

35. Check for validity & applicability
Step 4: APPRAISE
Check for validity & applicability

36. Appraise What are the results of the study? Are the results valid?
Can I apply the results to my patient?

37. Search Strategy & Application
• Write out your clinical question
• Search Terms
• How else can you limit your search?
• Source of information
• Results/Discussion of findings
• References
• How will you use this information in your clinical practice?

38. Step 5: APPLY
Determine if you can use this newly acquired information in your clinical practice

39. EBM during the Inpatient Rotation
Senior residents (PL-3 & PL-2) will generate a clinical question based on a patient admitted to the pediatric service during weeks 1-2 of the rotation
Senior residents will independently go to the literature to try to answer their clinical question
At the end of the block, senior residents will present their EBM exercise to the inpatient team
In the future, the presentation will be to the entire Pediatric Residency at a morning conference

40. EBM Worksheet

41. Summary Clinicians are life long learners
EBM is an important process in clinical practice
The key to an effective search is a specific question
PICO is a useful tool to help start the process
Go to the literature but use it effectively

42. References
1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2.
2. Guyatt Gordon; Drummond Rennie. Users' guides to the medical literature : a manual for evidence-based clinical practice. Chicago: AMA Press; p.
3. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier. 4. 5. 6. 7. 8. 9.