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EVIDENCE-BASED MEDICINE AT ST. BARNABAS HOSPITAL Hai Jung Helen Rhim, MD, MPHSt. Barnabas Hospital, Bronx, NY Director, Inpatient Pediatrics September.

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Presentation on theme: "EVIDENCE-BASED MEDICINE AT ST. BARNABAS HOSPITAL Hai Jung Helen Rhim, MD, MPHSt. Barnabas Hospital, Bronx, NY Director, Inpatient Pediatrics September."— Presentation transcript:

1 EVIDENCE-BASED MEDICINE AT ST. BARNABAS HOSPITAL Hai Jung Helen Rhim, MD, MPHSt. 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? Dont worry, youre not alone.

4 It turns out that… For every 10 patients seen, clinicians generate 0.7 to 18.5 questions 1,2 66% of those questions are investigated but not resolved or never queried at all 3,4 But almost all unanswered questions could be answered if only for a better system for searching 2 Therefore we need a better system…

5 E vidence B ased M edicine We need…

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.Evidence based medicine: what it is and what it isn't

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 alone 2 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.Evidence based medicine: what it is and what it isn't 2. Guyatt Gordon; Drummond Rennie. Users' guides to the medical literature : a manual for evidence-based clinical practice. Chicago: AMA Press; 2002. 706 p.Users' guides to the medical literature : a manual for evidence-based clinical practice

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 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 it 4 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. http://library.downstate.edu/EBM2/intro.htm 5. http://www.openclinical.org/ebm.html

11 So how do we do it?

12 Evidence-based Information Cycle The Five As www.cche.net

13 The 5 As 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. www.cche.net

14 Identify an issue Step 1: ASSESS

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

18 Formulating a Clinical Question It is CRITICAL to formulate a specific question so that you dont 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 PICOPICO How do we ask a specific question? is your best friend for quick formulation of a clinical question

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

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 http://www.umdnj.edu/camlbweb/ebm/picomodel.htm

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? http://www.umdnj.edu/camlbweb/ebm/picomodel.htm

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 http://www.umdnj.edu/camlbweb/ebm/picomodel.htm

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? http://www.umdnj.edu/camlbweb/ebm/picomodel.htm

25 PICO Worksheet P for population I for intervention C for comparison O for outcome

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 Go to the Literature Step 3: ACQUIRE

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

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 Diagnosishow to select and interpret diagnostic tests Therapyhow to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them Prognosishow to estimate the patient's likely clinical course over time and anticipate likely complications of disease Harm/Etiologyhow to identify causes for disease (including iatrogenic forms) http://www.hsl.unc.edu/services/tutorials/ebm/Supplements/QuestionSupplement.htm

33 Which Study Design is the Best? Type of QuestionSuggested best type of Study TherapyRCT>cohort > case control > case series Diagnosisprospective, blind comparison to a gold standard Etiology/HarmRCT > cohort > case control > case series Prognosiscohort study > case control > case series PreventionRCT>cohort study > case control > case series Clinical Examprospective, blind comparison to gold standard Costeconomic analysis http://www.hsl.unc.edu/services/tutorials/ebm/Supplements/QuestionSupplement.htm

34 Hierarchy of evidence http://www.mclibrary.duke.edu/subject/ebm/ebmpyramid.html

35 Check for validity & applicability Step 4: APPRAISE

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

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.Evidence based medicine: what it is and what it isn't 2. Guyatt Gordon; Drummond Rennie. Users' guides to the medical literature : a manual for evidence-based clinical practice. Chicago: AMA Press; 2002. 706 p.Users' guides to the medical literature : a manual for evidence-based clinical practice 3. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier. 4. http://library.downstate.edu/EBM2/intro.htm 5. http://www.openclinical.org/ebm.html 6. www.cche.net 7. http://www.umdnj.edu/camlbweb/ebm/picomodel.htm 8. http://www.hsl.unc.edu/services/tutorials/ebm/Supplements/QuestionSupplement.htm 9. http://www.mclibrary.duke.edu/subject/ebm/ebmpyramid.html


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