Presentation on theme: "Evidence-Based Medicine at St. Barnabas Hospital"— Presentation transcript:
1 Evidence-Based Medicine at St. Barnabas Hospital Hai Jung Helen Rhim, MD, MPH St. Barnabas Hospital, Bronx, NYDirector, Inpatient Pediatrics September 24, 2009
2 Objectives Define Evidence-Based Medicine (EBM) Discuss the need for and the benefits of EBMPresent the Evidence-based Information CycleIntroduce the PICO format for clinical questionsDecide what types of studies address the questionDetermine which studies are most valid and reliableDescribe the new inpatient EBM curriculumPractice 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 questions1,266% of those questions are investigated but not resolved or never queried at all3,4But almost all unanswered questions could be answered if only for a better system for searching2Therefore 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"11. 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"1is a method of solving clinical problems that stresses the examination of clinical research rather than relying on intuition and clinical experience alone21. 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.
9 Why Do We Need EBM? Need to keep up to date Life long learner New discoveries everydayMust stay current with changing therapiesLife long learnerAssessing the medical literatureCuriosity/Self-directed learningTeaching othersTrainees/StudentsPatientsClinical Questions
10 What are the Benefits of EBM? Recognizes that it is impossible to know everythingBut 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”54.5.
13 The 5 A’sASSESS 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.
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…
17 Formulate a clinical question Step 2: ASKFormulate 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 easierIdentifies the search terms needed to enter into whichever searching service you choose
19 How do we ask a specific question? P I C Ois your best friend for quick formulation of a clinical question
20 Formulating a Specific Question P for populationI for interventionC for comparisonO 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 conditionsSometimes 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: ComparisonWhat 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: OutcomeWhat 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 interventionC for comparisonO for outcomePICO, 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 questionsThe key elements in the answers will become search terms in your on-line searchThe additional information will help you when analyzing the studies you findThen 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?
30 Go to the Literature AAP.org MEDLINE CAT Banks TRIP Database Cochrane PubMedGuidelines.gov
31 The Type of QuestionCertain resources are better for particular questionsIt will determine which resources you useIt will affect how you use itIt will influence the kind of answer you needIt will change the way you analyze the studies you find
32 Types of Questions Diagnosis how to select and interpret diagnostic testsTherapyhow to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using themPrognosishow to estimate the patient's likely clinical course over time and anticipate likely complications of diseaseHarm/Etiologyhow to identify causes for disease (including iatrogenic forms)
33 Which Study Design is the Best? Type of QuestionSuggested best type of StudyTherapyRCT>cohort > case control > case seriesDiagnosisprospective, blind comparison to a gold standardEtiology/HarmRCT > cohort > case control > case seriesPrognosiscohort study > case control > case seriesPreventionRCT>cohort study > case control > case seriesClinical Examprospective, blind comparison to gold standardCosteconomic analysis
35 Check for validity & applicability Step 4: APPRAISECheck 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: APPLYDetermine 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 rotationSenior residents will independently go to the literature to try to answer their clinical questionAt the end of the block, senior residents will present their EBM exercise to the inpatient teamIn the future, the presentation will be to the entire Pediatric Residency at a morning conference
41 Summary Clinicians are life long learners EBM is an important process in clinical practiceThe key to an effective search is a specific questionPICO is a useful tool to help start the processGo to the literature but use it effectively