1. Evidence-Based Medicine For KSOM Y2 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

2. Introductions and Business Introduction to Library Personnel ASK QUESTIONS Fill out evaluation forms at the end of the session. We value the feedback…we use it to improve over time. ######## News Flash ########  Student Portal Student Portal We will post the materials for this class to Norris Library website (path to materials is Key resources for:  Students  Medical  Year 2) Get a “clicker” and two handouts  Additional Resources, Evaluation

3. Outline for today 1. EBM Background 2. EBM Resources 3. Practice with Resources

4. I use MeSH terms when searching MEDLINE… 1. Always 2. Usually 3. Sometimes 4. Occasionally 5. Never

5. When searching for information related to clinical care, the first place I look is… 1. Cochrane database 2. MEDLINE 3. UpToDate 4. Google (Scholar) 5. Other

6. My understanding of EBM is… 1. Excellent 2. Good 3. So-so 4. Could be better 5. I am uninformed

7. Are you comfortable searching for information in UpToDate? 1. Yes 2. No

8. What is Evidence Based Medicine?

9. 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

10. Best available clinical evidence Clinician experience Patient needs, desires, resources Patient-Doctor Dyad – Not really changed through time The point at which effecting Doctor-Patient communication and planning is informed by the best evidence Three interacting realms of EBM

11. 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 (5 th ed.). Philadelphia : Wolters, pp. 40).

12. 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

13. Step-by-step EBM 1. Formulate search Scenario: Wintertime, yet another of your patients has come in for antibiotics for a common cold. Once again you 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.

14. 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!

15. Step-by-step EBM 1. Formulate search (Part 2) Identify information need Define clinical question Define searchable clinical question (SCQ) Identify concepts within SCQ to use as search concepts Identify: Shaken by this hostile encounter, you decide to review the literature of antibiotics for common cold. Define CQ: For healthy adult males with a 3-day history of cold symptoms and purulent rhinorrhea, do antibiotics speed recovery and improve symptoms? Define SCQ: Do antibiotics effectively treat the common cold? Concepts: Common cold/URI/purulent rhinitis/acute rhinosinusitis, antibiotics, treatment outcomes. Notice the confusing/overlapping naming: Common cold Upper Respiratory Infection Purulent rhinitis Acute rhinosinusitis Do you OR them all together?

16. 2. Search The traditional emphasis of information literacy instruction for health sciences students Good search skills insure you find what you want and not more or less… Choose appropriate sources for your search – background vs. foreground question?background vs. foreground question Search: Interlude 1

17. 2. Search (cont.) Background Sources  ACP Pier ACP Pier  Essential Evidence Essential Evidence  UpToDate UpToDate  Clinical Evidence Clinical Evidence  text books Foreground Sources  Ovid MEDLINE Ovid MEDLINE  PubMed@USC  Ovid EBM Databases Cochrane Database of Systematic Reviews ACP Journal Club, DARE (Database of Abstracts of Reviews of Evidence)  TRIP (tripdatabase.com) TRIP

18. 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 background Link to original Greenhalgh articles in Student portal Link to original Greenhalgh articles in Student portal

19. 4. Apply results… …to your patient, while factoring in clinician experience and patient desires.

20. 5. Reassess patient… … after application of results. Observe effect of intervention, results of diagnostic maneuver, etc. Reformulate EBM process if necessary

21. The Sacred Objects of EBM The Pyramid PICO

22. Evidence Pyramid Source: http://library.downstate.edu/EBM2/2100.htm The best evidence also is the least available!!

23. 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.

24. PICO  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. PPopulation, Patient, or Problem IIntervention or Exposure CComparison (optional) OOutcomes

26. 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

27. 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

28. 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) Clinical Evidence Guideline.gov (US government -- free) Guideline.gov TRIP (Turning Research Into Practice) TRIP SUMSearch (Quirky, will not look at today) SUMSearch PEDro (PT oriented) PEDro OTseeker (OT oriented) OTseeker

29. 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

30. Tips with these sources Keep searches simple This is all “key word” searching –  there is no mapping or translation function  try synonyms

31. Hands-on Portion Clinical Evidence (BMJ product) – beta-blocker AND MI – two aspects acute and secondary prevention Clinical Evidence Guideline.gov (free) – diagnosis of autism Guideline.gov Ovid – ankle sprain Ovid  Cochrane Database of Systematic Reviews  DARE (Database of Abstracts of Reviews of Effects)  ACP Journal Club  Use training account for class only. URL:ovidsp.ovid.com, UN: sci001, PW: medical TRIP (Turning Research Into Practice) – breast cancer, role of MRI in screening. TRIP SUMSearch –same as TRIP SUMSearch

32. 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

33. 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

34. 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  Guideline.gov

35. Summary 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

36. My understanding of EBM is… 1.Excellent 2.Good 3.So-so 4.Could be better 5.I am uninformed

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