1. Finding and Using Best Evidence Rebecca Payne, MPH Laura Straw, MPH Health Analysis Department Navy and Marine Corps Public Health Center

2. FOR OFFICIAL USE ONLY 2 Disclaimer The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

3. Health Analysis Department  Department within the Population Health Directorate of the Navy and Marine Corps Public Health Center, Portsmouth, VA  Highly trained team consisting of:  Epidemiologists  Program Manager  Technical Affairs Officer  Biostatistician  Physician Lead  Navy Tumor Registry Consultant FOR OFFICIAL USE ONLY 3

4. 4 Objectives 1. Define “best evidence” 2. Describe how one would find best medical evidence 3. List the hierarchy of strength of evidence 4. List examples of best evidence in Navy Medicine

5. FOR OFFICIAL USE ONLY 5 “Evidence-Based…”? Evidence-based medicine: “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” 1 Evidence-based clinical practice: “Evidence-based clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option that suits the patient best” 2 Evidence-based practice in health care: Evidence-based health care “takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information” 3

6. Systematic Reviews Critically-Appraised Topics (Evidence Synthesis) Critically-Appraised Individual Articles (Article Synopses) Randomized Controlled Trials (RCTs) Cohort Studies Case-Controlled Studies, Case Series, Reports Background Information/Expert Opinion FOR OFFICIAL USE ONLY 6 Levels of Evidence Quality of evidence Filtered Information Unfiltered Information Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

7. Background Info/ Expert Opinion Quick references Medscape Reference 5 Minute Clinical Consult Textbooks Internet Colleagues/experts FOR OFFICIAL USE ONLY 7

8. Example: Medscape Reference FOR OFFICIAL USE ONLY 8

9. Systematic Reviews Critically-Appraised Topics (Evidence Synthesis) Critically-Appraised Individual Articles (Article Synopses) Randomized Controlled Trials (RCTs) Cohort Studies Case-Controlled Studies, Case Series, Reports Background Information/Expert Opinion FOR OFFICIAL USE ONLY 9 Levels of Evidence Quality of evidence Filtered Information Unfiltered Information Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

10. Unfiltered Information Reports Case series: Descriptive study of group with common exposures or outcomes Case-controlled studies: People with a specific health outcome are matched with people who do not have the outcome to compare if the groups differ with respect to potential causes Cohort studies: People exposed to a cause or a treatment are compared to those not exposed to determine if they differ with respect to risk of some outcome FOR OFFICIAL USE ONLY 10

11. Unfiltered Information FOR OFFICIAL USE ONLY 11 Randomized Controlled Trials “Gold standard” Experimental design Participants are randomly assigned to a control condition or to an experimental condition Minimizes bias Drawbacks: Expensive and time consuming

12. Unfiltered Information Resources PubMed http://www.ncbi.nlm.nih.gov/pubmed Ovid MEDLINE http://www.ovid.com/site/catalog/DataBase/901.jsp PsychINFO www.apa.org/psycinfo/ FOR OFFICIAL USE ONLY 12

13. Example: PubMed FOR OFFICIAL USE ONLY 13

14. Example: PubMed FOR OFFICIAL USE ONLY 14

15. Systematic Reviews Critically-Appraised Topics (Evidence Synthesis) Critically-Appraised Individual Articles (Article Synopses) Randomized Controlled Trials (RCTs) Cohort Studies Case-Controlled Studies, Case Series, Reports Background Information/Expert Opinion FOR OFFICIAL USE ONLY 15 Levels of Evidence Quality of evidence Filtered Information Unfiltered Information Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

16. Filtered Evidence Critically Appraised Individual Articles Synopsis and evaluation of individual research studies Critically Appraised Topics Synthesis and evaluation of multiple research studies FOR OFFICIAL USE ONLY 16

17. CAIA Resources ACP Journal Club http://acpjc.acponline.org/ Evidence Updates- from the BMJ Evidence Center http://plus.mcmaster.ca/evidenceupdates/ Any “Evidence-Based…” Journal series (i.e. Evidence- Based Nursing) FOR OFFICIAL USE ONLY 17

18. CAT Resources AHRQ National Guideline Clearinghouse http://guideline.gov/index.aspx http://guideline.gov/index.aspx Clinical Evidence http://clinicalevidence.bmj.com/x/index.html Essential Evidence Plus- POEMs http://www.essentialevidenceplus.com/ FOR OFFICIAL USE ONLY 18

19. Example: AHRQ National Guideline Clearinghouse FOR OFFICIAL USE ONLY 19

20. Example: AHRQ National Guideline Clearinghouse FOR OFFICIAL USE ONLY 20

21. FOR OFFICIAL USE ONLY 21 CAT Resources The VHA/ MHS have their own Clinical Practice Guidelines http://www.healthquality.va.gov/ VA/DoD Evidence-Based Practice Guideline Work Group (EBPWG) include representatives from all military branches and the VA EBPWG selects topics based on cost, volume, risk, and feasibility.

22. Example: VA/DoD CPGs FOR OFFICIAL USE ONLY 22

23. Systematic Reviews Critically-Appraised Topics (Evidence Synthesis) Critically-Appraised Individual Articles (Article Synopses) Randomized Controlled Trials (RCTs) Cohort Studies Case-Controlled Studies, Case Series, Reports Background Information/Expert Opinion FOR OFFICIAL USE ONLY 23 Levels of Evidence Quality of evidence Filtered Information Unfiltered Information Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

24. Filtered Information Systematic Review: Searching for, recording, analyzing and interpreting the existing evidence 4 Meta-Analysis: Applying a statistical formula to measure the effect, size, and impact of treatment programs 4 Example From Cochrane: Exercise or Exercise and Diet for preventing type 2 diabetes 7 8 trials, with ~5,000 participants Conclusion: Exercise and diet can decrease type 2 diabetes FOR OFFICIAL USE ONLY 24

25. FOR OFFICIAL USE ONLY 25 Systematic Review Resources Cochrane Database of Systematic Reviews www.cochrane.org The Database of Abstracts of Review of Effects (DARE) http://www.ovid.com/site/products/ovidguide/daredb.htm PUBMED http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?otool=yaleli b&dr=citation http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?otool=yaleli b&dr=citation Ovid MEDLINE Source: http://www.ebmpyramid.org/samples/complicated.html

26. FOR OFFICIAL USE ONLY 26 Example: USPSTF US Preventive Services Task Force (USPSTF) http://www.uspreventiveservicestaskforce.org/ Independent group of prevention and EBM experts that makes recommendations about clinical preventive services

27. Example: USPSTF FOR OFFICIAL USE ONLY 27

28. Evidence Based Applications and Examples

29. 29 The 5-Minute Clinical Consult 2009 OR UptoDate

30. 30 Restless Leg Syndrome

31. Cervical Cancer Screening What is the evidence for routine cervical caner screening in women? US Preventive Services Task Force FOR OFFICIAL USE ONLY 31 Source: Whitlock, E.P., Vesco, K.K., Eder, M., Lin, J., Senger, C., Burda, B., Liquid Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cencer: A Systematic Review for the US Preventive Services Task Force. Annals of Internal Medicine. 2011. Vol 155 No 10. p 687-697

32. Cervical Cancer, Ctd FOR OFFICIAL USE ONLY 32

33. Cervical Cancer, ctd. FOR OFFICIAL USE ONLY 33 Does everyone agree? Source: http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf

34. PTSD What is the best evidence available about treatment for PTSD? VA/DOD Clinical Practice Guideline: FOR OFFICIAL USE ONLY 34 Source: VA/DOD Clinical Practice Guideline: Management of Post Traumatic Stress Disorder and Acute Stress Reaction (2010). http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp

35. PTSD Cont’d FOR OFFICIAL USE ONLY 35

36. PTSD Cont’d FOR OFFICIAL USE ONLY 36 Cochrane Review: PTSD Psychological and psychosocial interventions “Some types of psychological treatment (individual trauma-focused cognitive behavioural therapy/exposure therapy [TFCBT], eye movement desensitisation and reprocessing [EMDR], stress management, and group TFCBT) were effective in the treatment of PTSD, and individual TFCBT and EMDR appeared to be superior to stress management at two to five months. Insufficient evidence was available to determine whether psychological treatment is harmful, but there was greater drop-out in active treatment groups. Caution is needed in interpreting these results because of considerable unexplained heterogeneity, and the potential impact of publication bias” Pharmacotherapy for post-traumatic stress disorder “Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of selective serotonin reuptake inhibitors as first-line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.” Source: http://www.thecochranelibrary.com/details/collection/1045825/Cochrane-Evidence-Aid-resources-for-post-traumatic-stress-disorder-following-nat.html

37. HEDIS NCQA’s Health Effectiveness Data and Information Set (HEDIS) Widely used set of health performance indicators Desirable attributes for HEDIS measures are: Relevance Scientific Soundness –Clinical Evidence! (There should be evidence documenting the link between clinical processes and outcomes that measures address) Feasibility Source: HEDIS Technical Specification Manual FOR OFFICIAL USE ONLY 37

38. FOR OFFICIAL USE ONLY 38 Evidence Applications In Military Medicine: Population Health Navigator/CarePoint

39. Analysis Application How could we apply best evidence when measuring healthcare? 1. Look for best evidence: systematic reviews, CPGs, research 2. Assess evidence 3. Look for existing measures; if none exist, look for “measurable points” in evidence. 4. Ensure proposed measure is meaningful and feasible 5. Develop measure FOR OFFICIAL USE ONLY 39

40. Application Example: mTBI Metrics Wounded, Ill, and Injured (WII) Program: Navy Medicine effort to monitor and improve the care offered to wounded, ill, and injured service members and their families mTBI Metrics TBI Screening: Percent of Coded Head Injury/Trauma Patients Coded as Screened for TBI Co-Occurring Conditions Screen: Percent of Coded mTBI Patients Coded as Screened for Co-Occurring Conditions Six Week Follow Up Visit: Percent of Coded mTBI Patients with Follow-Up within Six Weeks 40

41. mTBI Metrics Example (cont’d)  Metric Definitions:  The Department of Veterans Affairs (VA) and Department of Defense (DoD) Concussion and mTBI Clinical Practice Guideline (CPG)  Coding Guidance:  Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE PH/TBI)  Navy Medicine TBI subject matter experts (SMEs) 41

42. General Coding Guidance & CPG Recommendation mTBI Metrics Example (cont’d) 42

43. CPG Recommendation: “Regardless of the time that has elapsed since injury, management should begin with the patient’s first presentation for treatment,” and head injury cases should be screened for TBI. All Head Injury Cases: 5% Active Duty Only: 7% mTBI Metrics (cont’d) Not using codes? Not screening for TBI? Actual process different than recommendation? Not using codes? Not screening for TBI? Actual process different than recommendation? 43

44. FOR OFFICIAL USE ONLY 44 References 1. Sackett,D., Richardson, W., Rosenberg, W., & Haynes, R. (1997). Evidence-based medicine: How to practice and the EBM. New York:Churchill Livingston. 2. Muir Gray, J.A. (1997) Evidence-based healthcare: How to make health policy and management decisions. London:Churchill Livingstone. 3. Hicks, N. (1997). Evidence based healthcare. Bandolier, 4(39),8. 4. Roberts, A., Yeager, K. (2004). Evidence-Based Practice Manual. New York, NY: Oxford University Press. 5. Whitlock, E.P., Vesco, K.K., Eder, M., Lin, J., Senger, C., Burda, B. (2011). Liquid Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cencer: A Systematic Review for the US Preventive Services Task Force. Annals of Internal Medicine. 155 (10),687-697. 6. Framingham Heart Study http://www.framinghamheartstudy.org/about/history.htmlhttp://www.framinghamheartstudy.org/about/history.html 7. Orozco LJ, Buchleitner AM, Gimenez-Perez G, Roqué i Figuls M, Richter B, Mauricio D. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD003054. DOI: 10.1002/14651858.CD003054.pub3

45. Navy and Marine Corps Public Health Center Health Analysis CAPT Paul Rockswold, MD, MPH Head, Health Analysis P: 757-953-0690 Email: paul.rockswold@med.navy.milpaul.rockswold@med.navy.mil FOR OFFICIAL USE ONLY 45 Rebecca Payne, MPH P: 757-953-0620 Email: rebecca.payne.ctr@med.navy.milrebecca.payne.ctr@med.navy.mil Laura Straw, MPH P: 757-953-3776 Email: laura.straw.ctr@med.navy.millaura.straw.ctr@med.navy.mil web: http://www-nehc.med.navy.mil/Data_Statistics/Health_Analysis/ha_overview.aspxhttp://www-nehc.med.navy.mil/Data_Statistics/Health_Analysis/ha_overview.aspx