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FSU College of Medicine1 Selecting the Best Evidence- Based Medicine Resources Daniel J. Van Durme, MD Chairman, Dept. Family Medicine and Rural Health.

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Presentation on theme: "FSU College of Medicine1 Selecting the Best Evidence- Based Medicine Resources Daniel J. Van Durme, MD Chairman, Dept. Family Medicine and Rural Health."— Presentation transcript:

1 FSU College of Medicine1 Selecting the Best Evidence- Based Medicine Resources Daniel J. Van Durme, MD Chairman, Dept. Family Medicine and Rural Health Nancy Clark, MEd Director of Medical Informatics Education

2 FSU College of Medicine2 Objectives  What is EBM?  Formulate a clinical question  Apply levels of evidence to decision making process including patient concerns  What are the major EBM databases  Search for evidence based information Using EBM hunting tools

3 FSU College of Medicine3 Handouts and Resources  EBM Tutorial online  EBM Resources handout  Clinical Question Worksheet  Cases  Slawson article on EBM

4 New Resource EBM Teaching Materials FSU College of Medicine4

5 5 What is EBM?  Evidence based medicine (EBM) was originally defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. (Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-2)

6 6 What is EBM?  The revised and improved definition of evidence- based medicine is “ the integration of the best research evidence with clinical expertise and patient values ”  It reflects a systematic approach to clinical problem solving. (Sackett DL, Strauss SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2 nd Ed. London: Churchill-Livingstone,2000)

7 7 What EBM skills do all practicing clinicians really need?  Among other skills: Information mastery: finding the best evidence for every day practice Have at fingertips “just in time’ information at point of care for clinical decision making  web based and/or PDA Evaluate expert-based information, including colleagues, CME, presentations, reviews and guidelines Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med Jul;80(7):685-9.

8 FSU College of Medicine8 Advanced EBM Skills Only a small percentage of clinicians need to be able to do the following  Critical Appraisal and Interpretation of Research on: Therapies, Diagnostic Tests, Prognosis  Critical Evaluation and Interpretation of: Systematic Reviews, Including Meta-analysis, Decision Analysis, Practice Guidelines, Pharmaceutical Advertising, Including Pharmaceutical Representatives  Assigning Levels of Evidence to Research Findings  Teaching Level 1 Skills  Produce written Communication of Research Findings Physicians Patients (Slawson, et al)(Slawson, et al)

9 FSU College of Medicine9 Lifelong Learning  Old method: read a few journal articles per week  Reality: Primary care docs would need over 17 hrs/day just to review reasonable and pertinent material  Even in one narrow specialty would need 6+hrs/wk  Practicing docs (all specialties) average hrs/wk

10 Lifelong Learning from Day to Day Encounters  Reading the articles that happen to cross the desk does not help MY PATIENTS TODAY  Finding evidence based optimal care for my patients today helps them AND helps me to stay current in my field and be an efficient and effective lifelong learner FSU College of Medicine10

11 FSU College of Medicine11 The EBM Process “The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning in which caring for one's own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues.” (Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship education. Am J Med May;102(5): ) Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship education. Am J Med May;102(5): )

12 FSU College of Medicine12 The EBM Process The patient 1. Start with the patient -- a clinical problem or question arises out of the care of the patient The question 2. Construct a well built clinical question derived from the case The resource 3. Select the appropriate resource(s) and conduct a search The evaluation 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) The patient 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice Self-evaluation 6. Evaluate your performance with this patient

13 FSU College of Medicine13 Constructing A Clinical Question P patient I intervention C comparison O outcome Who?What? Alternative Intervention? Outcomes “How would I describe a group of patients similar to this particular patient?” ”Which treatment, test or other intervention?” “Compared to what other treatment, test, or perhaps compared to doing nothing” What is the patient oriented outcome – better prognosis? Higher rate of cure? Etc.?”

14 FSU College of Medicine14 Examples PICO Kids with acute otitis media -2-4 y/o Antibiotics No treatment except acetaminophen for pain/fever No pain after two days? Adult with microhematuria IVPCT scan Diagnostic accuracy (Predictive value or likelihood ratio) Adult patients <70 TIANo TIA Rates of CVA within 90 days Healthy adolescents Routine scoliosis screen No screening – evaluate only if problems Pain, disability, need for intervention

15 FSU College of Medicine15 Types of Questions Best Answered by EBM Resource  Therapy Question In patients with migraine headaches without auras, is Depakote more effective than Inderal for prophylaxis of headaches?  Prognosis Question In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis with MRI as predictive of healing as an audible pulse on Doppler examination?  Diagnosis Question In geriatric patients with suspected carotid stenosis, is duplex ultrasound as good as magnetic resonance angiography in detecting significant carotid stenosis?  Harm Question For pregnant patients, does the consumption of large amounts of coffee, (compared to non-coffee drinkers) increase the rate of spontaneous abortion?

16 FSU College of Medicine16 Question Worksheet  P - Who?  I - What?  C- Alternatively?  Outcome?  Type of Question Therapy Prognosis Diagnosis Harm/Etiology Using the worksheet provided, construct a clinical question from your own practice.

17 Assessing Validity  Definitions Level of Evidence (LOE): usually one study Strength of Recommendation (SOR): recommendation based on multiple studies  A value of the confidence in the recommendation based on the quality of research  Assigned by experts using specific criteria 17 Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. Feb ;69(3):

18 FSU College of Medicine18 Levels of Evidence  Level 1: Systematic Review (with meta- analysis) of Randomized Clinical Trials  Level 2: Cohort Studies  Level 3: Case-Control Studies  Level 4: Case-series  Level 5: Expert Opinion Centre for Evidence-Based Medicine, Oxford

19 FSU College of Medicine19 Strength of Recommendation Taxonomy A : There is good research-based evidence to support the recommendation. B: There is fair research-based evidence to support the recommendation. C: The recommendation is based on expert opinion and panel consensus. X: There is evidence of harm from this intervention.

20 FSU College of Medicine20 Bottom Line on LOE or SOR  Level 1AHighest level  Level 2  Level 3B  Level 4  Level 5CLowest Level But still evidence

21 FSU College of Medicine21 Evidence Based Medicine Databases (Foraging Tools) People who do the heavy lifting for you.

22 22 EBM Foraging Tools A high-quality foraging tool employs a transparent process that Systematically searches and reviews literature Identify useful, valuable, “quality” research Synthesizes into “bottom line” recommendation  Patient oriented outcomes (POEM); not disease- oriented outcomes (DOE) Assign level of evidence  How to apply recommendations? ( Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med. Jul 2005;80(7): )

23 FSU College of Medicine23 Major EBM Databases (Foraging Tools)  Cochrane  Clinical Evidence  DARE  ACP Journal Club  InfoPOEMS  Evidence Based _____  USPSTF  National Guidelines Clearinghouse

24 FSU College of Medicine24 Cochrane Library  The current resource with the highest methodological rigor  For each clinical question, all of the English literature meticulously searched for randomized trials  Large systematic reviews with valid methods + collaborative effort by Review Groups  Conclusions are based on all the evidence from valid randomized trials (treatment and harm questions)

25 FSU College of Medicine25 Cochrane Library  Full text at Cochrane Library at Wiley  Abstracts in InfoRetriever  Limitations limited to English only addresses questions amenable to randomized trials most of medicine has not been studied enough to allow for conclusions $235/year or abstracts only free 

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27 FSU College of Medicine27 ACP Journal Club  About 140 internal medicine journals systematically surveyed  Highest-validity articles abstracted  Structured abstracts to guide critical appraisal  Clinical commentary  Web site  Also published in Annals of IM  Alerts available

28 FSU College of Medicine28 ACP Journal Club  Limitations Limited pediatrics individual article summaries may not account for the “big picture” may have to read multiple items No “control” over what is covered $78/year ?

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30 FSU College of Medicine30 DARE  Database of Abstracts of Reviews of Effects Structured Abstracts Provisional Abstracts Effective health bulletins Cochrane reviews  National Health Service -- UK  Updated monthly  Available in OVID

31 FSU College of Medicine31 InfoPOEMS  Patient Oriented Evidence that Matters  Journal of Family Practice and other specialty journals  Systematic surveillance of 100 journals  Reviews of recent research articles  Effect patient concerns – morbidity, mortality, quality of life  Included in Essential Evidence Plus (formerly InfoRetriever)  Daily updates available POEMS

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33 Evidence Based Practice  Summaries: structured search, critical appraisal, authoritative recommendations, clinical perspective, and rigorous peer review  – Family Physicians Inquiries Network  Appear in PEPID FSU College of Medicine33

34 FSU College of Medicine34

35 FSU College of Medicine35  Stored at National Guidelines Clearinghouse  Agency for Healthcare Research and Quality  1600 Guidelines may be Explicit evidence-based Evidence-based Research-based (highly referenced) “expert consensus”  Multiple guidelines on one condition

36 FSU College of Medicine36 US Preventive Services Task Force  First convened by the U.S. Public Health Service in 1984  Since 1998 Agency for Healthcare Research and Quality  Leading independent panel of private-sector experts in prevention and primary care  Conducts rigorous, impartial assessments of the scientific evidence for effectiveness of broad range of clinical preventive services, including screening, counseling, and preventive medications  Its recommendations considered "gold standard" for clinical preventive services

37 FSU College of Medicine37 USPSTF Tool  Free PDA and online tool (ePSS)  Enter age, gender  Get recommendations  Filter level of recommendations 

38 FSU College of Medicine38 Hunting Tools Most Bang for Your Buck

39 39 Drilling Down for Information Grandage KK, Slawson DC, Shaughnessy AF. When less is more: a practical approach to searching for evidence-based answers. J Med Libr Assoc Jul;90(3):

40 FSU College of Medicine40 EBM Hunting Tools A high-quality Hunting tool employs a transparent process that  Searches multiple EBM databases (several foraging tools)  Organizes results to make them easy to find  Provides levels of evidence (Slawson, et al)

41 FSU College of Medicine41 EBM Pyramid 5, C MEDLINE InfoRetriever DynaMed

42 Major EBM Hunting Tools Tools CochraneACP Journal Club Guide- lines US- PSTF LOE Essential Evidence +  Dynamed  Clinical Evidence  ACP Pier (Web only)  PEPID FSU College of Medicine42 Web and PDA Summaries

43 FSU College of Medicine43 Clinical Evidence  Includes >250 conditions  Summaries of evidence  Specific clinical questions: treatment and prevention  Makes specific recommendations  States when there is a lack of evidence  Book Free from United Health Foundation  Web and PDA versions available

44 FSU College of Medicine44 Clinical Evidence

45 Do Clinical Evidence Case FSU College of Medicine45

46 FSU College of Medicine46 Essential Evidence Plus (EE+)  POEMS -- JFP >104 journals surveyed Over 3500 article synopses Link out to PubMed  Cochrane abstracts  Selected evidence-based guidelines  Basic drug info  Clinical calculators/prediction rules

47 New Content  Essential Evidence summaries Organized like disease quick reference Bottom Line at top Links to InfoPOEMs, Cochranes Links to calculators and algorythms, images Uses SORT for level of evidence FSU College of Medicine47

48 FSU College of Medicine48 EE+ Features  Essential Evidence (replaces 5MCC)  EBM Guidelines  Pearls –PDA; Favorites on Desktop  Levels of Evidence explained  ICD-9 and E/M coding tools  Immunization Guide  USPSTF Guidelines  Derm Expert

49 FSU College of Medicine49 Symbols New 8/09

50 FSU College of Medicine50 Essential Evidence Plus  Comes in web, desktop and PDA versions  Daily POEMS are available in mp3 podcast version  Limitations individual article summaries may not account for the “big picture” may have to read multiple items $79/year

51 Do EE+ Case FSU College of Medicine51

52 PEPID  FPIN summaries included in CRC module  Drug and disease reference, interaction tool  Clinical rotation aids for students with basic principles  Lab manual, calculators, images  Compares favorably with Epocrates, 5MCC Compares  PDA and Online  $199 for individual subscription FSU College of Medicine52

53 Using PEPID FSU College of Medicine53

54 Links to Evidence Based Summaries FSU College of Medicine54

55 FSU College of Medicine55 DynaMed  Designed as entry point to information  Textbooks and Medline not efficient  Intuitive clinical organization  Brief summarized information presented  Links out to articles and reviews if more details needed  ICD-9 codes and links to patient information handouts

56 FSU College of Medicine56 DynaMed Sources  Systematic surveillance of 18 primary journals – e.g. BMJ, JAMA, Lancet, NEJM, Pediatrics  12 major EBM resources – e.g. ACP Journal Club, Cochrane Library, InfoPOEMs, Alternative Therapies,  4 drug info sources – e.g. The Medical Letter, FDA MedWatch

57 57 DynaMed Organization of Results  Description (including ICD-9 Codes) Description, Also called, ICD-9 Codes, Types, Organs Involved, Who Is Most Affected, Incidence/Prevalence  Causes and Risk Factors Causes, Pathogenesis, Likely risk factors, Possible risk factors  Complications and Associated Conditions  History CC, HPI, Meds, PMH, FH, SH, ROS  Physical Skin, HEENT, Neck, Extremities, Neuro, Pelvic  Diagnosis Making the diagnosis, Rule out, Tests to order, Blood tests, Urine studies, Imaging studies, Pathology tests, Other diagnostic testing  Prognosis  Treatment Treatment Overview, Diet, Activity, Counseling, Medications, Surgery, Consultation and referral, Other management, Follow-up  Prevention and Screening  References (including Reviews and Guidelines)  Patient Information

58 FSU College of Medicine58 DynaMed  Limitations variable quality if not Cochrane or review areas with a lot of research can get hard to navigate. Lot of information-slower to wade through Hard to navigate on PDA $200/year or effort

59 Do DynaMed Case Use CTRL-F to Find words in articles FSU College of Medicine59

60 ACP PIER  PIER: The Physicians' Information and Education Resource.  Available online at ACP and PDA ($69/yr)  Modules on Disease, Screening and prevention, complementary medicine, procedures, quality measures and drug resource (Clinical Pharmacology)  Provide A-B-C levels of evidence  Excellent Tables summarize recommendations FSU College of Medicine60

61 Do ACP PIER Case FSU College of Medicine61

62 FSU College of Medicine62 Searching All Resources at Once WebFeat In development, but getting better all the time. Web Only

63 Summary Need Resource Treatment of common diagnosis Clinical Evidence Need to create a presentation on a topic DynaMed Answers to clinical questions, use a clinical decision support calculator, ICD-9 code Essential Evidence Plus Tabular summaries of diagnoses, treatment, and follow-up of chronic or acute illness ACP PIER Broad and basic overview for med students organized by rotation PEPID 63 CTRL-F

64 FSU College of Medicine64 Find the Answer to Your Question Group exercise

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