1. Locating the Best Evidence at the MUSM Libraries Mercer Medical Library Macon reference.ill@gain.mercer.edu Health Sciences Library Memorial University Medical Center Savannah library@memorialhealth.com

2. What is EBM? Evidence-based medicine (EBM) is the integration of 3 components: Best Research Evidence Clinical Expertise Patient Values EBM

3. Steps in the EBM Process Formulate a clinical question. Use EBM resources to find evidence. Evaluate evidence for validity. Apply evidence to your patient.

4. Formulating a Clinical Question A well-built clinical question has 4 components. The mnemonic PICO is useful for remembering these.

5. Formulating a Clinical Question Patient or Population – Sex, age, race? Primary complaint? Disease History? Intervention – What do you want to do for them? Prescribe a drug? Order a test? Comparison – What alternatives do you want to compare the intervention to? Outcome – What do you hope to accomplish, improve or affect? Relieve or reduce symptoms? Improve function or improve test scores?

6. Sample PICO In elderly patients, are ACE inhibitors more effective than beta blockers in controlling high blood pressure and minimizing adverse effects? The “Population” is elderly patients, the “Intervention” is ACE inhibitors, the “Comparison” is beta blockers, and the “Outcome” is controlling high blood pressure and minimizing adverse effects.

7. Sample PICO In children with asthma, are inhaled steroids more likely to result in growth delay than standard therapy with beta- agonists? The “Population” is children with asthma, the “Intervention” is inhaled steroids, the “Comparison” is beta-agonists and the “Outcome” is growth delay.

8. Locating the Best Evidence Medical literature is immense. Only a small portion is immediately useful in answering clinical questions. Literature reports the whole spectrum of the scientific research process. Journey from in-vitro studies to double-blind randomized control trials is called the “pyramid of evidence.”

9. Pyramid of Evidence

10. Levels of Evidence (LOE) Rules of evidence have been established to grade evidence according to its strength. Several dozen of these hierarchies exist. Some systems comprise three levels and others eight or more.

11. Example of Levels of Evidence 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. Agency for Healthcare Research and Quality (AHRQ)

12. Two Ways to Locate Evidence Foraging – Keeping up with the new literature and finding information/research that is relevant Hunting – Answering a specific well-formed question in a timely efficient manner to include at patient point of care