Finding the Evidence Based Health Care Literature Dr. Rhett Jackson Marty Thompson

Agenda  Welcome & Introductions  Well-built Clinical Questions  “Background questions”  “Foreground questions”  Sources for locating Information  Bibliographic Databases  EBM Reviews  DynaMed  UpToDate  Additional Resources

The “Well-built” Clinical Question n Why formulate a “well-built” clinical question? –Focuses your thinking –Improves efficiency –Directs your search activities –Facilitates communication with colleagues –Delineates knowledge gaps

The “Well-built” Clinical Question n “Background” questions –Two components: Question root (who, what, where, how, why) with a verb A disorder, or an aspect of a disorder n Examples: –“What causes babesiosis?” –“When do complications of acute pancreatitis usually occur?”

The “Well-built” Clinical Question n “Foreground” questions –Ask for specific knowledge about managing patients with a disorder –Have four (or three) essential components 1.Patient and/or problem 2.Intervention 3.Comparison intervention (if relevant) 4.Clinical outcome

The “Well-built” Clinical Question n Example “foreground” question “In older patients with heart failure from isolated diastolic dysfunction, does adding digoxin to standard diuretic, ACE inhibitor, and B-blocker therapy reduce morbidity and/or mortality?”

The “Well-built” Clinical Question n Practice formulating “well-built” clinical questions –Background –Foreground

The “Well-built” Clinical Question n A 49 yo man presents with signs and symptoms of pneumonia. A CXR confirms a LUL infiltrate. He has no significant underlying illness. He cannot afford your choice of antibiotic, which is the recommended levofloxacin. He can, however, afford a course of doxycycline. n Formulate a “background” question. –Question root with a verb –Disorder, or aspect of a disorder

The “Well-built” Clinical Question n What organisms cause pneumonia outside of the hospital setting? n What is the natural course of pneumonia? n Why does pneumonia result in radio- opacity on a CXR? n What other diseases produce infiltrate on CXR?

Background Question n AccessMedicine –Harrison’s Online –Current Medical Diagnosis and Treatment n STATRef –ACP Medicine n MDConsult –Cecil Medicine n –Washington Manual of Therapeutics

DynaMed n A clinical reference tool created by a physician for physicians and other health care professionals n For use primarily at the point-of-care n With clinically-organized summaries for nearly 2,000 topics n Updated daily and monitors the content of over 500 medical journals and systematic evidence review databases directly and indirectly by using many journal review services

UpToDate n Answers clinical questions in daily practice n Recognize clinical manifestations n Summarized and specific recommendations n Authors – review the literature

ACP Journal Club  Database consists of two journals:  ACP Journal Club  Evidence-Based Medicine (BMJ)  Titles merged in 2000; new content appears in ACP Journal Club  Editors of ACP Journal Club:  screen the top clinical journals on a regular basis and identify studies that are both methodologically sound and clinically relevant  write an enhanced abstract of the chosen articles and provide a commentary on the value of the article for clinical practice  No controlled vocabulary

Cochrane Database of Systematic Reviews  Produced by the Cochrane Collaboration - an international network of individuals and institutions  Includes two types of reviews:  Complete Reviews – full text systematic reviews, updated and maintained by designated groups  Protocols – background, objectives, methods, and expected date of completion for reviews currently being prepared  No controlled vocabulary

Database of Abstracts of Reviews of Effects (DARE)  Produced by the expert reviewers and information staff of the National Health Services' Centre for Reviews and Dissemination (NHS CRD) at the University of York, England  Full text database containing critical assessments of systematic reviews from a variety of medical journals  No controlled vocabulary

BMJ Clinical Evidence n Summarize the current state of knowledge n Best available evidence from systematic reviews n “What Questions”

The “Well-built” Clinical Question n A 49 yo man presents with signs and symptoms of pneumonia. A CXR confirms a LUL infiltrate. He has no significant underlying illness. He cannot afford your choice of antibiotic, which is the recommended levofloxacin. He can, however, afford a course of doxycycline. n What do we want to know about Dx. Tx, or harm? n Formulate a “foreground” question –Patient –Intervention –Comparison intervention –Outcome

The “Well-built” Clinical Question n In middle-aged men with CAP, does the use of doxycycline, compared to levofloxacin, result in acceptable levels of morbidity/mortality? n In non-smokers with signs and symptoms of CAP, does the empiric use of ABX, compared to the culture-directed use of ABX, result in acceptable levels of morbidity/mortality?

MEDLINE  Produced by the National Library of Medicine  Indexes over 4,700 journals from the mid- 1960’s forward  Controlled vocabulary (MeSH) available  Premier bibliographic database for information in the fields of medicine, dentistry, veterinary medicine, nursing, the healthcare system, and preclinical sciences  International in scope

Publication Types n Clinical Trial, Phase I-IV n Controlled Clinical Trial n Randomized Controlled Trial n Evaluation Studies n Meta-Analysis n Multicenter Study n Practice Guideline

Clinical Queries (sensitivity, specificity, optimized) n Therapy n Diagnosis n Prognosis n Reviews n Clinical Prediction Guides n Qualitative Studies n Etiology n Costs n Economics

Subject Subsets n Systematic Reviews

EMBASE n Biomedical and pharmacological database n 11 million records since 1974 n 5,000 medical journals covered

The “Well-built” Clinical Question n A 52 yo male smoker presents complaining of intermittent chest pain that does not sound entirely consistent with ischemic heart pain. The pain usually occurs at rest, is in the central chest, and is described as sharp and dull. He wonders if he should have a “cath” like his brother-in-law had. n Formulate a “background” question –Question root with a verb –Disorder, or aspect of a disorder

The “Well-built” Clinical Question n What is the typical character of ischemic cardiac pain? n How does smoking result in decreased myocardial blood flow? n What tests are available to assess for cardiac ischemia? n What disorders, besides coronary disease, present with chest pain?

The “Well-built” Clinical Question n A 52 yo male smoker presents complaining of intermittent chest pain that does not sound entirely consistent with ischemic heart pain. The pain usually occurs at rest, is in the central chest, and is described as sharp and dull. His only medication is an aspirin a day. He wonders if he should have a “cath” like his brother-in-law had. n What do we want to know about Dx. Tx, or harm? n Formulate a “foreground” question –Patient –Intervention –Comparison intervention –Outcome

The “Well-built” Clinical Question n In middle-aged males, does smoking (compared to not smoking) increase the risk of myocardial infarction? n In middle-aged males, does the H&P, compared to coronary angiography, accurately predict the presence of significant CAD? n In middle-aged males without prior evidence of CAD, does taking ASA 325 mg daily (compared to not taking it) result in less myocardial infarctions?

The “Well-built” Clinical Question n History and Physical Exam –A 23-year-old woman was admitted to the emergency room complaining of severe, stabbing left anterior chest pain and tingling in the left arm. She had some shortness of breath on exertion. The pain was worsened by deep inspiration. She had no cough or sputum production and no leg symptoms. Risk factors included a 10-hour motorcycle ride two days before admission and she had been taking birth control pills for about six months. –On physical examination, she was in no acute distress. Blood pressure was 120/80, the pulse rate was 80, and the respiratory rate was 16. Examinations of the chest and cardiovascular system were negative for significant abnormalities and the extremities revealed no clinical evidence of deep vein thrombosis. n Formulate a “background” question. –Question root with a verb –Disorder, or aspect of a disorder

The “Well-built” Clinical Question n What are the different types of chest pain? n How does cardiac pain differ from pleural pain? n How do abnormal clots form? n At what age does myocardial infarction typically occur?

The “Well-built” Clinical Question n History and Physical Exam –A 23-year-old woman was admitted to the emergency room complaining of severe, stabbing left anterior chest pain and tingling in the left arm. She had some shortness of breath on exertion. The pain was worsened by deep inspiration. She had no cough or sputum production and no leg symptoms. Risk factors included a 10-hour motorcycle ride two days before admission and she had been taking birth control pills for about six months. –On physical examination, she was in no acute distress. Blood pressure was 120/80, the pulse rate was 80, and the respiratory rate was 16. Examinations of the chest and cardiovascular system were negative for significant abnormalities and the extremities revealed no clinical evidence of deep vein thrombosis. n What do we want to know about Dx, Tx, or harm? n Formulate a “foreground” question –Patient –Intervention –Comparison intervention –Outcome

The “Well-built” Clinical Question n In young women, does the taking of OCP’s (as opposed to not taking OCP’s) increase the likelihood of venous thromboembolism? n In young women, what is the likelihood of DVT with a negative clinical exam (as opposed to a positive clinical exam)? n In VTE, does the use of 6 months of warfarin therapy, as opposed to 3 months, result in a lower mortality rate?

Additional Resources  National Guideline Clearinghouse  Evidence Based Medicine Tool Kit  Netting the Evidence  Evidence-Based Medicine: How to Teach and Practice EBM

National Guideline Clearinghouse   Developed and maintained by the Agency for Healthcare Research and Quality (AHRQ)  Resource to identify clinical practice guidelines  Includes links to additional resources, a guideline compare tool, and full-text if available

Evidence Based Medicine Tool Kit n Collection of tools for identifying, assessing and applying relevant evidence n Originally published in JAMA as a result Evidence Based Medicine Working Group n

Netting the Evidence n Intended to facilitate evidence-based healthcare by providing support and access to helpful organizations and useful learning resources n Resources can be browsed by type n Search engine available n

Electronic Books n AccessMedicine n StateRef n MDConsult

Electronic Journals n GoldRush n Database links

Evidence-Based Medicine: How to Teach and Practice EBM n Tells how to integrate best available evidence into clinical expertise n Available BHS Library WB 102 F (copy on reserve and one circulating copy)

Things to Keep in Mind…  All of these resources are:  Keyword searchable  Under development thus limited in scope  Excellent for identifying other sources of evidence based practice materials that may not be included in more traditional databases

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