1. Evidence Based Obstetric Medicine Robert Hopkins, MD, FACP, FAAP UAMS Associate Professor of Medicine and Pediatrics Robert Hopkins, MD, FACP, FAAP UAMS Associate Professor of Medicine and Pediatrics

2. Outline EBM Overview –What is EBM –Why is EBM important –Basics of E-B medical practice Evidence Based Obstetrics 2005 –Selected examples EBM Overview –What is EBM –Why is EBM important –Basics of E-B medical practice Evidence Based Obstetrics 2005 –Selected examples

3. Overcoming inertia… “Human nature: apply minimum work in order to complete the task at hand…” “We need to learn not only HOW to read the literature--- but also WHAT to read and WHEN to read it…” “Usefulness = Validity * Relevance [of data] Work (required to find data)” “Human nature: apply minimum work in order to complete the task at hand…” “We need to learn not only HOW to read the literature--- but also WHAT to read and WHEN to read it…” “Usefulness = Validity * Relevance [of data] Work (required to find data)”

4. What is EBM? [1] Patient centered Ask answerable questions Search for best evidence –Can be time consuming… unless using E-B sources Critical assessment of evidence –For validity and applicability –May be time consuming, as above –If we do not assess critically, our educated consumers/patients will go elsewhere… Patient centered Ask answerable questions Search for best evidence –Can be time consuming… unless using E-B sources Critical assessment of evidence –For validity and applicability –May be time consuming, as above –If we do not assess critically, our educated consumers/patients will go elsewhere…

5. What is EBM? [2] Evaluate applicability [of search results] –Does the evidence apply to this patient? –Integrate evidence with clinical expertise –Is the intervention applicable to this specific person –‘Guideline dilemma’: is this a replication of expert (egocentric) opinion or a compendium of evidence… Critically assess the impact of change –To the patient –To the clinician –To ‘my medical practice’ Evaluate applicability [of search results] –Does the evidence apply to this patient? –Integrate evidence with clinical expertise –Is the intervention applicable to this specific person –‘Guideline dilemma’: is this a replication of expert (egocentric) opinion or a compendium of evidence… Critically assess the impact of change –To the patient –To the clinician –To ‘my medical practice’

6. So… What is the problem? Medical knowledge continues to grow 3000 new papers published DAILY 1000 new Medline article citations DAILY 46 new RCT’s published DAILY We do NOT read enough: < ½ hour/week: 3 % 1 hour/week:46 % 1-2 hr/week:43% 3+ hours/week:8 % Medical knowledge continues to grow 3000 new papers published DAILY 1000 new Medline article citations DAILY 46 new RCT’s published DAILY We do NOT read enough: < ½ hour/week: 3 % 1 hour/week:46 % 1-2 hr/week:43% 3+ hours/week:8 %

7. BUT…Aren’t we doing OK??? Data re: practice variability (200+ studies) –[IM] Example: Determinants of need to Rx HTN Level of BP Patient age Year MD awarded End-organ damage Can we realistically expect to provide the best care for 100+ patients/wk relying on memory and experience alone??? Data re: practice variability (200+ studies) –[IM] Example: Determinants of need to Rx HTN Level of BP Patient age Year MD awarded End-organ damage Can we realistically expect to provide the best care for 100+ patients/wk relying on memory and experience alone???

8. Where does the data come from? Print source –Texts: General/Subspecialty/PDR –Journals –Reprints Human source –Consultations –CME Conferences –Pharmaceutical rep’s Other: –Electronic: Best Evidence CD, UpToDate, PIER,… –Paper: Clinical Evidence [Updates] –Specialty Societies Print source –Texts: General/Subspecialty/PDR –Journals –Reprints Human source –Consultations –CME Conferences –Pharmaceutical rep’s Other: –Electronic: Best Evidence CD, UpToDate, PIER,… –Paper: Clinical Evidence [Updates] –Specialty Societies

9. The CME Conundrum CME is a ‘growth industry’ Most presentations are ‘Fact’ oriented Several RCT’s have demonstrated no improvement in clinical performance… Freemantle N., et.al. Cochrane Database of Systematic Reviews 2000;2. CME is a ‘growth industry’ Most presentations are ‘Fact’ oriented Several RCT’s have demonstrated no improvement in clinical performance… Freemantle N., et.al. Cochrane Database of Systematic Reviews 2000;2.

10. What are the answers? Seek out and apply evidence others generated Learn how to practice EBM ourselves Ultimate goal is …to apply evidence-centered strategies to answer questions in our practice-- leading to refinement of our clinical behavior. Seek out and apply evidence others generated Learn how to practice EBM ourselves Ultimate goal is …to apply evidence-centered strategies to answer questions in our practice-- leading to refinement of our clinical behavior.

11. What evidence do we need? Evidence about: –Predictive values and likelihood ratios for diagnostic tests –Power and specificity of prognostic markers –Comparative efficacy and safety of interventions Evidence about: –Predictive values and likelihood ratios for diagnostic tests –Power and specificity of prognostic markers –Comparative efficacy and safety of interventions

12. How often do we need EBM? Studies estimate at least: –5 valid questions for every inpatient stay –2 questions for every 3 outpatient visits And yet –We get less than 1/3 of these answered… Studies estimate at least: –5 valid questions for every inpatient stay –2 questions for every 3 outpatient visits And yet –We get less than 1/3 of these answered…

13. To summarize- Why EBM? Too many patients Too many questions Too much information to glean all the PEARLS No time to read “Selection pressure” on the reading we do –Reading often focused on familiar source/topic –It is common practice to avoid difficult issues and focus on ‘quick answers’ Too many patients Too many questions Too much information to glean all the PEARLS No time to read “Selection pressure” on the reading we do –Reading often focused on familiar source/topic –It is common practice to avoid difficult issues and focus on ‘quick answers’

14. What is the BEST evidence? 1989 Georgia [One man’s opinion] ‘Old Professors’ Case series Systematic Review Randomized Controlled Meta-Analysis Case Control Colleague/Consultant Case report 1989 Georgia [One man’s opinion] ‘Old Professors’ Case series Systematic Review Randomized Controlled Meta-Analysis Case Control Colleague/Consultant Case report

15. Structuring the Question Unstructured: Too many ‘hits’ –Example: >13000 [Pregnancy + HTN] articles PubMed [1/15/05] Structuring questions –Background: W 5 s and How ‘W’ + Verb + Disease… –Foreground: most daily ‘clinical care’ issues Unstructured: Too many ‘hits’ –Example: >13000 [Pregnancy + HTN] articles PubMed [1/15/05] Structuring questions –Background: W 5 s and How ‘W’ + Verb + Disease… –Foreground: most daily ‘clinical care’ issues

16. Background Questions Who, What, When, Where, Why, How.. –+ [verb] + [DISease] Results: –Often answered by textbooks, reviews –Most common when unfamiliar with a topic Who, What, When, Where, Why, How.. –+ [verb] + [DISease] Results: –Often answered by textbooks, reviews –Most common when unfamiliar with a topic

17. Foreground Questions Question Structure –Patient or problem –Intervention or exposure considered –Comparison intervention (If relevant) –Outcome of interest Question Structure –Patient or problem –Intervention or exposure considered –Comparison intervention (If relevant) –Outcome of interest

18. CQ Example –In pregnant woman with severe HTN [>170/100] is Labetalol as effective as Hydralazine in reduction of BP and maternal morbidity? Result: Cochrane DB Systematic Reviews: 2003 [Other than Diazoxide [more symptomatic hypotension], there are no clear differences in studied agents including Labetalol, Hydralazine, Nifedipine ER,…] –In pregnant woman with severe HTN [>170/100] is Labetalol as effective as Hydralazine in reduction of BP and maternal morbidity? Result: Cochrane DB Systematic Reviews: 2003 [Other than Diazoxide [more symptomatic hypotension], there are no clear differences in studied agents including Labetalol, Hydralazine, Nifedipine ER,…]

19. Search for the Evidence Database: Pub Med, Ovid and others Search engines are highly sensitive…but they are not specific (Specificity left to the questioner/searcher) MeSH: Structured medical subject headings- freely available from NLM (topic map) allow targeting of search to topic ‘Related articles’ is useful if narrow topic evaluated Limits: Clinical Trial ORSystematic Reviews English(?) language Human subjects Database: Pub Med, Ovid and others Search engines are highly sensitive…but they are not specific (Specificity left to the questioner/searcher) MeSH: Structured medical subject headings- freely available from NLM (topic map) allow targeting of search to topic ‘Related articles’ is useful if narrow topic evaluated Limits: Clinical Trial ORSystematic Reviews English(?) language Human subjects

20. Evaluating the Evidence Some ‘pre-assessed’ sources for your use: –ACP Journal Club, Journal of Evidence-Based Medicine –NGC: http://www.guideline.gov –Cochrane database –Clinical Evidence (BMJ Publications) –UpToDate JAMA Guide: EBM Working Group –Are the results valid? –What are the results? –Will the results help in my patients’ care? –http://medicine.ucsf.edu/resources/guidelines/users.htmlhttp://medicine.ucsf.edu/resources/guidelines/users.html Some ‘pre-assessed’ sources for your use: –ACP Journal Club, Journal of Evidence-Based Medicine –NGC: http://www.guideline.gov –Cochrane database –Clinical Evidence (BMJ Publications) –UpToDate JAMA Guide: EBM Working Group –Are the results valid? –What are the results? –Will the results help in my patients’ care? –http://medicine.ucsf.edu/resources/guidelines/users.htmlhttp://medicine.ucsf.edu/resources/guidelines/users.html

21. Data vs. Availability vs. Utility DataSource Access Quality ExperienceLongitudinalRapidVariable ColleagueVariableVariableVariable PatientsRapidRapid??? GuidelinesVariableVariableVariable TextsRapidSlowGood? ResearchSlowSlowGood? JournalsBuriedVariableGood DataSource Access Quality ExperienceLongitudinalRapidVariable ColleagueVariableVariableVariable PatientsRapidRapid??? GuidelinesVariableVariableVariable TextsRapidSlowGood? ResearchSlowSlowGood? JournalsBuriedVariableGood

22. Who are we?? Evidence Users Evidence Finders Evidence Generators [And I hope Never…] Evidence Ignorers Evidence Users Evidence Finders Evidence Generators [And I hope Never…] Evidence Ignorers

23. What is our goal in EBM? To NOT have to wade through 100+ papers To NOT have to go through Medline TO have evidence indexed by strength TO have a brief (1 word ?) answer… TO see questions that are already answered i.e. ALL applicable knowledge in 15 seconds …FLAT…. To NOT have to wade through 100+ papers To NOT have to go through Medline TO have evidence indexed by strength TO have a brief (1 word ?) answer… TO see questions that are already answered i.e. ALL applicable knowledge in 15 seconds …FLAT….

24. Evidence Based OB 2005 13043 “Pregnancy + HTN” articles [Pubmed 1/18/05] 207 when limited to Clinical trial, Human subjects, English language 13043 “Pregnancy + HTN” articles [Pubmed 1/18/05] 207 when limited to Clinical trial, Human subjects, English language

25. Evidence Based OB 2005 15852 “Preeclampsia” articles in 2005 [Pubmed 1/13/05] –263 articles when limited to: adults, human, English, published within 1 year –170 articles with MeSH ‘major topic’ limit –15 Clinical trials [Publication type] –7 Randomized Controlled Trials 15852 “Preeclampsia” articles in 2005 [Pubmed 1/13/05] –263 articles when limited to: adults, human, English, published within 1 year –170 articles with MeSH ‘major topic’ limit –15 Clinical trials [Publication type] –7 Randomized Controlled Trials