Transcript Pathology Resident Journal Club Objectives

CATS, PEARLS, POEMS, BETS
and Training in EBM
K. Michael Parker, Ph.D., DABCC
Professor and Vice Chair
Department of Pathology
Oklahoma University Health Sciences
Center
Oklahoma City, OK
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Learning Map
• Closing the information gap
• Teaching EBM to residents/fellows
• Challenges as we move forward
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Evidence-based practice is
essential to improving the quality
of health care
Institute of Medicine. Crossing the
Quality Chasm: a New Health System
for the 21st Century
2001
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Why Evidence-based Practice?
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•
•
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Improves the quality of patient care
Standardizes the delivery of healthcare
Reduces the expense of healthcare
Incorporates patient values into healthcare
decisions
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Evidence-Based Medicine
EBM is an approach to health care that
promotes the collection, interpretation, and
integration of valid, important and
applicable patient-reported, clinician
observed, and research-derived evidence.
The best available evidence, moderated by
patient circumstances and preferences, is
applied to improve the quality of clinical
judgments.
Health Information Resources Unit
McMaster University
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Two Types of Information
• New information
• Revised Information
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Information Gap
What biochemical
marker is most
useful in the
diagnosis of
AMI?
Information Gap occurs when
a situation is encountered and
new information is needed.
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Information Gap
I think the measurement of SGOT is
most useful in the
diagnosis of
AMI?
Information Gap occurs when
a situation is encountered and
revised information is needed.
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Information Gap
How often does an information Gap occur?
Depends on nature of the situation
and level of individual expertise.
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Information Gap
We need evidence (about the accuracy of
diagnostic tests, the power of prognostic
markers, and the comparative efficacy and
safety of interventions, etc.) about 5 times
for every in-patient and twice for every 3
outpatients. – David Sackett, M.D.
IT HAPPENS FOR EVERYONE !!!!!!!!
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Information Gap
How Does One Fill the Gap?
• Guess and hope you’re correct
• Use your ability to reason, your
experience, and your intuition to fill the
gap
• Ask a colleague and hope she’s correct
• Check textbooks for pertinent information
• Use the medical literature to provide the
needed information
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Information Gap
Use of the Medical Literature
• Traditional Approach
– Subscribe to large
number of journals
– Browsing mode
– Creates piles on the
desk
– Inefficient and
Frustrating
– Just-in-case
information
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Information Gap
Use of the Medical Literature
• Focused Approach
– Problem-based
mode
– Focused on a
relative
problem/decision
– Just-in-time
information
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Use of the Medical Literature
Why the Focused Approach?
• You will not have time to read all the
“important” articles in the medical literature
– Number of journals continues to increase
– Scientific discovery is occurring at an
increased rate
• You will be asked to quickly make
increasing complex decisions
– Sorting the “good” information from the less
useful takes time
• You will be expected to “standardize” your
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practice
Use of the Medical Literature
How to Use the Focused
Approach?
• Become familiar with the new tools
available to access information
• Develop a strategy to quickly and
conveniently access relevant information
and to use the information to facilitate
decision making
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Steps to EBM
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•
•
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Ask an answerable question
Search for the best evidence
Appraise the evidence
Proceed to act on the evidence
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Benefit of Questions
• Help focus efforts on evidence directly
relevant to case, issue, problem.
• Can suggest where information might be
found.
• Improve communication with colleagues.
• Improve “background” information for
future situations.
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Critical Appraisal
• Identify the type of study
• Assess the quality of the study
• Determine the strength of the evidence
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Critical Appraisal
• Identify the type of study
– Primary Study: Therapy, Diagnosis,
Prognosis, Harm
– Integrative Study: Review, Guideline
• Assess the quality of the study
• Determine the strength of the evidence
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Critical Appraisal
• Identify the type of study
• Assess the quality of the study
– Internal validity
• Bias = systematic error
• Chance = random error
– External validity
• Generalizability
• Determine the strength of the evidence
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Critical Appraisal
• Identify the type of study
• Assess the quality of the study
• Determine the strength of the evidence
– Strength of individual study
• Hierarchy: SR>RCT>Cohort Studies>Case
Studies>Opinions
– Strength of multiple studies
• Grade: A>B>C
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Assessment Tips
• Use checklist and guides for assessment
– Books
– Websites
– Quadas
• Seek evidence from high-quality journals
– CONSORT
– STARD
– QUOROM
RCTs
Observational Studies
Systematic Reviews
• Be critical – not everything that’s published is
gold
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Do Physicians Fill the Information
Gaps ?
Only about 30% of the time do primary
care physicians pursue an answer to their
questions.
Gorman PN and Helfand M
Medical Decision Making 15(2):113-9, 1995
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Do Physicians Fill the Information
Gaps ?
Two factors predicted whether physicians
pursued new information:
• Belief that a definitive answer existed
• Urgency of the patient’s problem
Gorman PN and Helfand M
Medical Decision Making 15(2):113-9, 1995
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Barriers to the Practice of EBM
(Physicians)
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Time
Difficulty phrasing clinical questions
Knowing when to stop searching
Lack of awareness, access and skills in
searching medical information resources
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Learning Map
• Closing the information gap
• Teaching EBM to residents/fellows
• Challenges as we move forward
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Information Gap
OUHSC Pathology Resident Survey: On
average an Information Gap occurs four times
each day.
IT HAPPENS FOR EVERYONE !!!!!!!!
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Barriers to the Practice of EBM
(Physicians in Training)
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Access to electronic information resources
Skills in searching information resources
Clinical question tracking
Time
Clinical question priority
Green ML and Ruff TR
Personal initiative
Acad Med 2005: 80(2);
Team dynamics
176
Institutional culture
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MANDATED
EBM Training for Residents
ACGME
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Venues for EBM Training
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Lectures
Mini-courses
Tutorials
Workshops
Journal Clubs
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“…that sort of journal club (review of a
current paper) is run by the postman,
not the clinicians or patients, and it is
no wonder that it is becoming extinct.”
“On the other hand, a few journal clubs
are flourishing and a growing number
of them are designed and conducted
along EBM lines.”
David L. Sackett, M.D.
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OUHSC Pathology
Journal Club
• Identify an Information Gap
• Presentation (2 residents/mo.)
• Written Summary
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Presentation
(20-30 minutes)
• Give the question you are seeking to answer.
• Describe the clinical situation that prompted this
question.
• Describe the search strategy used to find the
relevant paper(s).
• Describe the paper(s) that you found.
• Assess the quality of the information.
• Discuss how well the paper(s) answer the
original question.
• Summarize the “best” answer to the question.
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OUHSC Pathology
Journal Club
• Identify an Information Gap
• Presentation
• Written Summary
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Summarizing the Information
• PEARLS
– Presentation of Evidence Abstracted from the
Research Literature for the Solutions of Real
Individuals’ Clinical Problems
• POEMS
– Patient-Oriented Evidence That Matters
• BETS
– Best Evidence Topics
• CATS
– Critically Appraised Topics
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EXAMPLES
POEMS
http://www.aafp.org/afp/20050215/tips/
BETS
http://www.bestbets.org/background/publications.html
CATS
http://w3.ouhsc.edu/pathology/Learning_Ctr/Journal_Club.htm
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Written Summary
Critically Appraised Topic
CAT
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Ask an answerable question
Search for the best evidence
Appraise the evidence
Proceed to act on the evidence
CAT
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Critically Appraised Topic
Conclusion
Scenario
Definition of Clinical Question
Target Condition
Intervention
Outcome
Search Terms
The Study
Quality
Target disorder and gold standard
Patients
The Evidence
Sensitivity and specificity
Predictive values
Likelihood ratios
Comments
References
Name of Reviewer
Date of Review
References:
Sauve, et al. The Critically
Appraised Topic: A Practical
Approach to Learning
Critical Appraisal. Annales
CRMC1995;28:396-398.
Price and Christenson in
Evidence-Based
Laboratory Medicine,
AACC Press, Washington,
DC (2003).
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CAT Template
http://www.med.umich.edu/pediatrics/ebm/Jcguide.htm#overheads
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CAT Websites
http://w3.ouhsc.edu/pathology/Learning_Ctr/Journal_Club.htm
http://www.med.umich.edu/pediatrics/ebm/index.html
http://www.med.unc.edu/medicine/edursrc/!catlist.htm
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A Conceptual Model for the
Eight EBM Barriers
Unknown
Information
needed
Time
Institutional
culture
Clinical
decision
tracking
Clinical question
priority
Team dynamics
Personal initiative
Defer
pursuit
Clinical
question
Consider
pursuit
Commit to
pursue
Access
Appraise
information
Apply
information
Choose and
search information
resource
Identify
information
Skills
Green ML and Ruff TR
Acad Med 2005: 80(2); 176
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Learning Map
• Closing the information gap
• Teaching EBM to residents/fellows
• Challenges as we move forward
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Challenges
• Teaching critical appraisal skills
• Making information readily availability
• Moving theory to practice (i.e. integrating
EBM into the flow of patient care)
• Creating a culture for EBM
• Finding mentors who teach the practice
• Modeling the practice of EBM
• Documenting resident practice of EBM
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Challenges
• Teaching critical appraisal skills
• Making information readily available
• Moving theory to practice (i.e. integrating
EBM into the flow of patient care)
• Creating a culture for EBM
• Finding mentors who demonstrate practice
• Modeling the practice of EBM
• Documenting resident practice of EBM
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Evidence to Action
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Aware
Agree
Adopt
Adhere
Pathman DE, Konrad TR, Freed GL, et al.
Med Care 1996;34:873-889.
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Glasziou P and Haynes B
EBN 2005;8:36-38
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Challenges
• Teaching critical appraisal skills
• Making information readily available
• Moving theory to practice (i.e. integrating
EBM into the flow of patient care)
• Creating a culture for EBM
• Finding mentors who demonstrate practice
• Modeling the practice of EBM
• Documenting resident practice of EBM
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EBM is here to stay. It has
become an essential way of
teaching and practicing in the
uncertain world of medicine. The
challenge is to engage the whole
healthcare team in learning about
it and making it part of the routine
of clinical practice.
Editorial
BMJ 2004;329:989-990
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