Transcript lllllllllllll - Northeastern State University

Existing knowledge can prevent…
•Waste
•Errors
•Poor quality clinical care
•Poor patient experience
•Adoption of interventions of low value
•Failure to adopt interventions of high value
Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health
Service. Quoted on http://www.nks.nhs.uk/.
Learning Objectives
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At the end of the presentation, you will be able to:
• Define evidence-based medicine (EBM)
• Understand the Five Steps to practice EBM
• Use the 4S approach to organizing clinical research
evidence
• Conduct an efficient online search to track down best
evidence
• Access online and print tools to critically appraise the
evidence
• Use the Five Steps in future clinical encounters
What is EBM?
www.cebm.net
“Evidence-based medicine is the integration of best
research evidence with clinical expertise and patient
values”
Patient
Concerns
EBMClinical
Best research
evidence Expertise
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.
Evolution of EBM in the Literature
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Term first appeared in the literature in a 1991 editorial in
ACP Journal Club Volume 114, Mar-April 1991, pp A-16
Seminal article by the Evidence-Based Medicine
Working Group published in JAMA Volume 268, No. 17,
1992, pp 2420-2425
Fundamentally new approach
becomes widely recognized
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JAMA published a series of Users’ Guides to the Medical
Literature that served as the first learning tools
Courses were developed in residency training and
medical school curricula
The first handbook, Evidence-Based Medicine: How to
practice and teach EBM, by Sackett, et al, was published
in 1996. Fourth edition published in 2010.
New York Times listed EBM as one of its ideas of the
year in 2001
BMJ listed EBM as one of the 15 greatest medical
milestones since 1840
Integration of EBM into medical school
curricula patient-doctor courses
Information Retrieval for Evidence
Based Patient Care
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Using research findings versus conducting research
Retrieving and evaluating information that has direct
application to specific patient care problems
Selecting resources that are current, valid, and
available at point of care
Developing search strategies that are feasible within
time constraints of clinical practice
Key developments that streamlined the
practice of EBM
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Advances in ease of accessing and understanding
information
Development of preprocessed (preappraised) tools
Improvements in search interfaces to MEDLINE
Collaboration between EBM Working Group and
National Library of Medicine in development of
“hedges”, clinical queries that filter search results by
“type of study” to match clinical question
Dissemination of systematic reviews of primary studies
and growth of the Cochrane Collaboration
Cochrane Collaboration
Cochrane Database of Systematic Reviews
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Part of the Cochrane Library (1996)
Over 3,000 reviews
Mostly Treatment; Diagnosis since 2008
Eyes & Vision Research Group includes 156 reviews
Among the highest level of evidence upon which to base
treatment decisions
Access full text of reviews through Ovid
Systematic Review
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Analyzes data from several primary studies to answer a
specific clinical question
Provides search strategies and resources used to locate
studies
Includes specific inclusion and exclusion criteria (results
in less bias)
Meta-Analysis (subclass) statistically summarizes results
of several individual studies
Ongoing Developments
1.
2.
3.
Continuing development of point of care (POC),
evidence based summaries, e.g., Dynamed, Up to Date
Evolving decision support tools that embed evidence
based summaries in the electronic medical record and
clinical workflow
Uptake of EBM process by health policy, nursing, allied
health, and psychosocial fields
EBM Process – 5 Steps
1.
2.
3.
4.
5.
ASSESS: Recognize and prioritize important patient
problems
ASK: Construct clinical questions that facilitate an
efficient search
ACQUIRE: Track down the best evidence to answer the
questions
APPRAISE: Systematically evaluate best available
evidence for validity, importance, and usefulness
APPLY: Interpret the applicability of evidence to
specific problems, given patient preferences and values
Step 1
1.
ASSESS the clinical problem
Begin with the patient encounter
Select question that
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Is most important to the patient’s well being
Fills gaps in your clinical knowledge
Is feasible to answer in the time available (30 minutes per
week)
Step 2
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ASK focused clinical questions
Four common types of clinical questions:
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Therapy/prevention
Diagnosis
Etiology
Prognosis
Well Built Clinical Questions
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Deal with patient management issues
Contain elements of PICO format
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Patient/Population
Intervention
Comparison Intervention (if useful)
Outcome
Facilitate an efficient search
Example – Therapy/Prevention
Question
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In patients with ocular hypertension, will
treatment with timolol versus no treatment
decrease the risk of developing
glaucoma?
Extract search terms from question
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Therapy/Prevention Question
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In patients with ocular hypertension
[Patient/Population], does treatment with
timolol [Intervention] versus no treatment
[Comparison Intervention], decrease the risk
of developing glaucoma [Outcome]?
Search Terms: ocular hypertension,
IOP,timolol, glaucoma, (POAG)
Step 3
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ACQUIRE: Track down the evidence to
answer the question
Use the 4S approach to select the most
likely resource
Start with the highest level resource
available
Best Study Design for Type of Question
Type of Question
Study Design
Therapy/prevention
Randomized controlled
trials
Diagnosis
Prospective cohort, blind
comparison to a gold
standard
Prognosis
Cohort, Case Control, Case
Series
Etiology/Harm
Cohort, Case Control, Case
Series
Randomized controlled trials are considered the best studies for assessing
therapeutic interventions.
Source: Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to
practice and teach EBM. London: Churchill-Livingstone.
4S Hierarchy
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POC Tools: Up-to-date,
Dynamed, FIRSTConsult, ACP
PIER
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ACP Journal Club
Evidence Based Ophthalmology
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Cochrane and other Systematic
Reviews (OVID EBMR)
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MEDLINE Searches with Clinical
Queries
SOURCE: Haynes, R. B. (2001). Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding
current best evidence. Evidence-Based Medicine, 6 (2), 36-38. Retrieved 2-07-07 from
http://ebm.bmj.com/cgi/reprint/6/2/36
Critically Appraised Content
Appraise the Filter (pre-appraised
content)
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Criteria
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Speed of updating
Scope and number of summaries
Summaries with graded evidence
Authors’ credentials, affiliations listed
Developing and using a rubric for evaluating evidence-based medicine point-of-care
tools. Journal of the Medical Library Association, Volume 99, No. 3, July 2011
Speed of updating online evidence based point of care summaries: prospective cohort
analysis. BMJ 2011;343:doi:10.1136/bmj.d5856 (Published 23 September 2011)
Appraisal Required by User
Step 4
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Appraise best available evidence from
original studies
If the other “S’s” don’t provide the answer,
search for original studies
Use “clinical queries” limit in Ovid
MEDLINE to speed retrieval
Least efficient (in terms of time) to answer
clinical questions
Primary (Original) Studies
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Articles that report results of original
research investigations
Conclusions supported by data and
reproducible methodology
Require time to acquire and appraise
Good Source: MEDLINE (OVID)
MEDLINE
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Premiere biomedical database from the NLM
(National Library of Medicine)
Covers 1950-present
Indexes >4000 international biomedical
journals
Full text available for many articles
Ovid interface includes tools to quickly filter
search results to specific study types
Access from http://library.nsuok.edu/collegeop/index.html
Ovid MEDLINE Clinical Queries
Levels of Evidence
• Grade the quality of evidence based on
the design of the clinical study
• Variety of hierarchies in use
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American Academy of Family Physicians Rating System
 Level A
 Systematic reviews of randomized controlled trials including metaanalyses
 Good-quality randomized controlled trials
 Level B
 Good-quality nonrandomized clinical trials
 Systematic reviews not in Level A
 Lower-quality randomized controlled trials not in Level A
 Other types of study: case control studies, clinical cohort studies,
cross sectional studies, retrospective studies, and uncontrolled
studies
 Level C
 Evidence-based consensus statements and expert guidelines
Dynamed
Step 5
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APPLY the evidence to patient care
problems
Practice the EBM process in daily patient
encounters
Access databases and tools from
http://library.nsuok.edu/collegeop/index.html
UptoDate available at Hastings Hospital
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Use Resource tab and scroll down to UptoDate
link
Take Home Points
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Focused clinical question (PICO) reveals
your search terms
Start your search at top of 4S hierarchy
and work down
Be aware of the filter, i.e., levels of
evidence, speed of updating
Look at more than one resource in the
hierarchy. Findings may differ.
Practice makes perfect
Evidence Based Medicine Lecture
NSUOCO Residents Journal Club
Sandra A. Martin, M.L.I.S.
Health Sciences Resource Coordinator
Instructor of Library Services
John Vaughan Library Room 305B
[email protected] – 918-444-3263