Transcript Slide 1

Evidence-based medicine:
a hands-on workshop
Presented by
Chris Maloney, MD
Director, Medical Student Education in Pediatrics
Venus Wilke, MD
Assistant Clerkship Director for Pediatrics
University of Utah
Salt Lake City, Utah
Objectives and Priorities
• Pediatrics Topics Session 1 and 2
– Formulate a clinical question relative to a
patient’s problem. Conduct an effective
search of the medical literature. Critically read
the pediatric literature and apply the
information in developing a differential
diagnosis, diagnostic plan, or management
plan.
Clinical judgment
and experience
Best research
evidence
EBM
Patient values
Evidence-based medicine
Defined
David L. Sacket
Evidence-based Medicine
How to practice and teach EBM
The integration of best research evidence
with clinical expertise and patient values
EBM: Defined
Best research evidence – clinically relevant research . . . into
the accuracy and precision of diagnostic tests, the power
of prognostic markers, and the efficacy and safety of
therapeutic, rehabilitative and preventive regimens.
Clinical expertise – the ability to use clinical skills and past
experience to rapidly identify each patient’s health state
and diagnosis, their individual risks and benefits of
potential interventions.
Patient’s values – the unique preferences, concerns and expectations
each patient brings to a clinical encounter and which must be
integrated into clinical decisions if they are to serve the patient.
slide 4.2
barriers between research and practice
30 kg of guidelines per family doctor per year
25000 biomedical journals in print
8000 articles published per day
95% of studies cannot reliably guide clinical decisions
2001 Bazian Ltd
The steps toward the practice of EBM
Step 1: Converting the need for information to an answerable question.
Step 2: Tracking down the best evidence with which to answer the question.
Step 3: Critically appraising that evidence for its validity (closeness to the truth),
impact (size of the effect), and applicability (usefulness in our
clinical practice).
Step 4: Integrating the critical appraisal with our clinical expertise and with
our patients unique biology, values and circumstances.
Step 5: Evaluating our effectiveness and efficiency at achieving steps 1-4
and seeking new ways to improve them both for next time.
How evidence changed clinical practice
31. Extracranial to intracranial vascular
anastomosis for occlusive Cerebrovascular
disease: experience in 110 patients. Surgery
1977; 82: 648-654.
32. Failure of extracranial-intracranial arterial
bypass to reduce the risk of Ischemic
stroke. Results of an international
randomized trial. The EC/IC Bypass
Study Group. New England Journal of
Medicine 1985; 313: 1191 – 1200.
slide 7.1
hierarchy of major study designs
systematic review of RCTs
RCT
interventional
cohort
observational
case control
validity
2001 Bazian Ltd
Formulating a Question
Foreground
Background
A
Novice
B
Experience with the condition
C
Expert
Formulating a Question:
“Background Information”
Ask for general knowledge about a disorder
This question has 2 essential components
• A question root with a verb
(who, what, where, when, how or why)
• A disorder or an aspect of a disorder
Formulating a Question:
“Foreground Information”
Ask for specific information about managing a
patient with a specific disorder
This question has 3 or 4 essential components
P–
I –
C–
O–
Patient/Population/Problem
Intervention/Exposure
Control/Comparison (if relevant)
Outcome
Evidence-based Resources
• ACP Journal Club -- http://www.acpjc.org/index.html
– articles report original studies and systematic reviews that warrant
immediate attention by physicians attempting to keep pace with
important advances in internal medicine
• Clinical Evidence -- http://www.clinicalevidence.org
– from the BMJ Publishing Group; an international source of the
best available evidence for effective health care
• Guidelines -- http://www.guidelines.gov
– a public resource for evidence-based clinical practice guidelines
• Evidence-based Reviews http://www.ovid.com
– Contains ACP Evidence-based Medicine reviews and Cochrane
Library databases
• Centre for EBM -- http://www.cebm.utoronto.ca
– this website helps develop, disseminate, and evaluate resources
that can be used to practice and teach EBM
Major Electronic Resources
(available from Eccles Library)
• Access Medicine
– http://www.accessmedicine.com/ home.aspx
– A collection of textbooks, hot topics and self-assessment
tools: Harrison’s, Goodman and Gilman, etc.
• Cochrane Library
– http://www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME
– A database of systematic reviews and more
• DynaMed
– http://www.dynamicmedical.com/
– 1,800 clinical topic summaries; designed for use at point of
care, providing best available evidence; updated daily
Major Electronic Resources
(available from Eccles Library)
• PubMed/MEDLINE with LinkOut
– http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=uutahlib
– Buttons indicate if material is available in print or electronic formats
• STAT!Ref – ACP’s PIER
– http://online.statref.com/Splash.aspx?SessionId=4C78EFPGJWMMVSYS
– Physicians' Information and Education Resource
– Plus 23 other textbooks for background information
• UpToDate
– http://www.utdol.com/enterprise.asp?bhcp=1
– Author evaluated review of the best evidence
• FreeMedicalJournals
– http://www.freemedicaljournals.com
– Promoting free access to medical journals
General areas covered today
Therapy
Harm/Etiology
Diagnosis
Prognosis
One approach to critically selecting an article
1. What is the Authors reputation?
2. What is the Institutions reputation?
3. What is the Type of study? i.e RCT, review
4. What is the Population and how do they
compare with my situation?
5. Regardless of the outcome will it change
my practice?
6. What are the Methods?
7. What are the Results?
Group Exercise
1. Working in groups of 2 - 4
2. Identify a question
preferably a foreground question
3. Determine a search strategy
4. Perform the search and obtain an article
5. Critically review the article(s) using the
worksheets
6. Share your question, strategy and results
References
1. How to practice and teach EBM. Sackett DL, Straus SE,
Richardson WS, Rosenberg W, and Haynes RB.
Churchill Livingstone. Second Ed. 2000.
2. Users guide to the medical literature. A manual for evidenceBased clinical practice. Guyatt G and Rennie D.
AMA Press. 2001.
Worksheets
http://www.med.ualberta.ca/ebm/ebm.htm