September 16, 2010 Larissa J. Lucas, MD Senior Deputy Editor, DynaMed

Disclosure

 Senior Deputy Editor,  DynaMed, EBSCO Publishing, Ipswich, MA  Clinical Instructor in Medicine  Harvard Medical School, Boston, MA

Evidence Based Medicine

 conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients  integrating individual clinical expertise with the best available external clinical evidence from systematic research Sackett DL BMJ. 1996 Jan 13;312(7023):71-2

Clinical Expertise and Patient Preference

Haynes RB ACP J Club. 2002 Mar-Apr;136(2):A11-4.

Evidence Based Decision Making

Tilburt JC. J Eval Clin Pract. 2008 Oct;14(5):721-5

Why we need EBM tools

 Barriers to answering clinical questions  Ebell MH. Am Fam Physician. 2009 Feb 15;79(4):293  Time  Doubt  Culture  Access  Rising health care costs  Quality of care  Industry sponsored studies ( BMJ. 2007 Dec 8;335(7631):1202 )

Answering clinical questions

 112 primary care physicians  3,511 visits with 635 questions    22.8% questions were investigated 14% of questions investigated not answered time to answer questions  2 minutes during consultation  32 minutes after consultation  48 primary care physicians  1,062 questions      55% questions investigated doubt that answer existed for 11% questions resource failure in 26% 41% of answers were found easily 31% found with difficulty J Am Med Inform Assoc. 2005 Mar-Apr;12(2):217-24 Ann Fam Med. 2007 Jul-Aug;5(4):345-52.

How to ask a question

 Cochrane systematic review  4 trials     PICO training PubMed searching training Information seeking training Question formulation training  Short-term benefits  Improved searching time  Improved question quality  Improved satisfaction with searching  Increased correct answers Cochrane Database Syst Rev. 2010 May 12;5:CD007335.

Existing tools

 Textbooks and handbooks  PubMed  Guidelines  Google  News services  Subscription online databases

Types of Tools

  Alerting “foraging”      Prompts clinicians to ask questions Filtered for relevance and validity Transparent evaluation and appraisal process Evidence rating Differentiate between “news” and practice changing outcomes Finding “hunting”  Finding the answer to a clinical question     Transparent evidence rating criteria Transparent reproducible methodology Ease of use Ease of access

Relevance: Patient Oriented Outcomes

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Symptoms Functioning Quality of Life Lifespan

Validity

Validity

 Use of appropriate criteria for appraisal  Randomized trials  Systematic reviews  Diagnostic studies  Prognostic studies  Criteria include patient oriented outcomes

Effect on Patient-

Oriented Outcomes

  Symptoms (drivers license) Functioning (visual loss)  Quality of Life (leg ulcers)  Lifespan Effect on Disease Markers  Diabetes (Photocoagulation, GFR, NCV)  Arthritis (x-ray, sed rate)  Peptic Ulcer (endoscopic ulcer) Effect on Risk Factors for Disease  Improvement in markers (blood pressure, HBA1C, cholesterol)

SORT C SORT B SORT A

Uncontrolled Observations & Conjecture Physiologic Research Preliminary Clinical Research  Case reports  Observational studies Validity of Evidence Highly Controlled Research   Randomized Controlled Trials Systematic Reviews

Adapted with permission from Slawson D. Evidence Based Medicine: Don’t We Need Information Management Instead?

Defining Evidence-Based for a Clinical Reference Evidence-Based = conclusions based on best available evidence 1.

2.

3.

4.

5.

6.

7.

Systematically identifying all applicable evidence Systematically selecting the best available evidence from that identified Systematically evaluating the selected evidence (critical appraisal) Objectively reporting the relevant findings and quality of the evidence Synthesizing multiple evidence reports Deriving overall conclusions and recommendations from the evidence synthesis Changing the conclusions when new evidence alters the best available evidence

What clinicians need

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Comprehensive

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Valid

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Systematic

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Current

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Synthesized

Access

 Desktop  Mobile  Electronic Health Record