Evidence-Based Journal Club: An Overview

Akbar Soltani MD.

Tehran University of Medical Sciences (TUMS) Endocrine and Metabolism Research Center (EMRC) Evidence-Based Medicine Research Center (EBMRC) Shariati Hospital www.soltaniebm.com

www.ebm.ir

EBMRC Dr SOLTANI RDC

Agenda

• Introduction and problems • Conventional Vs Evidence-Based Journal club • What is CAT?

• Examples • Goals for journal club • Limitations of CATs • Summary EBMRC Dr SOLTANI RDC

The Problems

• We need information to make decisions. • How often?

From 5 times for every in-patient .

To 2 times for every 3 out-patients.

• We get less than a third of it.

• To keep up to date it is estimated: I need to read 17 articles a day, 365 days a year.

Covell DG, Uman GC, Manning PR: Information needs in office practice: Are they being met? Ann Intern Med 1985;103:596-9.

EBMRC Dr SOLTANI RDC

Sample scenario • In ICU patients, do you suggest tight blood glucose control?

• Wrong format!

EBMRC Dr SOLTANI RDC

Traditional approach

• Pathophysiologic approach • Recency bias (in a paper that i read last night or a case that i had ,… • Rarity bias (complications,…) • Personal habit bias • Territory bias • In my experience (selection bias , information bias,…) EBMRC Dr SOLTANI RDC

Traditional journal club

• Journal clubs are dying or dead in many clinical centers, especially when they rely on a rotating schedule by which members are asked to summarize the latest issues of pre assigned journals.

• Postman

• Usefulness?

EBMRC Dr SOLTANI RDC

Information Sources for Use at the Point of Care

POEM

Usefulness = Relevance x Validity Work

EBM EBMRC Dr SOLTANI RDC

Evidence Based Medicine

1.Translate these needs into answerable questions 2. Track down the best evidence to answer them 3. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in our clinical practices) 4.Integrate that evidence with our clinical expertise and apply it in practice (MDM) 5. Evaluate our performance EBMRC Dr SOLTANI RDC

Evidence based journal club

part 1

• Journal club members describe patients who exemplify clinical situations which they are manage. uncertain how best to diagnose or • This discussion continues until there is consensus that a particular clinical problem , is worth the time and effort necessary to find its solution.

EBMRC Dr SOLTANI RDC

EBMRC Dr SOLTANI RDC

Pt Name: Mr, XY Learner : Resident

P

atient: Elderly, Stroke, HTN…

E

xposure, Intervention : Carotid Stenosis (+/- comparison):

O

utcome: Risk of (dying from) recurrent Stroke Date and Place to be filled: Discuss: Search strategy Search results Validity Importance of the valid results Can you apply this to your pt EBMRC Dr SOLTANI RDC

PICO P: Among patients who are in ICU I: does the use of intensive insulin therapy to maintain tight blood glucose control C: standard therapy O: lead to improvements in ICU outcome?

reduce their risk of dying? Right format EBMRC Dr SOLTANI RDC

Evidence based journal club

part 2

The results of the evidence search the previous session’s problem are on shared in the form of photocopies of the abstracts of four to six systematic reviews, original articles or other evidence.

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Evidence based journal club

part 3

The main part of the journal club session is spent in a critical appraisal of the evidence found in response to a clinical question posed two sessions ago and selected for detailed study last session.

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Evidence Based Journal Club

part

3

Making Your Presentation

EBMRC Dr SOLTANI RDC

Agenda

• Introduction and problems • Conventional Vs Evidence-Based Journal club • What is CAT?

• Examples • Goals for journal club • Limitations of CATs • Summary EBMRC Dr SOLTANI RDC

Definition

• A Critically Appraised Topic (CAT) is “a one- or two page ‘summary of a search and critical appraisal of the literature related to a focused clinical question, which should be kept in an easily accessible place so that it can be used to help make clinical decisions’” .

EBMRC Dr SOLTANI RDC

Six Necessary Elements of CATs

• • • • • • 1. Date of completion (of the CAT) 2. Question – The person or problem being addressed – The intervention or exposure being considered – The comparison of the intervention or exposure, when relevant – The outcomes of interest.

3. Clinical Bottom Line (CAT summary should include applicability of results to your client) 4. Evidence (CAT summary should include a summary of evidence) 5. Gold Standard (For Diagnosis or Screening - compare to best test out there; for Risk and Harm - compare to existing treatments.

6. Notes (important issues, your reflections).

EBMRC Dr SOLTANI RDC

Agenda

• Introduction and problems • Conventional Vs Evidence-Based Journal club • What is CAT?

• Examples • Goals for journal club • Limitations of CATs • Summary EBMRC Dr SOLTANI RDC

EBMRC Dr SOLTANI RDC

Bottom line read in seconds EBMRC Dr SOLTANI RDC

Get bottom line quickly (seconds) Tight blood glucose control improves ICU survival For every 29 patients given intensive insulin therapy, to keep glucose 4.4-6.1 mmol.l

-1 , compared to standard therapy, one less patient dies in ICU (95% CI 17 to 101).

Increased risk of biochemical, but not symptomatic, hypoglycaemia.

Level 1 + evidence

EBMRC Dr SOLTANI RDC

Get bottom line quickly (seconds) Declarative title Tight blood glucose control improves ICU survival For every 29 patients given intensive insulin therapy, to keep glucose 4.4-6.1 mmol.l

-1 , compared to standard therapy, one less patient dies in ICU (95% CI 17 to 101).

Increased risk of biochemical, but not symptomatic, hypoglycaemia.

Level 1 + evidence

EBMRC Dr SOLTANI RDC

Get bottom line quickly (seconds) Tight blood glucose control improves ICU survival For every 29 patients given intensive insulin therapy, to keep glucose 4.4-6.1 mmol.l

-1 , compared to standard therapy, one less patient dies in ICU (95% CI 17 to 101).

Increased risk of biochemical, but not symptomatic, hypoglycaemia.

Level 1 + evidence Summary of treatment effect, and level of evidence

EBMRC Dr SOLTANI RDC

Citation details and search strategy, read in hours

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Read the study (for hours) Citation/s:

Intensive Insulin Therapy in Critically Ill Patients NEJM 2001; 345: 1359 - 67.

Three-part Clinical Question:

In ICU patients, does the use of intensive insulin therapy to maintain tight blood glucose control, compared to standard therapy, lead to improvements in ICU

Search Terms:

outcome?

1. exp sepsis/ or severe sep$.tw or sept$.tw or sepsi$.tw (50301), 2. exp critical care/ or critical ca$.tw or intensive ca$.tw (22553), 3. exp insulin or insuli$.tw (50202), 4. 1 and 2 and 3 (25), 5.

therapy filter (652119), 6. 4 and 5 (17) EBMRC Dr SOLTANI RDC

Read the study (for hours) Hyperlink to journal web site Citation/s:

Intensive Insulin Therapy in Critically Ill Patients NEJM 2001; 345: 1359 - 67.

Three-part Clinical Question:

In ICU patients, does the use of intensive insulin therapy to maintain tight blood glucose control, compared to standard therapy, lead to improvements in ICU

Search Terms:

outcome?

1. exp sepsis/ or severe sep$.tw or sept$.tw or sepsi$.tw (50301), 2. exp critical care/ or critical ca$.tw or intensive ca$.tw (22553), 3. exp insulin or insuli$.tw (50202), 4. 1 and 2 and 3 (25), 5.

therapy filter (652119), 6. 4 and 5 (17) EBMRC Dr SOLTANI RDC

Read the study (for hours) Citation/s:

Intensive Insulin Therapy in Critically Ill Patients NEJM 2001; 345: 1359 - 67.

Three-part Clinical Question:

In ICU patients, does the use of intensive insulin therapy to maintain tight blood glucose control, compared to standard therapy, lead to improvements in ICU

Search Terms:

outcome?

1. exp sepsis/ or severe sep$.tw or sept$.tw or sepsi$.tw (50301), 2. exp critical care/ or critical ca$.tw or intensive ca$.tw (22553), 3. exp insulin or insuli$.tw (50202), 4. 1 and 2 and 3 (25), 5.

therapy filter (652119), 6. 4 and 5 (17)

Search terms used, for reference, and to repeat in future

EBMRC Dr SOLTANI RDC

Trial details read in minutes

EBMRC Dr SOLTANI RDC

Read trial details (minutes) The Study:

Single-blinded randomised controlled trial with intention-to-treat.

The Study Patients:

All patients admitted to a surgical ICU in Belgium (62% had cardiac surgery). Median APACHE 9 (IQ range 7-13). Median TISS 43. 13% had diabetes. Randomised at ICU admission. All patients given iv glucose on admission, next day: parenteral / enteral nutrition or enteral nutrition alone.

Matched for blood glucose at admission.

Control group group

(N = 783; 783 analysed): Insulin infusion (1 U.ml

-1 started if glucose > 12 mmol.l

-1 , and titrated to range 10.0 - 11.1 mmol.l

-1 . Blood ) glucose checked 1 - 4 hourly, algorithm used and discussion with study clinician not involved in patient care.

Experimental group

(N = 765; 765 analysed): Insulin infusion (1 unit/ml) started if glucose > 6.1 mmol.l

-1 , and titrated to keep glucose in range 4.4 - 6.1 mmol.l

-1 . Blood glucose checked 1 - 4 hourly, algorithm used and discussion with study clinician not involved in patient care. EBMRC Dr SOLTANI RDC

Read trial details (minutes) Key design validity features The Study:

Single-blinded randomised controlled trial with intention-to-treat.

The Study Patients:

All patients admitted to a surgical ICU in Belgium (62% had cardiac surgery). Median APACHE 9 (IQ range 7-13). Median TISS 43. 13% had diabetes. Randomised at ICU admission. All patients given iv glucose on admission, next day: parenteral / enteral nutrition or enteral nutrition alone.

Matched for blood glucose at admission.

Control group group

(N = 783; 783 analysed): Insulin infusion (1 U.ml

-1 started if glucose > 12 mmol.l

-1 , and titrated to range 10.0 - 11.1 mmol.l

-1 . Blood ) glucose checked 1 - 4 hourly, algorithm used and discussion with study clinician not involved in patient care.

Experimental group

(N = 765; 765 analysed): Insulin infusion (1 unit/ml) started if glucose > 6.1 mmol.l

-1 , and titrated to keep glucose in range 4.4 - 6.1 mmol.l

-1 . Blood glucose checked 1 - 4 hourly, algorithm used and discussion with study clinician not involved in patient care. EBMRC Dr SOLTANI RDC

Read trial details (minutes) The Study:

Single-blinded randomised controlled trial with intention-to-treat.

The Study Patients:

All patients admitted to a surgical ICU in Belgium (62% had cardiac surgery). Median APACHE 9 (IQ range 7-13). Median TISS 43. 13% had diabetes. Randomised at ICU admission. All patients given iv glucose on admission, next day: parenteral / enteral nutrition or enteral nutrition alone.

Matched for blood glucose at admission.

Control group group

(N = 783; 783 analysed): Insulin infusion (1 U.ml

-1 started if glucose > 12 mmol.l

-1 , and titrated to range 10.0 - 11.1 mmol.l

-1 . Blood ) glucose checked 1 - 4 hourly, algorithm used and discussion with study clinician not involved in patient care.

Experimental group

(N = 765; 765 analysed): Insulin infusion (1 unit/ml) started if glucose > 6.1 mmol.l

-1 , and titrated to keep glucose in range 4.4 - 6.1 mmol.l

-1 . Blood glucose checked 1 - 4 hourly, algorithm used and discussion with study clinician not involved in patient care. EBMRC

Intervention (s)

Dr SOLTANI RDC

Read trial details (minutes)

Outcome Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% ARR 0.034

-0.06 to -0.026

NNT 29 0.01 to 0.058

-0.043

17 to 101 -23 -38 to -17 EBMRC Dr SOLTANI RDC

Read trial details (minutes)

Outcome Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% ARR 0.034

-0.06 to -0.026

NNT 29 0.01 to 0.058

-0.043

17 to 101 -23 -38 to -17

Outcome (s) of interest

EBMRC Dr SOLTANI RDC

Read trial details (minutes) Control group event rate

Outcome Mortality Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% Hypoglycaemia (biochemical) ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% ARR 0.034

NNT 29 0.01 to 0.058

-0.043

17 to 101 -23 -0.06 to -0.026

-38 to -17 EBMRC Dr SOLTANI RDC

Read trial details (minutes) Control group event rate Experimental group event rate

Outcome ARR NNT Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% 0.034

29 0.01 to 0.058

-0.043

17 to 101 -23 -0.06 to -0.026

-38 to -17 EBMRC Dr SOLTANI RDC

Read trial details (minutes) Relative risk reduction

Outcome Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% ARR 0.034

-0.06 to -0.026

NNT 29 0.01 to 0.058

-0.043

17 to 101 -23 -38 to -17 EBMRC Dr SOLTANI RDC

Read trial details (minutes) Relative risk reduction Absolute risk reduction

Outcome ARR NNT Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% 0.034

29 0.01 to 0.058

-0.043

17 to 101 -23 -0.06 to -0.026

-38 to -17 EBMRC Dr SOLTANI RDC

Read trial details (minutes) Relative risk reduction Absolute risk reduction

Outcome ARR NNT Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% 0.034

29 0.01 to 0.058

-0.043

17 to 101 -23 -0.06 to -0.026

-38 to -17

Negative risk reduction = an increase !

EBMRC Dr SOLTANI RDC

Read trial details (minutes) Number needed to treat to benefit

Outcome Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% ARR 0.034

-0.06 to -0.026

NNT 29 0.01 to 0.058

-0.043

17 to 101 -23 -38 to -17 EBMRC Dr SOLTANI RDC

Read trial details (minutes) Number needed to treat to benefit

Outcome Mortality Hypoglycaemia (biochemical) Time to outcome CER EER RRR ICU 63/783 0.08

35/765 0.046

95% Confidence Intervals 43% ICU 6/783 0.008

39/765 0.059

95% Confidence Intervals -61% ARR 0.034

-0.06 to -0.026

NNT 29 0.01 to 0.058

-0.043

17 to 101 -23 -38 to -17

Number needed to treat to harm

EBMRC Dr SOLTANI RDC

Particularised for your own practice, integrate with your expertise

EBMRC Dr SOLTANI RDC

Remember to particularise for your patient

1. Predominantly cardiac surgery patients (59% had CABG) could this group be more like the DIAGMI group of patients?

2. No, main effect was reduction in deaths due to multiple organ failure due a proven septic focus.

3. No details provided of algorithm in article – aimed for normoglycaemia.

4. Reduction in Now available via NEJM website

sepsis

.

and critical illness neuropathy, but are EMG recordings are a surrogate end-point.

5. Insulin is an inexpensive drug, especially compared to activated protein C, and may be more widely applicable.

6. Only single episodes of hypoglycaemia reported with no physical complications.

7. We have a higher MR, death (and death due to sepsis) is more common per 100 patients, we need to treat fewer patients to save a life = NNT / f = 29 / 3 = 10.

Note this is a rough estimate.

EBMRC Dr SOLTANI RDC

Antioxidant vitamins did not reduce death, vascular events, or cancer in high risk patients

presenter: endocrine fellows EMRC EBMRC Dr SOLTANI RDC

Q

• Inpatients with a high risk of death ,does antioxidant supplementation reduce death,vascular events,and cancer?

EBMRC Dr SOLTANI RDC

Design

• RCT • Blinded • F/U 5 y •

Setting

: 69 UK hospitals EBMRC Dr SOLTANI RDC

Patients

• 20536 patients who were 40-80y(28%were >70y ,75%men) • Total cholestrol >3.5

mmol/l • 5y risk of death because history of CHD ,oclusive disease of noncoronary arteies,DM,or treated HTN EBMRC Dr SOLTANI RDC

Exclusion Criteria

• Indication of statin therapy • Abnormal LFT or RFT • Severe heart failure • COPD • Cancer • Indication Of high dose vitamin E f/u :99.7% EBMRC Dr SOLTANI RDC

Intervention

• Patients : Synthetic vitamin E 600 mg/d plus vitamin C 250 mg/d , B-caroten 20 mg/d ( n=10269) • Placebo(10267) EBMRC Dr SOLTANI RDC

Outcome

• All cause,vascular or non vascular mortality • Secondary outcome;coronary(non fatal MI or death from CHD) stroke ; revascularisation cancer EBMRC Dr SOLTANI RDC

Main results

• Antioxidants did not differ from placebo for any outcome EBMRC Dr SOLTANI RDC

Outcome Vitamins Placebo All cause mortality Vascular Mortality Major coronary event 14.1% 8.6% Non vas Mortality 5.5% 10.4% 13.5% 8.2% 5.3% 10.2% RRI (95%CI) 4% (-3_12) 5% (-5_15) 4% (-8_17) NNH Not significant Not significant Not significant 2% (-6_11) Not significant EBMRC Dr SOLTANI RDC

Outcome Vitamins Placebo Stroke Revascula risation Cancer 5% 10.3% 7.8% 5% 10.6% 8% RRR (95%CI) NNT 1% (-12_13) Not significant 2% (-6_10) Not significant 2% (-8_11) Not significant EBMRC Dr SOLTANI RDC

Conclusion

Antioxidants

did not reduce

mortality coronary events, stroke, revascularization, or cancer EBMRC Dr SOLTANI RDC

In the name of god

Journal club Dr hasani ranjbar.sh

21 Jan 2006

EBMRC Dr SOLTANI RDC

The Effects of Strontium Ranelate on the Risk of Vertebral Fracture in Women with Postmenopausal Osteoporosis

EBMRC Dr SOLTANI RDC

The New England Journal of Medicine 350;5 www.nejm.org january 29, 2004 EBMRC Dr SOLTANI RDC

Q

In postmenopausal women with osteoporosis, is strontium ranelate more effective than placebo for reducing the risk of vertebral fractures?

EBMRC Dr SOLTANI RDC

Design: randomized controlled trial Follow up:3 Y Blinded (patients and healthcare providers)

EBMRC Dr SOLTANI RDC

Patient:

1649 women who were >50 y of age and had been menopausal for> 5y ,had >1fracture confirmed by radiography ,and BMD (spine)<0.840g/cm2

Exclusion criteria:

1)severe diseases that interfere with bone metabolism 2)use of antiosteoporosis treatment EBMRC Dr SOLTANI RDC

Intervention:

Throughout the study, subjects received daily calcium supplements at lunchtime (up to 1000 mg of elemental calcium, depending on their dietary calcium intake), to maintain a daily calcium intake above 1500 mg, and vitamin D (400 to 800 IU, depending on the base-line serum concentration of 25-hydroxyvitamin D). After a run-in period of 2 to 24 weeks, depending on the severity of the deficiency of calcium and vitamin D, the subjects were randomly assigned to receive 2 g a day of strontium ranelate (two packets a day of a powder that they mixed with water) or placebo powder for 3 years.

(case:n=828)and(control:n=821) EBMRC Dr SOLTANI RDC

Outcome:

• New vertebral fracture: the semiquantitative grading scale was as follows: grade 0, normal; grade 1, a decrease in the height of any vertebra of 20 to 25 percent; grade 2, a decrease of 25 to 40 percent; and grade 3, a decrease of 40 percent or more.

• Non vertebral fracture and • BMD (spine and proximal femur) EBMRC Dr SOLTANI RDC

Main Results:

fewer patients had height loss of at least 1 cm in the strontium ranelate group (30.1 percent) than in the placebo group (37.5

percent, P=0.003) Over the entire three-year study period, the strontium ranelate group had a 41 percent lower risk of a new vertebral fracture than the placebo group (20.9 percent vs. 32.8 percent; relative risk, 0.59; 95 percent confidence interval,0.48 to 0.73; P<0.001) EBMRC Dr SOLTANI RDC

In strontium group BMD had increased from base line by 12.7 percent at the lumbar spine, 7.2 percent at the femoral neck, and 8.6 percent at the total hip (P<0.001 for all three comparisons with base-line values), corresponding to differences between the placebo and the treatment groups at three years of 14.4 percent, 8.3 percent, and 9.8 percent EBMRC Dr SOLTANI RDC

Outcome Strontium Placebo RRR (95%CI) NNT (CI) New V Fx 21% 33% 36% (24-47) 9 (7-14) Vertebral Height Loss>1 cm Non Vertebral Fx 30% 16% 37.5% 17% 20% (7-31) 14 (9-40) 8% (-17-27) Not significant EBMRC Dr SOLTANI RDC

Conclusion:

Strontium ranelate ingested daily reduced the risk of new vertebral fractures by 49 percent at one year and by 41 percent over a three-year period among postmenopausal women with osteoporosis EBMRC Dr SOLTANI RDC

Commentary:

• 2 trials (PREVOS and SOTI)showed that strontium increased corrected BMD(lumbar) over 2 y • Meunier showed strontium reduced morphometric vertebral fracture by 47%(NNT:17)at 1y and 36% (NNT 9)by 3y • the reduction in the risk of vertebral fracture seems similar to the reduction reported with alendronate (47 percent), 5 mg of risedronate (49 percent), 60 mg of raloxifene(30 percent), and parathyroid hormone (65 percent after 21 months of treatment EBMRC Dr SOLTANI RDC

Example :Diagnosis

CAT

Ferritin can diagnose iron deficiency in the elderly

Clinical bottom line

Serum ferritin can be very useful in diagnosing iron deficiency anemia in the elderly.

Clinical scenari

o . 75 y/o retired schoolteacher (in for a check-up) found to have a Hb of 10, with an MCV of 80, a negative history and physical, and no meds likely to suppress her marrow or cause a bleed. I think her probability of iron deficiency is 1 out of 2 or 50%.

Three-part questio

n . In an elderly symptomless woman with mild anemia, would a serum ferritin help determine whether her bone marrow iron stores were depleted?

EBMRC Dr SOLTANI RDC

Search terms . In Best Evidence, I searched on “ferritin” and got six hits (plus normal value ), including a great single study and an overview.

Appraised by : Sackett in the CEBM, Oxford; Friday, July 09, 1999 The study Independent … ? Yes Blind …? Yes Standard applied regardless of test result … ? Yes Appropriate spectrum … ? Can’t tell Target disorder and gold standard. Bone marrow, stained for iron.

EBMRC Dr SOLTANI RDC

Patients. Consecutive anemic patients in several in-patient and out-patient settings. Transfused patients excluded.

Diagnostic test. Serum ferritin by radioimmunoassay The evidence Test result Present Absent No. Prop. No. Prop . LR < 15 15 –34 35 –64 65 –94



95 Comments 474 175 82 30 48 0.59 0.22 0.10

0.04

0.06

20 79 171 168 1332 0.01

0.04

0.11

0.09

0.75

51.85

4.85

1.05

0.39

0.08

EBMRC Dr SOLTANI RDC

Critically Appraised Topic (CAT)

A one page summary: • Declarative title • Bottom line • Question • Name of paper • Search terms • Design • Setting • Patients • Intervention • Outcome Measures • Results • Table • Commentary and Conclusion EBMRC Dr SOLTANI RDC

Making Your Presentation

1.The clinical question. How it was formed. (5 min) 2.HOW you found what you found. (2 min) 3.WHAT you found. (3 min) 4.The VALIDITY & APPLICABILITY of what you found. (7 min) 5.How what you found will ALTER your MANAGEMENT of the patient. (8 min) EBMRC Dr SOLTANI RDC

Agenda

• Introduction and problems • Conventional Vs Evidence-Based Journal club • What is CAT?

• Examples • Goals for journal club • Limitations of CATs • Summary EBMRC Dr SOLTANI RDC

Goals for Journal Club

• Be able to develop a well-built (PICO) question from a clinical scenario • Understand key search terms and use them to identify relevant literature • Critically appraise an article in the style outlined by Sackett et al.

• Apply the results of the EBM process to the care of a patient (clinical reasoning) EBMRC Dr SOLTANI RDC

Goals for Journal Club

• Present journal club in an educational fashion, giving equal emphasis to both the clinical content and the EBM process • Highlight one aspect of study design or statistics during the journal club, making it relevant and useful to those in attendance. • Contribute a well-done Critically-Appraised Topic ( CAT ) to the files EBMRC Dr SOLTANI RDC

Agenda

• Introduction and problems • Conventional Vs Evidence-Based Journal club • What is CAT?

• Examples • Goals for journal club • Limitations of CATs • Summary EBMRC Dr SOLTANI RDC

Limitations

• 􀁺First is the limited applicability of individual CAT.

–Created in

busy

practice –It is a

single piece

of evidence summarized –

Incomplete, non-representative

of the entire body of evidence • 􀁺Individual CATs can be wrong –First appear as drafts,

without peer review

.

–May contain

inferior evidence, or errors

of fact, calculation, or interpretation.

• 􀁺They have a short “half life” –be

obsolete

as new evidence becomes available.

EBMRC Dr SOLTANI RDC

EBMRC Dr SOLTANI RDC

EBMRC Dr SOLTANI RDC

Bottom Line!

1. The new challenge in medicine is information mastery. (Vs content expert) 2. In order to survive in the information age every clinician needs tools, based on the information mastery equation: Usefulness = (Relevance x Validity)/ Work 3. CATs have evolved to be highly useful !

EBMRC Dr SOLTANI RDC

EBMRC Dr SOLTANI RDC

Thank you

EBMRC Dr SOLTANI RDC