FSU College of Medicine1 Selecting the Best Evidence- Based Medicine Resources Daniel J. Van Durme, MD Chairman, Dept. Family Medicine and Rural Health.

FSU College of Medicine 1

Selecting the Best Evidence-Based Medicine Resources

Daniel J. Van Durme, MDChairman, Dept. Family Medicine and Rural Health

Nancy Clark, MEdDirector of Medical Informatics Education


Objectives What is EBM? Formulate a clinical question Apply levels of evidence to decision making

process including patient concerns What are the major EBM databases Search for evidence based information

Using EBM hunting tools


Handouts and Resources EBM Tutorial online

www.med.fsu.edu/informatics/EBMTutorial.asp EBM Resources handout Clinical Question Worksheet Cases Slawson article on EBM

New Resource EBM Teaching Materials



What is EBM? Evidence based medicine (EBM) was

originally defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

(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)

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What is EBM? The revised and improved definition of evidence-

based medicine is “the integration of the best research evidence with clinical expertise and patient values”

It reflects a systematic approach to clinical problem solving.

(Sackett DL, Strauss SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2nd Ed. London: Churchill-Livingstone,2000)

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What EBM skills do all practicing clinicians really need? Among other skills:

Information mastery: finding the best evidence for every day practice

Have at fingertips “just in time’ information at point of care for clinical decision making web based and/or PDA

Evaluate expert-based information, including colleagues, CME, presentations, reviews and guidelines

Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med. 2005 Jul;80(7):685-9.


Advanced EBM SkillsOnly a small percentage of clinicians need to be able to do the

following Critical Appraisal and Interpretation of Research on:

Therapies, Diagnostic Tests, Prognosis Critical Evaluation and Interpretation of:

Systematic Reviews, Including Meta-analysis, Decision Analysis, Practice Guidelines, Pharmaceutical Advertising, Including Pharmaceutical Representatives

Assigning Levels of Evidence to Research Findings Teaching Level 1 Skills Produce written Communication of Research Findings

Physicians Patients (Slawson, et al)


Lifelong Learning Old method: read a few journal articles per

week Reality: Primary care docs would need over

17 hrs/day just to review reasonable and pertinent material

Even in one narrow specialty would need 6+hrs/wk Practicing docs (all specialties) average 1-1.5

hrs/wk

Lifelong Learning from Day to Day Encounters

Reading the articles that happen to cross the desk does not help MY PATIENTS TODAY

Finding evidence based optimal care for my patients today helps them AND helps me to stay current in my field and be an efficient and effective lifelong learner



The EBM Process

“The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning in which caring for one's own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues.”(Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship education. Am J Med. 1997 May;102(5):427-32.)


The EBM ProcessThe patient 1. Start with the patient -- a clinical problem or question

arises out of the care of the patient

The question 2. Construct a well built clinical question derived from the case

The resource 3. Select the appropriate resource(s) and conduct a search

The evaluation 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)

The patient 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

Self-evaluation 6. Evaluate your performance with this patient


Constructing A Clinical QuestionP

patient

I intervention

C comparison

O outcome

Who? What?Alternative

Intervention?Outcomes

“How would I describe a group of patients similar to this particular patient?”

”Which treatment, test or other intervention?”

“Compared to what other treatment, test, or perhaps compared to doing nothing”

What is the patient oriented outcome – better prognosis? Higher rate of cure? Etc.?”


ExamplesP I C O

Kids with acute otitis media -2-4 y/o

AntibioticsNo treatment except

acetaminophen for pain/fever

No pain after two days?

Adult with microhematuria

IVP CT scanDiagnostic accuracy (Predictive value or

likelihood ratio)

Adult patients <70 TIA No TIARates of CVA within 90 days

Healthy adolescentsRoutine

scoliosis screen

No screening – evaluate only if problems

Pain, disability, need for intervention


Types of Questions Best Answered by EBM Resource Therapy Question

In patients with migraine headaches without auras, is Depakote more effective than Inderal for prophylaxis of headaches?

Prognosis Question In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis

with MRI as predictive of healing as an audible pulse on Doppler examination?

Diagnosis Question In geriatric patients with suspected carotid stenosis, is duplex

ultrasound as good as magnetic resonance angiography in detecting significant carotid stenosis?

Harm Question For pregnant patients, does the consumption of large amounts of

coffee, (compared to non-coffee drinkers) increase the rate of spontaneous abortion?


Question Worksheet P - Who? I - What? C- Alternatively? Outcome?

Type of Question Therapy Prognosis Diagnosis Harm/Etiology

Using the worksheet provided, construct a Using the worksheet provided, construct a clinical question from your own practice.clinical question from your own practice.

Assessing Validity Definitions

Level of Evidence (LOE): usually one study Strength of Recommendation (SOR):

recommendation based on multiple studies A value of the confidence in the

recommendation based on the quality of research

Assigned by experts using specific criteria17

Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. Feb 1 2004;69(3):548-556.


Levels of Evidence

Level 1: Systematic Review (with meta-analysis) of Randomized Clinical Trials

Level 2: Cohort Studies Level 3: Case-Control Studies Level 4: Case-series Level 5: Expert Opinion

Centre for Evidence-Based Medicine, Oxford


Strength of Recommendation Taxonomy

A: There is good research-based evidence to support the recommendation.

B: There is fair research-based evidence to support the recommendation.

C: The recommendation is based on expert opinion and panel consensus.

X: There is evidence of harm from this intervention.


Bottom Line on LOE or SOR Level 1 A Highest level Level 2 Level 3 B Level 4 Level 5 C Lowest Level

But still evidence


Evidence Based Medicine Databases (Foraging Tools)

People who do the heavy lifting for you.

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EBM Foraging ToolsA high-quality foraging tool employs a

transparent process that Systematically searches and reviews literature Identify useful, valuable, “quality” research Synthesizes into “bottom line” recommendation

Patient oriented outcomes (POEM); not disease-oriented outcomes (DOE)

Assign level of evidence How to apply recommendations?(Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be

teaching information management instead? Acad Med. Jul 2005;80(7):685-689.)


Major EBM Databases (Foraging Tools) Cochrane Clinical Evidence DARE ACP Journal Club InfoPOEMS Evidence Based _____ USPSTF National Guidelines

Clearinghouse


Cochrane LibraryCochrane Library

The current resource with the highest methodological rigor

For each clinical question, all of the English literature meticulously searched for randomized trials

Large systematic reviews with valid methods + collaborative effort by Review Groups

Conclusions are based on all the evidence from valid randomized trials (treatment and harm questions)


Cochrane Library

Full text at Cochrane Library at Wiley Abstracts in InfoRetriever Limitations

limited to English only addresses questions amenable to

randomized trials most of medicine has not been studied

enough to allow for conclusions $235/year or abstracts only free

www.cochrane.org

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ACP Journal Club About 140 internal medicine journals systematically

surveyed Highest-validity articles abstracted Structured abstracts to guide critical appraisal Clinical commentary Web site acpjc.org Also published in Annals of IM Alerts available


ACP Journal Club Limitations

Limited pediatrics individual article summaries may not account for the “big

picture” may have to read multiple items No “control” over what is covered $78/year ?

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InfoPOEMS Patient Oriented Evidence that Matters Journal of Family Practice and other specialty journals Systematic surveillance of 100 journals Reviews of recent research articles Effect patient concerns – morbidity, mortality, quality of

life Included in Essential Evidence Plus (formerly InfoRetriever)

Daily e-mail updates available

POEMS

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Evidence Based Practice Summaries: structured search, critical

appraisal, authoritative recommendations, clinical perspective, and rigorous peer review

FPIN.org – Family Physicians Inquiries Network

Appear in PEPID




Guidelines.gov Stored at National Guidelines Clearinghouse Agency for Healthcare Research and Quality 1600 Guidelines may be

Explicit evidence-based Evidence-based Research-based (highly referenced) “expert consensus”

Multiple guidelines on one condition


US Preventive Services Task Force First convened by the U.S. Public Health Service in 1984 Since 1998 Agency for Healthcare Research and Quality Leading independent panel of private-sector experts in

prevention and primary care Conducts rigorous, impartial assessments of the scientific

evidence for effectiveness of broad range of clinical preventive services, including screening, counseling, and preventive medications

Its recommendations considered "gold standard" for clinical preventive services


USPSTF Tool Free PDA and online tool (ePSS) Enter age, gender Get recommendations Filter level of recommendations http://epss.ahrq.gov/PDA/


Hunting Tools

Most Bang for Your Buck

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Drilling Down for Information

Grandage KK, Slawson DC, Shaughnessy AF. When less is more: a practical approach to searching for evidence-based answers. J Med Libr Assoc. 2002 Jul;90(3):298-304.


EBM Hunting ToolsA high-quality Hunting tool employs a transparent

process that Searches multiple EBM databases (several

foraging tools) Organizes results to make them easy to find Provides levels of evidence (Slawson, et al)


EBM Pyramid

5, C

MEDLINE

InfoRetrieverDynaMed

Major EBM Hunting Tools

Tools Cochrane ACP Journal

Club

Guide-lines

US-PSTF

LOE

Essential Evidence + Dynamed Clinical Evidence ACP Pier (Web only) PEPID


Web

an

d P

DA

Summaries

Summaries

Summaries


Clinical Evidence Includes >250 conditions Summaries of evidence Specific clinical questions: treatment and prevention Makes specific recommendations States when there is a lack of evidence Book Free from United Health Foundation Web and PDA versions available


Clinical Evidence

Do Clinical Evidence Case



Essential Evidence Plus (EE+) POEMS -- JFP

>104 journals surveyed Over 3500 article synopses Link out to PubMed

Cochrane abstracts Selected evidence-based guidelines Basic drug info Clinical calculators/prediction rules

New Content Essential Evidence summaries

Organized like disease quick reference Bottom Line at top Links to InfoPOEMs, Cochranes Links to calculators and algorythms, images Uses SORT for level of evidence



EE+ Features Essential Evidence (replaces 5MCC) EBM Guidelines Pearls –PDA; Favorites on Desktop Levels of Evidence explained ICD-9 and E/M coding tools Immunization Guide USPSTF Guidelines Derm Expert


Symbols

New 8/09


Essential Evidence Plus Comes in web, desktop and PDA versions Daily POEMS are available in mp3 podcast version Limitations

individual article summaries may not account for the “big picture”

may have to read multiple items $79/year

Do EE+ Case


PEPID FPIN summaries included in CRC module Drug and disease reference, interaction tool Clinical rotation aids for students with basic

principles Lab manual, calculators, images Compares favorably with Epocrates, 5MCC PDA and Online $199 for individual subscription


Using PEPID


Links to Evidence Based Summaries



DynaMed

Designed as entry point to information Textbooks and Medline not efficient Intuitive clinical organization Brief summarized information presented Links out to articles and reviews if more

details needed ICD-9 codes and links to patient information

handouts


DynaMed Sources

Systematic surveillance of 18 primary journals – e.g. BMJ, JAMA, Lancet, NEJM, Pediatrics

12 major EBM resources – e.g. ACP Journal Club, Cochrane Library, InfoPOEMs, Alternative Therapies,

4 drug info sources – e.g. The Medical Letter, FDA MedWatch

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DynaMed Organization of Results Description (including ICD-9

Codes) Description, Also called,

ICD-9 Codes, Types, Organs Involved, Who Is Most Affected, Incidence/Prevalence

Causes and Risk Factors Causes, Pathogenesis,

Likely risk factors, Possible risk factors

Complications and Associated Conditions

History CC, HPI, Meds, PMH, FH,

SH, ROS Physical

Skin, HEENT, Neck, Extremities, Neuro, Pelvic

Diagnosis Making the diagnosis, Rule

out, Tests to order, Blood tests, Urine studies, Imaging studies, Pathology tests, Other diagnostic testing

Prognosis Treatment

Treatment Overview, Diet, Activity, Counseling, Medications, Surgery, Consultation and referral, Other management, Follow-up

Prevention and Screening References (including Reviews

and Guidelines) Patient Information


DynaMed Limitations

variable quality if not Cochrane or review areas with a lot of research can get hard to

navigate. Lot of information-slower to wade through

Hard to navigate on PDA $200/year or effort

Do DynaMed Case

Use CTRL-F to Find words in articles


ACP PIER PIER: The Physicians' Information and Education

Resource. Available online at ACP and PDA ($69/yr) Modules on Disease, Screening and prevention,

complementary medicine, procedures, quality measures and drug resource (Clinical Pharmacology)

Provide A-B-C levels of evidence Excellent Tables summarize recommendations


Do ACP PIER Case



Searching All Resources at Once

WebFeatIn development,

but getting better all the time.Web Only

SummaryNeed Resource

Treatment of common diagnosis Clinical Evidence

Need to create a presentation on a topic DynaMed

Answers to clinical questions, use a clinical decision support calculator, ICD-9 code

Essential Evidence Plus

Tabular summaries of diagnoses, treatment, and follow-up of chronic or acute illness

ACP PIER

Broad and basic overview for med students organized by rotation

PEPID63

CTRL-F


Find the Answer to Your Question

Group exercise

FSU College of Medicine1 Selecting the Best Evidence- Based Medicine Resources Daniel J. Van Durme, MD Chairman, Dept. Family Medicine and Rural Health.

Documents

ebm slide

medicine ebm

levels of evidence

best research evidence

ebm hunting tools slide

hrswk slide

expertbased information

resources ebm tutorial