Online Resources for Evidence-Based Clinical Care

Online Resources for Online Resources for Evidence-Based Clinical Evidence-Based Clinical

CareCareElizabeth Eckstrom, MD, MPHElizabeth Eckstrom, MD, MPH

Oregon Health & Science UniversityOregon Health & Science University

Carol Howe, MD, MLSCarol Howe, MD, MLS

University of ArizonaUniversity of Arizona

Today we will:Today we will:

Discuss levels of evidence and how to efficiently find the highest level of evidence for your question

Differentiate foreground and background questions and find the best evidence for each

Practice using some of these resources

Mr. DrakeMr. Drake Mr. Drake is a 72 year old new patient to your

practice. He has a history of HTN and CAD, both medically managed and stable. He exercises regularly, and is enjoying retirement; doing lots of travel with his wife. He wants to plan well for his wife’s future, so is wondering what is his risk of having a heart attack in the next five years?

He has never had a pneumovax, so you recommend one today. He states he has read the literature and doesn’t think he needs one. You have always followed the recommendation to vaccinate your patients over 65, but decide to review the evidence yourself so you can show him why he needs vaccination.

Foreground vs Background Foreground vs Background questionsquestions 5 year prognosis for patients with 5 year prognosis for patients with

stable HTN and CADstable HTN and CAD Pneumonia risk reduction with Pneumonia risk reduction with

pneumovax in a fairly healthy 72 pneumovax in a fairly healthy 72 year oldyear old

What is the best evidence you could What is the best evidence you could find to answer these questions?find to answer these questions?

pyramid modified from: Navigating the Maze, University of Virginia, HealthSciences Library. From The University of Washingtonhttps://healthlinks.washington.edu/ebp/ebptools.html

Background QuestionsBackground Questions

Background questions tend to be Background questions tend to be general questions about a disease general questions about a disease such assuch as– typical clinical presentationtypical clinical presentation– epidemiologyepidemiology– natural history natural history – treatment.treatment.

For Background For Background questions….questions….

TextbooksTextbooks Textbook databases : Textbook databases : Stat!Ref; MD Consult; Stat!Ref; MD Consult;

AccessMedicineAccessMedicine UptoDate -UptoDate -essentially a continuously updated essentially a continuously updated

online textbookonline textbook Clinics of North Clinics of North America-quarterly journal of America-quarterly journal of

review articlesreview articles eMedicine- eMedicine- part of Medscape-regularly updated part of Medscape-regularly updated

point of care reference. (FREE For health care point of care reference. (FREE For health care providers)providers)

Other resources you find useful and reliable?Other resources you find useful and reliable?

Foreground QuestionsForeground Questions

Foreground questions are much Foreground questions are much more focused, targeted questions. more focused, targeted questions.

PICO is an ideal mnemonic for PICO is an ideal mnemonic for helping to build an answerable helping to build an answerable question. question.

The nature of the question will The nature of the question will help you determine the best help you determine the best strategy for how to answer itstrategy for how to answer it..

PICOPICO P-patient, population or problemP-patient, population or problem I-Intervention (diagnostic test, I-Intervention (diagnostic test,

exposure, prognostic factor, therapy)exposure, prognostic factor, therapy) C-Comparison- (population without C-Comparison- (population without

that disease, placebo drug, that disease, placebo drug, comparison drug)comparison drug)

O-outcome-Measurable outcome O-outcome-Measurable outcome such as improvement in symptoms, such as improvement in symptoms, adverse effects, mortality.adverse effects, mortality.

Clinical questions usually fall Clinical questions usually fall into these categories:into these categories:

Etiology (can also include Cause Etiology (can also include Cause and Harm)and Harm)

DiagnosisDiagnosis Therapy (also includes Therapy (also includes

Prevention)Prevention) PrognosisPrognosis

What is the best evidence you could What is the best evidence you could find to answer these questions?find to answer these questions?

pyramid modified from: Navigating the Maze, University of Virginia, HealthSciences Library. From The University of Washingtonhttps://healthlinks.washington.edu/ebp/ebptools.html

Type Of Question Suggested best type of study

Diagnosis prospective, blind comparison to a gold standard

Therapy RCT > cohort > case control > case series

Prognosis cohort study > case control > case series

Harm/Etiology RCT > cohort > case control > case series

Prevention RCT > cohort > case control > case series

Clinical Exam prospective, blind comparison to a gold standard

Cost Benefit economic analysis

From Introduction to Evidence-Based Practice, Duke university Medical Center Library and Health Sciences Library, UNC-Chapel Hill http://www.hsl.unc.edu/services/tutorials/ebm/welcome.htm

For most foreground For most foreground questions:questions:

Look in first in “filtered” or “pre-Look in first in “filtered” or “pre-appraised sources” such as the appraised sources” such as the Cochrane Library ,ACP Medicine Cochrane Library ,ACP Medicine (available also from Stat!Ref), or BMJ (available also from Stat!Ref), or BMJ Clinical Evidence (to name just a Clinical Evidence (to name just a few!)few!)

If there is no recent review, PubMed If there is no recent review, PubMed has some excellent optionshas some excellent options —which we —which we will spend most of the rest of our time reviewingwill spend most of the rest of our time reviewing

Sources for further Sources for further exploration:exploration:

Introduction to Evidence-Based Practice, Duke university Introduction to Evidence-Based Practice, Duke university Medical Center Library and Health Sciences Library, UNC-Medical Center Library and Health Sciences Library, UNC-Chapel Hill . Fifth Edition. (updated July 2010) Chapel Hill . Fifth Edition. (updated July 2010) http://www.hsl.unc.edu/services/tutorials/ebm/index.htm http://www.hsl.unc.edu/services/tutorials/ebm/index.htm

University of Illinois: Evidence Based Medicine: Finding the Best University of Illinois: Evidence Based Medicine: Finding the Best Clinical Literature . Last updated 2008 Clinical Literature . Last updated 2008 www.uic.edu/depts/lib/lhsp/resources/ebm.shtmlwww.uic.edu/depts/lib/lhsp/resources/ebm.shtml

SUNY Downstate Medical Center Evidence Based Tutorial (last SUNY Downstate Medical Center Evidence Based Tutorial (last updated 2004) http://library.downstate.edu/EBM2/contents.htmupdated 2004) http://library.downstate.edu/EBM2/contents.htm

Centre for Evidence-Based Medicine Toronto Centre for Evidence-Based Medicine Toronto http://ktclearinghouse.ca/cebmhttp://ktclearinghouse.ca/cebm

Buckingham J, Fisher B, Saunders D. Evidence-Based Medicine: Buckingham J, Fisher B, Saunders D. Evidence-Based Medicine: mini manual. Based in part on the Evidence-Based Medicine mini manual. Based in part on the Evidence-Based Medicine Toolkit, http://ebm.med.ualberta.ca/ . Last updated July, 2009. Toolkit, http://ebm.med.ualberta.ca/ . Last updated July, 2009. http://www.med.ualberta.ca/dsme/documents/Mini-http://www.med.ualberta.ca/dsme/documents/Mini-manual2009.pdfmanual2009.pdf