EBP in practice…

• 43-year-old woman with 1-3 migraine headaches per week.

• Otherwise healthy.

• Stress is a significant trigger for her headaches,

• Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost.

• She prefers “alternative” approaches

• Has heard that acupuncture can help migraines.

The patient asks:

• Should she pursue treatment with us or try an “alternative” approach such as acupuncture?

• What do we think would be the most effective treatment for her?

The 5-step process:

1. Convert information needs into a clear question.

2. Search for the best evidence in the literature.

3. Critically appraise the evidence.

4. Integrate with a patient’s needs, preferences, circumstances, and values.

5. Evaluate the outcome.

Background Questions

• What are the most effective treatments for chronic migraine headache? • Pharmacological• Non-pharmacological

• Is acupuncture an effective treatment for migraine headache?

• Are there any significant risks associated with acupuncture?

P = I =

C =

O =

Foreground Questions

In middle aged women with migraine headaches

is there any evidence that acupuncture

compared to sham treatment, biofeedback, relaxation training, and cognitive-behavioral therapy

reduces the frequency, intensity, and/or duration of migraines?

Background vs. Foreground Questions: Where to lookBackground vs. Foreground Questions: Where to look

Background questions EB e-textbooks [UpToDate, Clinical Evidence] EB guidelines, systematic reviews, ESTs

Foreground questions if not found at a higher level, search MEDLINE / PsycINFO search

• UptoDate and Clinical Evidence for background information

• Two evidence-based guidelinesAAN (pharmacological and non)Headache Consortium (behavioral and

physical treatments)

Acupuncture for idiopathic headache

Conclusion from Cochrane Systematic Review:

Existing evidence supports the value of acupuncture for the treatment of idiopathic headaches…

There is insufficient evidence to assess … whether it is as effective as other headache treatments.”

No significant risks.

What did we find?

Clinical Evidence and UptoDate, e-textbooks: • Evidence-based up to date background

information on migraineRecent evidence-based guidelines on HA management:

• American Academy of Neurology • Headache Consortium (behavioral and physical

treatments) Systematic reviews:

• From the Cochrane Library:• “Acupuncture for idiopathic headache”• Two reviews on “Is acupuncture safe?”

Specific EBP search tools in Medline and PsycINFO (MeSH terms/ filters/ clinical queries in PubMED)

SUMMARIES

SYNTHESES

Individual articles

What did we know thus far?• Acupuncture > sham or no tx• ? Compared to other txs • Relatively safe

• Relaxation, CBT, and BFT

….have all been shown to reduce migraine headaches between 40-60%.

Foreground questions:• In middle aged women with migraine, is CBT more

effective than biofeedback in reducing frequency, duration or intensity of migraine headaches?

• Or…In middle aged women with migraine, is acupuncture more effective than CBT in reducing frequency, duration or intensity of migraine headaches?

Medline and PsycINFO

PsycINFO and PubMed: Important search concepts• Why not just type in keywords?• Truncation• Alerts

Why not just type keywords?

Keywords look for that exact word in the article.

Acupuncture……………Acupressure Behavior……………….. BehaviourTension headache……… Muscle contraction

headacheDepression………………Major depressive

disorderdysthymia

Controlled Vocabulary

Librarians “tag” each article with labels based on the concepts in the article. These labels are standardized.

This allows the user to retrieve information that uses different terminology for the same concept.

Medline: MeSH terms

Truncation

Keywords look for that exact word in the article.

Acupuncture……………Acupressure (acup$)Behavior……………….. Behaviour (behav*)Tension headache……… Muscle contraction

headache Depression………………Major depressive

disorder dysthymia

How to do a Medline/ PsycINFO EBP search:

1. Select terms from the controlled vocabulary list

2. Search each term individually

3. Use AND / OR to combine the sets.

4. Limit to Humans and English

5. Limit to EBM reviews.

…and we set up Alerts

AlertsIndividual journals and databases

Medline and PsycINFO:

save your searchautomatic email

Partner with your medical librarian

Ask people in your own field…

EBP begins and ends with the patient

Best research evidence

Patient Characteristics,

Values, and Context

Clinical Expertise

CD

Relaxation, BFT, CBT: A

Behavioral therapy + Med : B

Acupuncture: some evidence but inconclusive

• More evidence for acupuncture than other “alternative” treatments

• Acupuncture is low risk

Best research evidence

Patient Characteristics,

Values, and Context

Clinical Expertise

CD

Prefers “alternative” treatments

Concerned about cost

No co-morbid conditions

Similar to pts in studies

Behavioral treatments feasible

Insight into the link between stress and headaches

Cost of acupuncture unknown at time of assessment

Not needle-phobic

Best research evidence

Patient Characteristics,

Values, and Context

Clinical Expertise

CD

Assess the patient accurately

Communicate with the patient

• Integrate the research and clinical evidence

• Ability to deliver the txs of choice?

Step 4: Applying the evidence• Clinical intervention that involves the

patient• Clinical decision is made jointly

The Clinical Decision:

Begin treatment with BFT and relaxation training

“Alternative” treatment Affordable, feasible

Incorporate CBT

Monitor outcomeReconsider acupuncture therapy

Questions and Discussion….