Existing knowledge can prevent…
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Transcript of Existing knowledge can prevent…
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Existing knowledge can prevent…
•Waste•Errors•Poor quality clinical care•Poor patient experience•Adoption of interventions of low value•Failure to adopt interventions of high value
Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health Service. Quoted on http://www.nks.nhs.uk/.
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Learning Objectives
At the end of the presentation, learners will:• be able to define evidence based medicine
(also referred to as evidence based practice, evidence based eye care, etc.)
• be able to utilize a well-built clinical question to facilitate an efficient search
• understand the 4S approach to organizing medical evidence
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What is EBM?
Evidence Based Medicine (EBM) is defined as the practice of medicine that ‘requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances’.
Source: Straus SE, Richardson, WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd ed. New York: Elsevier Churchill Livingstone, 2005.
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Definitions
Best research evidence:• ‘Valid and clinically relevant research’.
Clinical expertise:• ‘Ability to use our clinical skills and past
experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal circumstances and expectations ‘.
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Focused Approach Saves Time
You will not have time to read all of the important articles in the literature• 500,000 new medical articles published each year
You will be expected to quickly make increasingly complex decisions • Sorting the valid information from the less useful takes time away from
decision making
You will be expected to “standardize” your practice• Standard of care critical in health care reform and legal issues
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New Skills
Efficient literature searching Evaluate the literature according to formal rules of
evidence
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Information Retrieval for Evidence Based Patient Care Using research findings versus conducting research Retrieving and evaluating information that has direct
application to specific patient care problems Selecting resources that are current, valid, and
available at point of care Developing search strategies that are feasible within
time constraints of clinical practice
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Steps to Practice EBM
1. Convert information need into answerable clinical question
2. Track down the best evidence to answer the question
3. Critically appraise the evidence for its validity (closeness to truth) , impact (size of the effect), and applicability (usefulness in practice)
4. Integrate appraisal with clinical expertise and with patient’s unique values and circumstances
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Improvements in EBM Practice
1. Development of efficient search strategies to retrieve the evidence, e.g., clinical queries in Ovid MEDLINE
2. Creation of systematic reviews
3. Development of new clinical decision support tools
4. Future: Systems that integrate and summarize relevant research evidence about specific clinical problems and link through the EMR to a specific patient’s circumstances
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“Using” EBM versus Doing EBM
Rapidly develop and practice EBM with limited time and resources
Use the 4S approach to locate critically appraised content
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4S Hierarchy
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Information Pyramid
Up-to-date, Dynamed, FIRSTConsult, ACP PIER
ACP Journal Club Evidence Based
Ophthalmology
Cochrane and other Systematic Reviews (OVID EBMR)
MEDLINE Searches with Clinical Queries
SOURCE: Haynes, R. B. (2001). Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence. Evidence-Based Medicine, 6 (2), 36-38. Retrieved 2-07-07 from http://ebm.bmj.com/cgi/reprint/6/2/36
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Critically Appraised Content
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Appraisal Required by User
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Steps to Using EBM
1. Convert information need into answerable clinical question
2. Track down the best evidence to answer the question
3. Use the 4S approach to locate critically appraised content
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Is the Evidence Available?
For many common, clinical issues in Optometry and Ophthalmology, there are few acceptable sources to guide decision making
Implementation of evidence-based practice in optometry, p. 240
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Using EBM – Step 1
Frame the well built clinical question Arises from the clinical encounter Used to initiate search for evidence
Four basic types of clinical questions Therapy/prevention Diagnosis Etiology Prognosis
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Selecting the Question
Begin with the patient encounter Which question
is most important to the patient’s well being fills gaps in your clinical knowledge is feasible to answer in the time available
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Foreground Clinical Questions
Deal with patient management issues Contain elements of PICO format
Patient/Population Intervention Comparison Intervention (if useful) Outcome
Facilitate an efficient search
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Example – Therapy Question
In patients with open angle glaucoma (POAG), does IOP lowering treatment (medical or surgical) versus no treatment delay visual field loss?
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Search Terms
Therapy Question In patients with open angle glaucoma
(POAG) [Patient/Population], does IOP (intraocular pressure) lowering treatment (medical or surgical) [Intervention] versus no treatment [Comparison Intervention], delay visual field loss [Outcome]?
Search Terms: open angle glaucoma, POAG, IOP, intraocular pressure, visual field loss
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Type of question leads to type of study to best answer the question
Type of Question Type of Studies
Therapy Select treatments that do more good than harm, worth the effort and costs
Diagnosis Select and interpret diagnostic tests against the gold standard
Prognosis Estimate the patient’s clinical course
Etiology/Harm Identify causes and risk factors
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Randomized controlled trials are considered the best studies for assessing therapeutic interventions.
Source: Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.
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Evidence Pyramid
Number of studies fewer at higher levels of the pyramid, but of higher quality and relevance to clinical practice
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Best Study Design for Type of Question
Type of Question Study Design
Therapy Randomized controlled trials
Diagnosis Prospective cohort, blind comparison to a gold standard
Prognosis Cohort, Case Control, Case Series
Etiology/Harm Cohort, Case Control, Case Series
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Using EBM – Steps 2 & 3
Track down the evidence to answer the question
Use the 4S approach to select the most likely resource
Start with the highest level resource available
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Critically Appraised Content
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Systems
• Dynamed– Summaries for more than 3000 topics– Monitors >500 medical journals and
systematic review databases– Updated daily– Each article evaluated for clinical relevance
and scientific validity
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Databases
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Databases
1:39
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Synopses
• A step down from Systems• Useful when no answer can be found in
the Systems• Summary of individual studies and reviews• Faster than reviewing the individual
studies• Examples: ACP Journal Club, Evidence
Based Ophthalmology
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Synopses
• ACP Journal Club– 1991-2009 archive of cumulative content– Periodically thinned– Selected from >100 journals– Published monthly– “Structured abstracts”, critically appraised– Commentaries on context, methods, and
clinical applications by expert clinicians– IM focus (Tx, Px, Harm, and Dx)
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ACP Journal Club
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Synopses
• Evidence Based Ophthalmology– Quarterly journal includes reviews of 24
critically relevant articles from ocular literature– Editorial board comprised of practicing
physicians with expertise in epidemiology and clinical trials
– Search NSU Journals@Ovid
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Evidence Based Ophthalmology
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Syntheses
• Systematic reviews• Supplement Synopses with more detail• Compare findings• Cochrane Database of Systematic
Reviews is the premiere example
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Syntheses
• Cochrane Database of Systematic Reviews– Part of the Cochrane Library (1996)– 916 completed reviews, 1905 protocols– Among the highest level of evidence upon
which to base treatment decisions– Includes Dx since 2008– Eyes & Vision Research Group
• Contains 136 reviews
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Systematic Review
• Analyzes data from several primary studies to answer a specific clinical question
• Provides search strategies and resources used to locate studies
• Includes specific inclusion and exclusion criteria (results in less bias)
• Meta-Analysis (subclass) statistically summarizes results of several individual studies
• Access through OVID
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Cochrane Database
:15
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Syntheses• All Evidence Based Medicine Reviews
– Database of seven EBM Resources• ACP Journal Club (synopsis)• Database of Abstracts of Reviews of Effects
(DARE) (synthesis)• Cochrane Database of Systematic Reviews
(synthesis)
– Access through Ovid– Expands search for summaries/reviews
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Appraisal Required by User
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Original Studies• Synopses and syntheses take 6 months to
years to appear• If the other “S’s” don’t provide the answer,
search for studies• Must critically appraise the evidence
yourself. Understand and apply measures of internal/external validity
• Least efficient (in terms of time) for clinical questions
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Primary (Original) Studies
• Articles that report results of original research investigations
• Conclusions supported by data and reproducible methodology
• Good Source: MEDLINE (OVID)
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Databases
• MEDLINE– Premiere biomedical database from the NLM
(National Library of Medicine)– Covers 1950-present– Indexes >4000 international biomedical
journals– Full text available for many articles– Access through Ovid
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MEDLINE Indexing
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Search Query
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Boolean Connectors
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MEDLINE Search Limits
• Limit search results to study type– Randomized controlled trials– Clinical trials
• In OVID, limit by “Clinical Queries” • Appraise study for validity and relevance
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Ovid MEDLINE Clinical Queries
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Levels of Evidence
• Grade the quality of evidence based on the design of the clinical study
• Variety of hierarchies in use
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American Academy of Family Physicians Rating System Level A
Systematic reviews of randomized controlled trials including meta-analyses
Good-quality randomized controlled trials Level B
Good-quality nonrandomized clinical trials Systematic reviews not in Level A Lower-quality randomized controlled trials not in Level A Other types of study: case control studies, clinical cohort studies,
cross sectional studies, retrospective studies, and uncontrolled studies
Level C Evidence-based consensus statements and expert guidelines
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Dynamed
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Take Home Points
Foreground question (PICO) reveals your search terms
Start your search at top of 4S hierarchy and work down
Be aware of the filter Look at more than one resource in the
hierarchy. Findings may differ. Practice makes perfect
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Evidence Based Medicine LectureNSUOCO Residency Journal Club
Sandra A. Martin, M.L.I.S.Health Sciences Resource Coordinator
Optometry Subject LibrarianJohn Vaughan Library Room 305B
[email protected] – 918-444-3263