EBM in Real Time

Jane Gagliardi, MDReal Inpatient Doctor

Lawrence Greenblatt, MDReal Outpatient Doctor

Objectives

• To see / use EBM as a clinical tool• To see some practical ways to keep up with

evidence in your field• To see how EBM can help even if you are

not a content expert• To recognize EBM as patient-centric• To use the best available evidence in the

everyday care of patients

EBM Strategy

• Take Care of Patients• Identify Area of Uncertainty (Rx, Dx,

Prognosis, Etiology/Harm)• Formulate a Clinical Question (PICOTT)• Search Medline and find article• Critically Appraise the Article• Apply what you learned back to the patient

What Barriers Exist?

• EBM Knowledge and Skills• Time• Access to Resources• Time• Conflicting Information• Time• Inadequate Incentives• Time

EBM in Residency

• Hospital-based questions• Citations for H & P’s• Impress your team• CAT’s• Heavy focus on therapy• Supplements broad “background

learning”• Less time available than desired

EBM in Practice

• Range of settings-Inpatient, Outpatient, ER, Hospital Policy, Health Insurance, Public Policy

• Questions across domains other than therapy

• More focus on latest data• Increased emphasis on foreground• Time available is further compressed

What EBM Resources Are You Using?

• Medline• BMJ Evidence Updates/ACP Journal Wise• Cochrane Library• Guidelines.gov

Global Warming (on a small scale)

• 52 year old woman reports poor sleep for the last 3 months. She has nightly “power surges” which disrupt her sleep. No menses for 4 months. FHx: Mother had CABG at 62 (smoker). She died at 68 of AMI.

• Wants to consider HRT but is concerned about increased risk of CAD events and CAD death.

• PICOTT

Patient: PAG

• ID: 66 year old WM active, generally healthy• CC: Crushing substernal chest pain, requesting

ambulance to ER• Wife believes this may be a panic attack

Soh KC, Lee C. Panic attack and its correlation with acute coronary syndrome - more than just a diagnosis of exclusion. Ann Acad Med Singapore. 2010 Mar;39(3):197-202.

How likely do you think it is that PAG is having unstable angina or an acute coronary

event? (write down/remember your number!)

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. A) 0-10%2. B) 11-20%3. C) 21-30%4. D) 31-40%5. E) 41-50%6. F) >50%

Pre-test Probability

• Estimate made prior to testing of how likely it is a patient has a disease

• Where does this come from?– Clinical judgment after H&P (and other tests)– Prevalence of disorder in your population

• Epidemiologic data– Clinical manifestations of disease articles– Differential diagnosis articles– Clinical Prediction Rules

Patient: PAG• ID: 66 year old WM active, generally healthy• CC: Crushing substernal chest pain, requesting

911. Never had chest pain before this episode• PMH: HTN, Paraesophageal hiatal hernia,

GERD, Barrett’s esophagus• FH:

– Sudden cardiac death (father, MI, age 61)– DM (both brothers)– Depression, dementia (mother, AD, age 86)

• SH: Nonsmoker, 1-2 etoh drinks per month, no drugs, increased stress at work over last year

How likely do you think it is that PAG is having unstable angina or an acute

coronary event? (write down/remember your number!)

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. A) 0-10%2. B) 11-20%3. C) 21-30%4. D) 31-40%5. E) 41-50%6. F) >50%

What likelihood of acute coronary syndrome would you be able to tolerate and

release PAG with outpatient follow-up? (write down/remember your

number!)

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. 40-50%2. 20-40%3. 15-20%4. 10-15%5. 5-10%6. 0-5%

What likelihood of ACS would cause you to send PAG to the CEU for r/o MI and do stress test in the a.m.? (write down/

remember your number!)

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. 40-50%2. 20-40%3. 15-20%4. 10-15%5. 5-10%6. 0-5%

What likelihood of ACS would cause you to send PAG directly to the interventional

cardiac catheterization lab? (write down/ remember your number!)

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. 40-50%2. 20-40%3. 15-20%4. 10-15%5. 5-10%6. 0-5%

Making a Diagnosis

Zone of Action Zone of ActionZone of Uncertainty

Patient: PAG• Medications:

– Lisinopril 10 mg PO daily– HCTZ 25 mg PO daily– Aspirin 81 mg PO daily– Nexium 40 mg PO BID

• ROS: Sudden onset crushing substernal chest pain, radiating to shoulders; shortness of breath, dizziness; slight nausea, no vomiting

• PE: 95/62, 96, 24, afebrile. Uncomfortable appearing WM, breathing OK but complaining of pain. Slight tachycardia. Clear lungs. No edema.

Diagnostic Tests

Where to find Likelihood Ratios?• Go to primary sources of literature

– Make 2x2 tables– Calculate sensitivity/specificity, LR+ and LR-– Many journal articles contain LR’s!

• Go to the Rational Clinical Examination

http://www.jamaevidence.com/content/3484335

http://www.jamaevidence.com/content/3484335

66 year old male with sudden onset crushing substernal chest pain radiating to shoulders; shortness of breath, dizziness; slight nausea, no vomiting

http://www.cebm.net/index.aspx?o=1161

EXERCISE: Use Interactive NomogramUse the nomogram at CEBM.net to arrive at a post-test probability of disease

How likely do you think it is that PAG is having unstable angina or an acute

coronary event?

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. A) 0-10%2. B) 11-20%3. C) 21-30%4. D) 31-40%5. E) 41-50%6. F) >50%

The Rational Clinical Examination > Myocardial InfarctionSection Authors: David L. Simel, Stephen W. Goodacre, L. Kristin Newby

Goldman Chest Pain Decision Rule

Patient: PAG

How likely do you think it is that PAG is having unstable angina or an acute

coronary event?

1 2 3 4 5 6 7

0% 0% 0% 0%0%0%

1. A) 0-10%2. B) 11-20%3. C) 21-30%4. D) 31-40%5. E) 41-50%6. F) He is having an MI

Should I bother?

• Your 76 year old patient, a retired piano teacher presents for a comprehensive visit. She is fairly thin (BMI 23), controlled type 2 DM, and good functional status with no cognitive or physical limitations.

• She objects when you recommend she undergo mammography. “I’ll probably be dead by the time I’m 80 anyway.”

Heart Failure and Potato Chips• 81 year old man presents with weakness and poor

exercise tolerance for 6 months. Recently he notes modest ankle swelling and some orthopnea. Exam has some suggestion of HF (JVP, ankle edema) and echocardiogram shows new, severe systolic failure.

• At his 1st follow up visit you are reviewing treatment and he asks you if he should follow a low sodium diet to minimize symptoms and risk of dying.

• PICOTT

BREAK

Patient: PAG

• 600-mg clopidogrel load• Directly to the ICC lab• Findings:

– Slow flow, no acute coronary obstruction

Patient: PAG

• Findings:– Massive aortic dissection,

root aneurysm– Acute aortic insufficiency

• Recommendation:– Dacron aortic graft– Hypothermic circulatory

arrest

Patient: PAG

• Seeking Reputable Background Information

Patient: PAG

66 year old WM s/p St Jude aortic valve

Dacron aortic arch SVG to the RCA

Intraoperative VF LidocaineAmiodarone loadDaily amiodarone

Patient: PAG

• Postoperative day 4: bad taste in mouth– Amiodarone discontinued

• Postoperative day 6: atrial fibrillation– Digoxin started

Ask/Acquire

“Neither digoxin nor verapamil reduced the likelihood of SVAs after CABG (digoxin: OR = 0.97, 95% confidence interval [CI] = 0.62-1.49; verapamil: OR = 0.91, CI = 0.57-1.46). The likelihood of developing an SVA in patients treated with beta-blockers was markedly decreased compared with controls (OR = 0.28, CI = 0.21-0.36).”

Patient: PAG

• Does prevention of postoperative atrial fibrillation provide benefit?– Mortality– Stroke/embolic phenomena– Hospital length of stay– Incidence of atrial fibrillation

The odds of postoperative atrial fibrillation with pharmacological intervention are 4/10 the odds of postoperative atrial fibrillation

without pharmacological intervention.No real differentiation between types of intervention is possible from these data.

Patient: PAG

• Attempting to resume usual activities, PAG is told by the PA at the cardiology practice never, ever to eat anything with cranberries while taking warfarin.

• Is cranberry consumption bad with warfarin?

Ask

• P• I• C• O• T• T

Patients on warfarin anticoagulationCranberry / Cranberry JuiceNo Cranberry / Cranberry Juice???

Acquire

Appraise

• FRISBE– Follow-up– Randomization / Concealment– Intention to Treat– Similar at Baseline– Blinding– Equal Treatment outside of Intervention

How would you advise PAG regarding cranberry juice consumption?

1 2 3 4 5

0% 0% 0%0%0%

1. It’s too dangerous: never consume it

2. With weekly INR checks, it’s OK.3. Stop taking warfarin and eat/drink

what you want.4. Data for harm are not convincing

despite anecdotal reports.

Evidence-based expert in medical-

decision-making

Dr. Larry Greenblatt

Don’t Ask Me Questions!

• 66 year old professor in for annual exam. Treated for asthma, HL, prediabetes and htn.

• Your 3rd year student wants to know why you choose to treat him with amlodipine and losartan. Why not a beta blocker and diuretic as recommended in the JNC VII guidelines?

• You mock the JNC VII as being ancient and look for a more up to date evidence-based guideline.

My Elbow Hurts!• 49 year old man, very unathletic, complains

of pain over the lateral aspect of the elbow. Pain is made worse by lifting a jug of milk or carrying his briefcase. No pain with elbow movement. There is focal tenderness the area of pain. Provocative testing by resisting wrist extension reproduces the pain.

• His orthopedics PA has recommended a steroid injection. Do you concur?

• PICOTT

Patient: PAG

• Two months post-operatively (2/26):– Fanatically monitoring all Vitamin K intake– Mildly irritated at differing recommendations

from differing providers– INR finally therapeutic

• Sudden onset right flank pain– arterial embolism to R kidney

Patient: PAG

• Renal function is stable (Cr 0.9-1.3)• Aortic dissection is stable, with nearly

equal-sized false and true lumens• Vascular surgeon considers the merits of

endovascular fenestration

(Circulation. 2006;114:II_362.)

BACKGROUND INFORMATION (what are they talking about, anyway?)

• Assess – 66 year old man with impaired renal blood

flow, recent type A dissection all the way to iliacs

• Ask– P (aortic dissection, impaired renal blood flow)– I (fenestration)– C (no fenestration)– O (end-organ damage, mortality, stroke)

• Acquire• Appraise• Apply

A Multitude of Questions:Should PAG get a home automated defibrillator?

Will taking warfarin increase PAG’s risk of prostate cancer?

What about inconsistent Vitamin K in PAG’s diet?Anything to make warfarin safer?

Is a target INR 2.5-3.5 superior to a target INR of 2-3 in a patient with a St. Jude aortic valve?

What is the likelihood of a future embolic event?

What preventive measures can one take after extensive aortic dissection to reduce probability of future bad outcomes?

Is there a benefit of unfractionated heparin over LMWH when PAG’s INR drifts to 1.4?

Should first-degree relativesbe screened for aortic aneurysm?

Should PAG go back to work?

Wrap-Up

• Evidence-Based Medicine is a clinical tool• You can use the process even (especially!)

if you are not a content expert• Knowing how to use the best available

evidence in the care of patients will be useful during your entire career (and life)

• OK to let someone else do the appraisal• EBM starts and ends with the PATIENT

ASSESS

ASK

ACQUIRE

APPRAISE

APPLY

The 5 A’s

EBMCycle

MUST CONSIDER: - Patient preference- Access to care- Quality of life- Goals of care

WHAT’S GOING ON?- History and Physical- Initial Formulation

PICOTT- Patient /

Population- Intervention- Control- Outcome- Type of Question- Type of Study

LITERATURE SEARCH

VALIDITY CRITERIA- Methods- Results- Sources of Bias- Strength of evidence

Questions?Complaints?Applause?