ebm wardwork
TRANSCRIPT
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MADELEINE GRACE M. SOSA, MDChair, Dept. of Clinical Epidemiology
EBM WARDWORK
Orientation
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ELGAs Objectives OR Expected LearningOutcomes
Content ActivitiesTeacher Student
Resources Evaluation
HEALTH
CAREPROVIDER( Competent,compassionate and SafePhysician)
RESEARCHER(Life Longlearner)
Psychomotor:To generatesound clinical
question relevantto themanagement ofthe patientTo criticallyappraise articlethat will answerthe clinicalquestion for
effectivemanagement ofpatientTo applyknowledge/techniques gained fromcritical appraisal,health economics,health policies and
health socialscience in thedecisionspertaining topatients, theirfamily andcommunityMaking decisionsand taking action
informed byresearch finding
EBMworkshop
PreceptorialEBMwardworkIndividualstudy periodLibrary Period
ComputerVideo
Journals
LibraryPatients
Criticalappraisal ofarticles in
diagnosis andtreatmentWritten exam
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Year level 3 ELGAELGAs Objectives OR
Expected LearningOutcomes
Content Activities
TeacherStudent
Resources Evaluation
HEALTHCAREPROVIDER( Competent
,compassionate andSafePhysician)RESEARCHE
R(Life Longlearner)
Affective/Attitudinal:
To conductcriticalappraisal in
an honest,correct andethicalmanner
Tocompetentlyaddressquestions andproblemspertaining tohealth tosubjects andtheir family
EBMWardwork
Patients Preceptorialgrade/evaluationEBMwardwork
grade
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Year level 3 ELGAELGAs Objectives OR
ExpectedLearningOutcomes
Content Activities
TeacherStudent
Resources Evaluation
TEACHER/ACADEMICIAN
(Effectivecommunicator
Cognitive:
To understandthe
significanceand use of theresultobtained fromcriticalappraisal
To understandthe
significance,applicationand variousmethods usedin healtheconomics,health policiesand socialscience
EBMwardworkPreceptorialLecturesndividual
study period
Hand outsVideosComputers
Criticalappraisal ofarticles indiagnosis andtreatmentWritten examEBM wardwork grade
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ELGAs Objectives OR Expected LearningOutcomes
Content ActivitiesTeacherStudent
Resources Evaluation
TEACHER/
ACADEMICIAN(Effectivecommunicator
Psychomotor:
To demonstrateacceptable levelof competence inthe conduct offocus groupdiscussions andinterviews amongpatients, theirfamily andcommunity whenappropriate
To applyacceptable levelof competence insearching forliteratures andknowledge toaddress medicalquestions andassignmentsTo publishresults in plainlanguage andacceptableformats
Focus groupdiscussionIndividualstudy periodLibrary period SimulatedGroupactivities
VideosComputers
Preceptorialgrade/evaluationCriticalappraisal ofarticles indiagnosis andtreatmentWritten exam
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Year Level 3 ELGAELGAs Objectives OR Expected Learning
Outcomes
Content ActivitiesTeacherStudent
Resources Evaluation
TEACHER/ACADEMICIAN
(Effectivecommunicator
Affective/Attitudinal:
To influence
subsequentrounds ofresearchbased on theimpact ofknowledge
use
Preceptorialevaluation/grade
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Year Level 3 ELGA
ELGAs Objectives OR Expected LearningOutcomes
Content ActivitiesTeacherStudent
Resources Evaluation
SOCIALMOBILIZER
Ethicallyandsociallyresponsive
Cognitive:1. To understand
the principlesof ethicalconduct in theconduct ofevidencebasedmedicine
2. To understandthe principlesof good clinicalpractice in thedesign,conduct,record andreport ofclinical trials inhumansubjects
LectureEBMwardwork
WrittenexamsEBM wardwork grade
Psychomotor:1. To apply the
principles ofethical conductin performing
EBM wardwork
Ward workgradePreceptorialevaluation
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What is evidence-basedmedicine?
Evidence-based medicine is the integrationof best research evidencewith clinicalexpertise andpatient values
- Dave Sackett 2001
Patient
Concern
s Clinical
Expertis
e
Bestresearc
h
evidenc
e
EBM
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RESEARCH
EVIDENCE
CLINICALCIRCUM-STANCE
PATIENT
PREFERENCES
CLINICAL
EXPERTISE
EBM : Evidence Based Medicine
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Its practice requires:
Asking
Acquiring
Appraising
Applying
Assessing
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The 4 steps of pull EBM
1. Formulate an answerable question
2. Track down the best evidence
3. Critically appraise the evidence
4. Individualise, based clinical expertise and patientconcerns
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Clinical Scenario
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Formulating a FocusedClinical Question
Population Intervention/Exposure
Comparison Outcome
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P - Who is the patient or whatproblem is being addressed?
I - What is the intervention orexposure?C What is the comparisongroup?
O - What is the outcome orendpoint?
Architecture of a focused
question:a 4-part review question
+ studydesignRichardson et al. The well-built clinical question: a key to evidence-based decisions. ACP Journal Club
1995;A-12Counsell C. Formulating questions and locating primary studies for inclusion in systematic reviews. AnnIntern Med 1997;127:380-7.
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Formulation of an etiologyquestion
Is snoring a risk factor fordiabetes?
Exposure
Outcome
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Formulation of an etiologyquestion
Is snoring a risk factor fordiabetes?
Are people who snore regularly at a greater risk ofdeveloping type II diabetes mellitus as compared tothose who do not snore?
Exposure
Outcome
Exposure
Patient
Outcome
Comparison
+ cohort & case-control
studies
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Finding the Evidence
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Finding the Evidencs
It is important when searching forevidence that search terms arereferred back to your original PICO
question. The process of findingevidence therefore follow three keysteps:
Identify terms to fit your PICO question
Look for secondary sources
Search for primary sources
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Finding the Evidence
1. Identify terms to fit your PICOquestion
Population
Intervention
Comparator
Outcome
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Finding the Evidence
2. Look for secondary sources
Guidelines: UKNational Library for Health, NICE, SIGN;US National Guidelines Clearinghouse;Canadian Medical Association;New Zealand Guidelines Group.
CATs: CAT CrawlerEvidence-Based Summaries:
Bandolier, Clinical Evidence
Structured Abstracts: EBM Online,ACP Journal Club
http://www.library.nhs.uk/http://www.nice.org.uk/http://www.sign.ac.uk/http://www.guideline.gov/http://mdm.ca/cpgsnew/cpgs/index.asphttp://www.nzgg.org.nz/http://www.bii.a-star.edu.sg/research/mig/cat_search.asphttp://www.jr2.ox.ac.uk/bandolier/http://www.clinicalevidence.com/http://ebm.bmjjournals.com/http://www.acpjc.org/shared/menu_about.htmlhttp://www.acpjc.org/shared/menu_about.htmlhttp://ebm.bmjjournals.com/http://www.clinicalevidence.com/http://www.jr2.ox.ac.uk/bandolier/http://www.bii.a-star.edu.sg/research/mig/cat_search.asphttp://www.nzgg.org.nz/http://mdm.ca/cpgsnew/cpgs/index.asphttp://www.guideline.gov/http://www.sign.ac.uk/http://www.nice.org.uk/http://www.library.nhs.uk/ -
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3. Search for Primary Sources
Use methodological filters to target
the right type of study. For instance,PubMED filters for:
Therapy
DiagnosisPrognosis
Aetiology
Systematic review
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmedhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed -
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2. Searching: finding goodanswers?
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Search Strategy
Step 1: Create a search strategy
Scenario: A 64 year old obese male
who has tried many ways to loseweight presents with a newspaperarticle about fat-blazer (chitosan).He asks for your advice.
Your question in PICO format mightbe:
Population/problem : obese patients
Intervention/indicator : chitosan
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Search Strategy
Step 2: Now convert this PICOquestion to a search strategy
To do this, you should do three things:
1.Underline the key terms those mostspecific to your question
2. Number the PICO elements in order
of importance from 1-4
3. Think of alternate spellings,synonyms and truncations
You might end up with:
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Search Strategy
NOTE: * is a truncation symbol that means further letters canbe added to the wordOR finds studies containing either of the specifiedwords/phrases, and broadens your searchAND finds studies containing both specified words/phrases,
and narrows your search
1. Open your browser (eg Explorer) and go towww.pubmed.gov
2. Type into the search box the term we chose as (1) :chitosan. Write down the number of results you found.
3. Select Clinical Queries (left hand menu)
4. Select the Therapy category (which is the default) andsearch on chitosan again. Write down the number of resultsyou now found.
Why has this decreased? It is because of the filter thatPubMed uses to focus on clinical trials (to see the actual filter
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Search Strategy
5. Try adding AND another stage, ietype in chitosan AND (obes* ORoverweight) note that you need
brackets around your OR search. Thisshould reduce the number of articleseven further and certainly down to a
manageable number.If we had used all terms the search
may looked like this:
Search #1:chitosan
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Clinical Question
Among patients with chronic cough andfever in a TB endemic country, how
accurate is a same day 2 smear sputum
exam in the diagnosis of pulmonarytuberculosis?
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Search Strategies
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Step 3: Appraise theevidence
Did you find goodquality studies?
Two steps PICO RAMMbo
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3. Rapid Critical Appraisal
Its peer-reviewed, therefore it must beOK?
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CRiTICAL APPRAISAL
CLAIMS OF EFFECTIVENESS
CLAIMS OF ACCURACY
CLAIMS ON CAUSATION
CLAIMS ON PROGNOSIS
Claims for Accuracy Articles
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Claims for Accuracy Articleson Diagnosis
A i i di ti t t 3 t
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Appraising diagnostic tests: 3 easy steps
1. Are the results valid?
2. What are the results?
3. Will they help melook after my patients?
A i i di ti t t 3 t
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Appraising diagnostic tests: 3 easy steps
1. Are the results valid?
2. What are the results?
3. Will they help melook after my patients?
Appropriate spectrum of patients?
Does everyone get the gold standard?Is there an independent, blind or
objective comparison with the goldstandard?
A i i di ti t t 3 t
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Appraising diagnostic tests: 3 easy steps
1. Are the results valid?
2. What are the results?
3. Will they help melook after my patients?
Sensitivity, specificity
Likelihood ratios
Predictive values
A i i di ti t t 3 t
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Appraising diagnostic tests: 3 easy steps
1. Are the results valid?
2. What are the results?
3. Will they help melook after my patients?
Can I do the test in my setting?Do results apply to the mix of patientsI see?Will the result change mymanagement?
Costs to patient/health service?
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l i f ff i
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Claims of Effectiveness
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THERAPY STUDY:Are the results of the trial valid? (Internal Validity)What question did the study ask?
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Patients
Intervention -
Comparison -
Outcome(s) -
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Claims of prognosis
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St 4 A l i t th
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Step 4: Applying to theindividual
What do theresults mean on
average?What do they
mean for thisindividual?
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Presentations will cover:1. searchstrat egy;2. searchresults;3. thevalidityof this evidence;4. theimportanceof this validevidence;5. canthis valid, important evidencebeappliedtoyour patient;
6. your evaluationof this process.
3-part Clinical
Patients Name Learner:
Target Disorder:
Dateandplacetobefilled:
Intervention(+/ - comparison):
Outcome:
Im sorry doctor
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I m sorry doctor,but again I have to
disagree.
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CLINICALQUESTION
ASSESSMENT OFVALIDITY
ASSESSMENT OFAPPLICABILITY
CLINICALCIRCUMSTANCE
AND PATIENT
VALUESEBM AS A
CYCLE
DECISION
SYSTEMATIC
SEARCH FORBEST EVIDENCE
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Life long learning
The hardest conviction to get into the mind of abeginner is that the education upon which he isengaged is not a medical course, but a life
course, for which the work of a few years underteachers is but a preparation.
Sir William Osler (1849-1919), from: The Studentof Medicine
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THANK YOU FORLISTENING
ANDGOOD LUCK!!
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Wardwork Report
Clinical Scenario
Focused question
Search StrategyCritical Appraisal
Discuss applicability
Conclusion