existing knowledge can prevent… waste errors poor quality clinical care poor patient experience...
TRANSCRIPT
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/.
Learning Objectives
At the end of the presentation, you will be able to:• Define evidence-based medicine (EBM)• Understand the Five Steps to practice EBM• Use the 4S approach to organizing clinical research
evidence• Conduct an efficient online search to track down best
evidence• Access online and print tools to critically appraise the
evidence• Use the Five Steps for research and clinical care
www.cebm.net
“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values”
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2.
Patient Concerns
Clinical Expertise
Best research evidence
EBM
What is EBM?
Evolution of EBM in the Literature
Term first appeared in the literature in a 1991 editorial in ACP Journal Club Volume 114, Mar-April 1991, pp A-16
Seminal article by the Evidence-Based Medicine Working Group published in JAMA Volume 268, No. 17, 1992, pp 2420-2425
Fundamentally new approach becomes widely recognized JAMA published a series of Users’ Guides to the Medical
Literature that served as the first learning tools Courses were developed in residency training and
medical school curricula The first handbook, Evidence-Based Medicine: How to
practice and teach EBM, by Sackett, et al, was published in 1996. Fourth edition published in 2010.
New York Times listed EBM as one of its ideas of the year in 2001
BMJ listed EBM as one of the 15 greatest medical milestones since 1840
New Approach Required New Skills
Clinical question formulation Search and retrieval of best evidence Critical appraisal of study methods to ascertain validity of
results
Integration of EBM into medical school curricula patient-doctor courses
Key developments that streamlined the practice of EBM Advances in ease of accessing and understanding
information Development of preprocessed (preappraised) tools Improvements in search interfaces to MEDLINE Collaboration between EBM Working Group and
National Library of Medicine in development of hedges, “clinical queries” tool, that filters search results to specific study types and levels of evidence
Dissemination of systematic reviews of primary studies and growth of the Cochrane Collaboration
EBM Process – 5 Steps
1. ASSESS: Recognize and prioritize important patient problems
2. ASK: Construct clinical questions that facilitate an efficient search
3. ACQUIRE: Track down the best evidence to answer the questions
4. APPRAISE: Systematically evaluate best available evidence for validity, importance, and usefulness
5. APPLY: Interpret the applicability of evidence to specific problems, given patient preferences and values
4S Hierarchy
6S Hierarchy
4S Examples
Point of Care Summaries: Uptodate, Dynamed, FIRSTConsult
DARE (synopses of syntheses)
ACP Journal Club (synopses of studies)
Cochrane and other Systematic Reviews
Clinical Key Searches Limited to Study Types, MEDLINE Searches limited to 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
Critically Appraised Content
Evidence Based Retrieval
1. Find the answer that is supported by valid studies appropriate to the type of question and that is available in a timely manner.
2. Requires search terms plus best study design for question plus highest level of evidence
Extract search terms from question
Therapy/Prevention Question in PICO In patients with primary open angle glaucoma
or ocular hypertension [Patient/Population], do topical medications to reduce intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field defect progression [Outcome]?
Possible Search Terms
Ocular hypertension, OHT, intraocular pressure, IOP, primary open angle glaucoma, POAG, medical treatment, medical intervention, visual fields, VF
As you move up the pyramid the amount of available literature decreases, but it increases in its relevance to the clinical setting.
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.
Best Study Design for Type of Question
Type of Question Study Design
Therapy/prevention 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
Systems/Summaries
• DynaMed– Summaries for more than 3,000 topics– Monitors >500 medical journals and
systematic review databases– Updated daily– Each article evaluated for clinical relevance
and scientific validity– Includes “graded evidence”
Glaucoma Summary
Evidence-based answer found in 1 minute, 39 seconds
Systems/Summaries• UptoDate
– Evidence based summaries of over 9,500 topics in over 20 specialties
– Ophthalmology not one of the specialties– Good for information on systemic conditions– Available through individual subscription.
Online access plus Mobile app for iPhone and iPad. Cost: $199 per year in training; $499 per year in practice
Syntheses
• Cochrane Database of Systematic Reviews (DSR)– 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 over 165 reviews
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 full text of Cochrane reviews in OVID
Review found in 15 seconds
Cochrane DSR
Copyright: The Cochrane Library, Copyright 2009, The Cochrane Collaboration
Levels of Evidence
Grade the quality of evidence based on the design of the clinical study
Variety of hierarchies in use
DynaMed
Levels of Evidence in Ovid based on AAFP SORT
Level A = “Specificity” in Ovid Clinical Queries Systematic reviews of randomized controlled trials including meta-
analyses Good-quality randomized controlled trials
Level B = “Sensitivity” in Ovid Clinical Queries 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
Appraisal Required by User
Primary (Original) Studies
Articles that report results of original research investigations
Conclusions supported by data and reproducible methodology
Require time to acquire and appraise Good Sources: MEDLINE and Clinical
Key
When to search for original studies If the other “S’s” don’t provide the answer,
search for original studies Appraise best available evidence or find
analysis in evidence based resource Use “clinical queries” limit in Ovid
MEDLINE Limit to “Study Type” in Clinical Key Least efficient (in terms of time)
Take Home Points
Focused clinical question (PICO) reveals your search terms
Start your search at top of 4S hierarchy and work down
Be aware of the filter, i.e., levels of evidence, speed of updating
Look at more than one resource in the hierarchy. Findings may differ
Practice makes perfect
Evidence Based Medicine Lecture
Sandra A. Martin, M.L.I.S.Health Sciences Resource Coordinator
Instructor of Library ServicesJohn Vaughan Library Room 305B
[email protected] – 918-444-3263