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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

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Existing knowledge can prevent
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
Learning Objectives

  • At the end of the presentation, learners will:

    • be able to define evidence based medicine

    • be able to utilize a well-built clinical question to facilitate an efficient search

    • understand the 4S approach to organizing medical evidence


“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

Best research

evidence

Clinical

Expertise

EBM

What is EBM?


Evolution of ebm in the literature
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
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



Information retrieval for evidence based patient care
Information Retrieval for Evidence Based Patient Care patient-doctor courses

  • 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


Key developments that streamlined the practice of ebm
Key developments that streamlined the practice of EBM patient-doctor courses

  • 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 that filter search results by “type of study” to match clinical question

  • Dissemination of systematic reviews of primary studies and growth of the Cochrane Collaboration


Cochrane collaboration
Cochrane Collaboration patient-doctor courses

  • Cochrane Database of Systematic Reviews

    • Part of the Cochrane Library (1996)

    • Over 3,000 reviews

    • Mostly Treatment; Diagnosis since 2008

    • Eyes & Vision Research Group includes 156 reviews

    • Among the highest level of evidence upon which to base treatment decisions

    • Access full text of reviews through Ovid


Systematic review
Systematic Review patient-doctor courses

  • 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


Ongoing developments
Ongoing Developments patient-doctor courses

  • Continuing development of point of care (POC), evidence based summaries, e.g., Dynamed, Up to Date

  • Evolving decision support tools that embed evidence based summaries in the electronic medical record and clinical workflow

  • Uptake of EBM process by health policy, nursing, allied health, and psychosocial fields


Focused approach saves time
Focused Approach Saves Time patient-doctor courses

  • 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


Ebm process 5 steps
EBM Process – 5 Steps patient-doctor courses

  • ASSESS: Recognize and prioritize important patient problems

  • ASK: Construct clinical questions that facilitate an efficient search

  • ACQUIRE: Track down the best evidence to answer the questions

  • APPRAISE: Systematically evaluate best available evidence for validity, importance, and usefulness

  • APPLY: Interpret the applicability of evidence to specific problems, given patient preferences and values


Step 1
Step 1 patient-doctor courses

  • ASSESS the clinical problem

    • Begin with the patient encounter

    • Select question that

      • Is most important to the patient’s well being

      • Fills gaps in your clinical knowledge

      • Is feasible to answer in the time available (30 minutes per week)


Step 2
Step 2 patient-doctor courses

  • ASK focused clinical questions

  • Four common types of clinical questions:

    • Therapy/prevention

    • Diagnosis

    • Etiology

    • Prognosis


Well built clinical questions
Well Built Clinical Questions patient-doctor courses

  • Deal with patient management issues

  • Contain elements of PICO format

    • Patient/Population

    • Intervention

    • Comparison Intervention (if useful)

    • Outcome

  • Facilitate an efficient search


Example therapy prevention question
Example – Therapy/Prevention Question patient-doctor courses

  • In patients with ocular hypertension, will treatment with timolol versus no treatment decrease the risk of developing glaucoma?


Extract search terms from question
Extract search terms from question patient-doctor courses

  • Therapy/Prevention Question

    • In patients with ocular hypertension [Patient/Population], does treatment with timolol [Intervention] versus no treatment [Comparison Intervention], decrease the risk of developing glaucoma [Outcome]?

  • Search Terms: ocular hypertension, IOP,timolol, glaucoma, (POAG)


Step 3
Step 3 patient-doctor courses

  • ACQUIRE: 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



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.


4s hierarchy
4S Hierarchy for assessing therapeutic interventions.


Information pyramid
Information Pyramid for assessing therapeutic interventions.

POC Tools: 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


Critically appraised content
Critically Appraised Content for assessing therapeutic interventions.


Appraise the filter pre appraised content
Appraise the Filter (pre-appraised content) for assessing therapeutic interventions.

  • Criteria

    • Speed of updating

    • Scope and number of summaries

    • Summaries with graded evidence

    • Authors’ credentials, affiliations listed

      Developing and using a rubric for evaluating evidence-based medicine point-of-care tools. Journal of the Medical Library Association, Volume 99, No. 3, July 2011

      Speed of updating online evidence based point of care summaries: prospective cohort analysis. BMJ 2011;343:doi:10.1136/bmj.d5856 (Published 23 September 2011)


Levels of evidence
Levels of Evidence for assessing therapeutic interventions.

Grade the quality of evidence based on the design of the clinical study

Variety of hierarchies in use


American Academy of Family Physicians Rating System for assessing therapeutic interventions.

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


Dynamed
Dynamed for assessing therapeutic interventions.


Appraisal required by user
Appraisal Required by User for assessing therapeutic interventions.


Step 4
Step 4 for assessing therapeutic interventions.

  • Appraise best available evidence from original studies

  • If the other “S’s” don’t provide the answer, search for original studies

  • Use “clinical queries” limit in Ovid MEDLINE to speed retrieval

  • Least efficient (in terms of time) to answer clinical questions


Primary original studies
Primary (Original) Studies for assessing therapeutic interventions.

  • Articles that report results of original research investigations

  • Conclusions supported by data and reproducible methodology

  • Require time to acquire and appraise

  • Good Source: MEDLINE (OVID)


Medline
MEDLINE for assessing therapeutic interventions.

  • Premiere biomedical database from the NLM (National Library of Medicine)

  • Covers 1950-present

  • Indexes >4000 international biomedical journals

  • Full text available for many articles

  • Ovid interface includes tools to quickly filter search results to specific study types

  • Access from http://library.nsuok.edu/collegeop/index.html


Ovid medline clinical queries
Ovid MEDLINE Clinical Queries for assessing therapeutic interventions.


Step 5
Step 5 for assessing therapeutic interventions.

  • APPLY the evidence to patient care problems

    • Practice the EBM process in daily patient encounters


Steps to using ebm
Steps to for assessing therapeutic interventions. “Using” EBM

  • Convert information need into answerable clinical question

  • Track down the best evidence to answer the question

  • Use the 4S approach to locate critically appraised content


Take home points
Take Home Points for assessing therapeutic interventions.

  • 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 optometry 6111 research methodology
Evidence Based Medicine Lecture for assessing therapeutic interventions. Optometry 6111 Research Methodology

Sandra A. Martin, M.L.I.S.

Health Sciences Resource Coordinator

Instructor of Library Services

John Vaughan Library Room 305B

[email protected] – 918-444-3263


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