Evidence based obstetric medicine
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Evidence Based Obstetric Medicine. Robert Hopkins, MD, FACP, FAAP UAMS Associate Professor of Medicine and Pediatrics. Outline. EBM Overview What is EBM Why is EBM important Basics of E-B medical practice Evidence Based Obstetrics 2005 Selected examples. Overcoming inertia….

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Evidence Based Obstetric Medicine

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Evidence based obstetric medicine

Evidence Based Obstetric Medicine

Robert Hopkins, MD, FACP, FAAP

UAMS Associate Professor of Medicine and Pediatrics


Outline

Outline

  • EBM Overview

    • What is EBM

    • Why is EBM important

    • Basics of E-B medical practice

  • Evidence Based Obstetrics 2005

    • Selected examples


Overcoming inertia

Overcoming inertia…

  • “Human nature: apply minimum work in order to complete the task at hand…”

  • “We need to learn not only HOW to read the literature---but also WHAT to read and WHEN to read it…”

  • “Usefulness = Validity * Relevance [of data]

    Work (required to find data)”


What is ebm 1

What is EBM? [1]

  • Patient centered

  • Ask answerable questions

  • Search for best evidence

    • Can be time consuming… unless using E-B sources

  • Critical assessment of evidence

    • For validity and applicability

    • May be time consuming, as above

    • If we do not assess critically, our educated consumers/patients will go elsewhere…


What is ebm 2

What is EBM? [2]

  • Evaluate applicability [of search results]

    • Does the evidence apply to this patient?

    • Integrate evidence with clinical expertise

    • Is the intervention applicable to this specific person

    • ‘Guideline dilemma’: is this a replication of expert (egocentric) opinion or a compendium of evidence…

  • Critically assess the impact of change

    • To the patient

    • To the clinician

    • To ‘my medical practice’


So what is the problem

So… What is the problem?

Medical knowledge continues to grow

  • 3000 new papers published DAILY

  • 1000 new Medline article citations DAILY

  • 46 new RCT’s published DAILY

    We do NOT read enough:

  • < ½ hour/week: 3 %

  • 1 hour/week:46 %

  • 1-2 hr/week:43%

  • 3+ hours/week:8 %


But aren t we doing ok

BUT…Aren’t we doing OK???

  • Data re: practice variability (200+ studies)

    • [IM] Example: Determinants of need to Rx HTN

      • Level of BP

      • Patient age

      • Year MD awarded

      • End-organ damage

  • Can we realistically expect to provide the best care for 100+ patients/wk relying on memory and experience alone???


Where does the data come from

Where does the data come from?

  • Print source

    • Texts: General/Subspecialty/PDR

    • Journals

    • Reprints

  • Human source

    • Consultations

    • CME Conferences

    • Pharmaceutical rep’s

  • Other:

    • Electronic: Best Evidence CD, UpToDate, PIER,…

    • Paper: Clinical Evidence [Updates]

    • Specialty Societies


The cme conundrum

The CME Conundrum

  • CME is a ‘growth industry’

  • Most presentations are ‘Fact’ oriented

  • Several RCT’s have demonstrated no improvement in clinical performance…

    Freemantle N., et.al. Cochrane Database of Systematic Reviews 2000;2.


What are the answers

What are the answers?

  • Seek out and apply evidence others generated

  • Learn how to practice EBM ourselves

    Ultimate goal is …to apply evidence-centered strategies to answer questions in our practice-- leading to refinement of our clinical behavior.


What evidence do we need

What evidence do we need?

Evidence about:

  • Predictive values and likelihood ratios for diagnostic tests

  • Power and specificity of prognostic markers

  • Comparative efficacy and safety of interventions


How often do we need ebm

How often do we need EBM?

Studies estimate at least:

  • 5 valid questions for every inpatient stay

  • 2 questions for every 3 outpatient visits

    And yet

  • We get less than 1/3 of these answered…


To summarize why ebm

To summarize- Why EBM?

  • Too many patients

  • Too many questions

  • Too much information to glean all the PEARLS

  • No time to read

  • “Selection pressure” on the reading we do

    • Reading often focused on familiar source/topic

    • It is common practice to avoid difficult issues and focus on ‘quick answers’


What is the best evidence

What is the BEST evidence?

1989 Georgia [One man’s opinion]

  • ‘Old Professors’

  • Case series

  • Systematic Review

  • Randomized Controlled

  • Meta-Analysis

  • Case Control

  • Colleague/Consultant

  • Case report


Structuring the question

Structuring the Question

  • Unstructured: Too many ‘hits’

    • Example: >13000 [Pregnancy + HTN] articles PubMed [1/15/05]

  • Structuring questions

    • Background: W5s and How

      • ‘W’ + Verb + Disease…

    • Foreground: most daily ‘clinical care’ issues


Background questions

Background Questions

  • Who, What, When, Where, Why, How..

    • + [verb] + [DISease]

  • Results:

    • Often answered by textbooks, reviews

    • Most common when unfamiliar with a topic


Foreground questions

Foreground Questions

  • Question Structure

    • Patient or problem

    • Intervention or exposure considered

    • Comparison intervention (If relevant)

    • Outcome of interest


Cq example

CQ Example

  • In pregnant woman with severe HTN [>170/100] is Labetalol as effective as Hydralazine in reduction of BP and maternal morbidity?

    • Result: Cochrane DB Systematic Reviews: 2003

      [Other than Diazoxide [more symptomatic hypotension], there are no clear differences in studied agents including Labetalol, Hydralazine, Nifedipine ER,…]


Search for the evidence

Search for the Evidence

Database: Pub Med, Ovid and others

Search engines are highly sensitive…but they are not specific

(Specificity left to the questioner/searcher)

MeSH: Structured medical subject headings- freely available from NLM (topic map) allow targeting of search to topic

‘Related articles’ is useful if narrow topic evaluated

Limits: Clinical Trial ORSystematic Reviews

English(?) language

Human subjects


Evaluating the evidence

Evaluating the Evidence

Some ‘pre-assessed’ sources for your use:

  • ACP Journal Club, Journal of Evidence-Based Medicine

  • NGC: http://www.guideline.gov

  • Cochrane database

  • Clinical Evidence (BMJ Publications)

  • UpToDate

    JAMA Guide: EBM Working Group

  • Are the results valid?

  • What are the results?

  • Will the results help in my patients’ care?

  • http://medicine.ucsf.edu/resources/guidelines/users.html


Data vs availability vs utility

Data vs. Availability vs. Utility

DataSource Access Quality

ExperienceLongitudinalRapidVariable

ColleagueVariableVariableVariable

PatientsRapidRapid???

GuidelinesVariableVariableVariable

TextsRapidSlowGood?

ResearchSlowSlowGood?

JournalsBuriedVariableGood


Who are we

Who are we??

  • Evidence Users

  • Evidence Finders

  • Evidence Generators

    [And I hope Never…]

  • Evidence Ignorers


What is our goal in ebm

What is our goal in EBM?

To NOT have to wade through 100+ papers

To NOT have to go through Medline

TO have evidence indexed by strength

TO have a brief (1 word ?) answer…

TO see questions that are already answered

i.e. ALL applicable knowledge in 15 seconds

…FLAT….


Evidence based ob 2005

Evidence Based OB 2005

13043 “Pregnancy + HTN” articles

[Pubmed 1/18/05]

  • 207 when limited to Clinical trial, Human subjects, English language


Evidence based ob 20051

Evidence Based OB 2005

15852 “Preeclampsia” articles in 2005 [Pubmed 1/13/05]

  • 263 articles when limited to: adults, human, English, published within 1 year

  • 170 articles with MeSH ‘major topic’ limit

  • 15 Clinical trials [Publication type]

  • 7 Randomized Controlled Trials


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