Evidence based medicine in the office and hospital
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Evidence Based Medicine in the office and hospital. Daniel J. Van Durme, MD Professor and Chair Dept. of Family Medicine and Rural Health. Who is this guy and what does he know?. Private practice in semi-rural Pasco county (north of Tampa) 1991-1996

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Evidence based medicine in the office and hospital

Evidence Based Medicine in the office and hospital

  • Daniel J. Van Durme, MD

  • Professor and Chair

  • Dept. of Family Medicine and Rural Health

Evidence Based Medicine D.J. Van Durme, MD


Who is this guy and what does he know

Who is this guy and what does he know?

  • Private practice in semi-rural Pasco county (north of Tampa) 1991-1996

  • Faculty at University of South Florida College of Medicine 1989-1991 and 1996-2004

  • Still seeing patients at Madison County Health Department

  • Creator, Course Director, and lecturer for “Evidence Based Medicine” course at USF COM

    • 40 hours of lecture and small group for Med 2’s

Evidence Based Medicine D.J. Van Durme, MD


I am not an ebm expert

I am NOT an EBM expert

  • Expert – from Latin

    • “ex” – has been

    • “spurt” – a drip under pressure

  • I struggle with stats

  • I am often overwhelmed with the volume of medical information and the need to critically review the important stuff

  • BUT – I can still provide high quality Evidence Based Care

Evidence Based Medicine D.J. Van Durme, MD


Learning objectives for today

Learning Objectives for today

  • At the conclusion of today’s session, the learner should be able to:

    • Define evidence based medicine

    • Demonstrate an ability to formulate a patient-oriented clinical question from a clinical scenario

    • Discuss appropriate search strategies for finding answer(s) to clinical questions

    • Demonstrate the use of PDA and computer resources for finding high quality evidence based answers

    • Discuss how evidence based findings would be applied to the care of a patient

Evidence Based Medicine D.J. Van Durme, MD


Ebm original official definition

EBM: Original “Official” Definition

The explicit, conscientious, and judicious use of the current best evidence in making decisions about the care of individual patients (and populations)

Evidence-Based Medicine Working Group

Sackett et al circa 1996

Evidence Based Medicine D.J. Van Durme, MD


Problems with ebm definition

Problems with EBM definition

  • EBM has been accused of being . . .

    • Cookbook medicine

      • “It takes away the art of medicine or the clinical judgment”

      • WRONG – the research results may not be applicable or appropriate for a given patient

    • Cost-Cutting medicine

      • “It is all a plot by managed care companies to cut cost of care and increase their profit share”

      • WRONG - When you find what is best for a given patient it may cost more OR it may save money

Evidence Based Medicine D.J. Van Durme, MD


Problems with ebm cont

Problems with EBM (cont.) …

  • EBM has been accused of being . . .

    • Impossible or impractical

      • “There is no way I can spend hours looking for and critically reviewing medical articles for each of the patients that I see.”

      • WRONG – there are many tools available at the point of care (PDA’s and computers and texts) that can help you find answers in a matter of 1-2 minutes.

Evidence Based Medicine D.J. Van Durme, MD


Better ebm definition

Better – EBM definition

  • The integration of best research evidence with clinical expertise and patient values

    • Sackett et al 2000

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

Evidence Based Medicine D.J. Van Durme, MD


Two fundamental principles of true evidence based practice

Two Fundamental Principles of true Evidence Based Practice

  • Clinical Decision Making:

    • Evidence is Never Enough

      a. Treatment of Pneumococcal pneumonia SHOULD be different for:

      Terminal Cancer Patient

      Elderly, Severely Demented Patient

      Young, mother of 2 children

      b. Importance of Values/Preferences

Evidence Based Medicine D.J. Van Durme, MD


Two fundamental principles of ebm

Two Fundamental Principles of EBM

  • A hierarchy of evidence

    a. There is a hierarchy of possible information

    b. Look for the highest level of evidence available

    BE ready to change your approach or management when a higher level of evidence contradicts your experience

    “Experience Based Medicine” – doing the wrong thing with increasing confidence for an impressive number of years.

Evidence Based Medicine D.J. Van Durme, MD


Best research evidence

Best research evidence

  • Clinically relevant – not just “well-done research”

  • Ideally patient-centered clinical research

    • What matters to patients?

      • Morbidity, mortality, quality of life

    • POEM

      • Patient Oriented Evidence that Matters

      • Matters to my practice and my patients

  • Sometimes disease-oriented evidence (DOE)

    • How many irregular heartbeats per hour?

    • Can be misleading (sometimes dangerously so)

  • Occasionally basic science

    • What is the level of C-reactive protein (CRP) in the serum?

    • Can be VERY misleading

Evidence Based Medicine D.J. Van Durme, MD


Clinical expertise

Clinical Expertise

  • Use of clinical skills and past experience

  • Identification of individual patient’s . . .

    • Health status and health risks

    • Personal values and expectations

    • (Probable) diagnosis

  • Knowledge of disease prevalence, access to medical or test availability, etc. in your community

  • Did you ask the correct clinical question(s)?

Evidence Based Medicine D.J. Van Durme, MD


Patient values

Patient values

  • Patient preferences and concerns

    • Cultural influences

    • Religious/spiritual influences

    • Psychosocial issues

  • May include . . .

    • Reimbursement or insurance status

    • Access to care

    • Societal factors

    • Other influences

Evidence Based Medicine D.J. Van Durme, MD


Why do we need ebm

Why do we need EBM?

  • Stay up to date

    • Medical information changes constantly

    • Unlike bread – our knowledge does not become visibly moldy or stale – we just keep using it

Evidence Based Medicine D.J. Van Durme, MD


Why do we need ebm1

Why do we need EBM?

  • Save LIVES!

    • Encainide and flecainide for ventricular arrhythmia

      • Well proven to decrease the number of premature ventricular beats – became widely used 1980’s

      • BUT

      • Further studies showed significant INCREASE in MORTALITY – died from other cardiac complications and dysrhythmias ( a dangerous “DOE”)

    • Thrombolytics for acute MI

      • CLEAR evidence of benefit in the 1970’s

      • Not widely recommended until 1988 – almost 13 yrs later

      • How many thousands of people died unnecessarily in the years in between?

Evidence Based Medicine D.J. Van Durme, MD


Why do we need ebm2

Why do we need EBM?

  • We want to do the “right thing” – what is “best” for our patients

  • Practice variations that do not make sense . . .

    • Not to doctors

    • Not to patients

    • Not to payors

    • Not to policy makers

Evidence Based Medicine D.J. Van Durme, MD


Assessment of radical prostatectomy time trends geographic variation and outcomes

Assessment of Radical Prostatectomy: Time Trends, Geographic Variation, and Outcomes

Lu-Yao: JAMA, Volume 269(20). May 26, 1993.

Evidence Based Medicine D.J. Van Durme, MD


So why not get info from textbooks and review articles

So why not get info from textbooks and review articles?

  • Texts and review articles?

    • Dated – perhaps by several years

    • Often heavily biased

      • Author chooses article that he/she agrees with (or has written)

  • May help more with background knowledge (help me learn about disease) not foreground (help me answer the specific clinical question for this patient)

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

Foreground questions

Background questions

Experienced clinician

Medical student

Evidence Based Medicine D.J. Van Durme, MD


But how does ebm really work

But how does EBM REALLY work?

  • Step 1: Translate clinical scenarios into an answerable clinical questions

    • TRUE STORY –

    • My 54 yr old patient was just diagnosed with prostate cancer

    • I received pathology report and he is coming in to see me tomorrow

Evidence Based Medicine D.J. Van Durme, MD


What are my questions

What are my questions?

  • What do I know about prostate cancer?

    • How common is it?

    • Is it usually aggressive and rapidly fatal?

    • How can it be treated – surgery, chemotherapy, radiation?

    • What about family history – what should I tell him about his son’s risk?

    • Etc.

    • These are called “background” questions

Evidence Based Medicine D.J. Van Durme, MD


Foreground questions apply to that specific patient or population

Foreground questions apply to that specific patient (or population)

  • After meeting with patient and spouse we find that he has seen the urologist who recommended surgery but the patient is reluctant

    • 54 year old male patient was diagnosed with intermediate grade prostate cancer and wants to know whether to get a radical prostatectomy or radiation treatment. He is concerned about death from prostate CA and also risks of impotence and incontinence.

Evidence Based Medicine D.J. Van Durme, MD


Question

Question?

  • Population:

    • For middle aged males with intermediate stage prostate cancer,

  • Intervention:

    • Treated with radical prostatectomy

  • Comparison:

    • Compared to radiation treatment

  • Outcome:

    • What are the rates of incontinence, impotence and cancer-related mortality?

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Developing the question requires:

    • Some background knowledge of the condition

    • Understanding of the patient and what are the outcomes that matter in this patient

      • Death?

      • Disability?

      • Quality of life? – Anxiety, Impotence, etc.

      • Cost?

Evidence Based Medicine D.J. Van Durme, MD


Hands on part 1

Hands on – Part 1

  • Think in your practice THIS week – what was a clinical question you had?

    • Think of a foreground question (not just a drug dose or drug interaction)

      • What diagnostic test would have been best for that pt with abdominal pain?

      • What treatment would have been best for the pt with Parkinsons?

      • What about the patient who was asking about acupuncture for osteoarthritis?

Evidence Based Medicine D.J. Van Durme, MD


How does ebm really work

How does EBM REALLY work?

  • Step 2: Translate question into effective searches for the best evidence

    • Requires knowledge of medical informatics

    • How to search – what terms to use, what types of studies, etc.

    • Where to search – utility of varied sources of information

      • Evidence based sources, Texts, Medline,

Evidence Based Medicine D.J. Van Durme, MD


Purpose specific resources

Purpose-specific resources

  • CDC Travel

  • Drug information resources

  • Patient Education handouts

  • Medical Search engines

  • Textbooks

  • Journals

Evidence Based Medicine D.J. Van Durme, MD


Ebm sources

EBM sources

  • EBM sources – Cochrane, USPSTF, Clinical Evidence

    • + Ideally best information source – hard to argue with, will explicitly state the level of evidence (weak to strong)

    • - There may not be any “good” evidence

Evidence Based Medicine D.J. Van Durme, MD


How does ebm really work1

How does EBM REALLY work?

  • Step 3: Critically appraise the evidence

    • Validity of the evidence

      • Internal – study design, blinding, randomized, sample size, appropriate statistics, etc.

    • Relevance of the evidence

      • Did they measure something pts care about?

      • Is population similar (enough) to mine?

      • Is the intervention feasible?

    • Importance of the evidence

      • Magnitude of effect or clinical significance?

      • P values, confidence intervals, relative risk or absolute risk reduction

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Step 3: Critically appraise the evidence (cont.)

  • Requires some knowledge of basic epidemiology and biostatistics

    • Sensitivity, specificity, prevalence, likelihood ratios

    • Absolute risk reduction, relative risk reduction, odds ratios, number needed to treat

  • Requires knowledge of study types

    • ASSUMING THAT IT IS A WELL DESIGNED STUDY

      • Appropriate sample size, randomization, stats, treatment allocation, etc., etc.

    • Meta-analysis of RCT’s > RCT > Cohort > Case Control > Case Series > Case Report

Evidence Based Medicine D.J. Van Durme, MD


Hierarchy of studies

Hierarchy of studies

Evidence Based Medicine D.J. Van Durme, MD


Step 3 critical appraisal of medical literature

Step 3 – Critical appraisal of medical literature

  • This is often confused with EBM

    • they are not the same thing

  • This is often the toughest part of EBM

  • Skipped by many doctors suffering from photonumerophobia

    • The fear that one’s fear of numbers and statistics will come to light

  • This is where most attempts come to a halt

    • Not enough time and expertise

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

EBM Databases

Systematic Literature Searches

  • Cochrane Library (OVID)

  • Clinical Evidence

    Systematic Literature Surveillance

  • ACP Journal Club (OVID)

  • DARE

  • DynaMed

  • Medical InfoRetriever

  • Journal of Family Practice POEMS

    EMB Search Engine

  • TRIP Database

Evidence Based Medicine D.J. Van Durme, MD


Drilling for the best information

Cochrane Library

Clinical Evidence

Clinical Inquiries

Specialty-specific

POEMs

ACP Journal Club

Textbooks, Up-to-Date, 5-Minute Clinical Consult

Usefulness

Journals/ Medline

PubMed

Drilling for the Best Information

Evidence Based Medicine D.J. Van Durme, MD


Cochrane library

Cochrane Library

  • The current resource with the highest methodological standards

  • For each clinical question, all of the English literature meticulously searched for randomized trials

  • Large systematic reviews with valid methods + collaborative effort

  • Conclusions are based on all the evidence from valid randomized trials

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

Cochrane Library

  • Included in OVID subscription

  • Limitations

    • limited to English

    • only addresses questions amenable to randomized trials

    • most of medicine has not been studied enough to allow for conclusions

    • $235/year or abstracts only

Evidence Based Medicine D.J. Van Durme, MD


Inforetriever

InfoRetriever

  • 104 journals surveyed for Evidence-Based Practice Newsletter

  • Over 1300 article synopses/ POEMS

  • Cochrane abstracts

  • Selected evidence-based guidelines (USPSTF, CDC, others)

  • Basic drug info

  • ICD-9 codes

  • Clinical calculators/prediction rules

Evidence Based Medicine D.J. Van Durme, MD


Inforetriever symbols

InfoRetriever Symbols

Evidence Based Medicine D.J. Van Durme, MD


Inforetriever1

InfoRetriever

  • Comes in web, desktop and PDA versions

  • Explicitly states Levels of Evidence

  • Limitations

    • individual article summaries may not account for the “big picture”

    • may have to read multiple items

    • $249/year

    • Optimized for use with Internet Explorer 5.x or Netscape 6.x

Evidence Based Medicine D.J. Van Durme, MD


Hands on with inforetriever

Hands on with InfoRetriever

  • 1. Look up “migraine”

    • 5 min clinical consult – level 5 evidence

      • Background info

    • Overview: practice guidelines

      • ACEP – guidelines for ED

    • Tx: Drug treatment – anticonvulsants?

      • Note symbols for Cochrane database or InfoPOEM

    • Info available on CAM, screening, Pt ed, etc

Evidence Based Medicine D.J. Van Durme, MD


Levels of evidence

Levels of Evidence

  • Level 1: Randomized Clinical Trials

  • Level 2: Head to Head Trial or Systematic Review of Cohort Studies

  • Level 3: Case-Control Studies

  • Level 4: Case-series

  • Level 5: Expert Opinion

Evidence Based Medicine D.J. Van Durme, MD


Guidelines

Guidelines

  • What is a guideline?

  • Guidelines may be

    • Explicitly evidence-based

    • Evidence-based

    • Research-based (highly referenced)

    • Opinion-based

    • “expert consensus”

Evidence Based Medicine D.J. Van Durme, MD


Guidelines1

Guidelines

  • National Guideline Clearinghouse

  • Primary Care Clinical Practice Guidelines

  • Agency/Association sites

    • AAFP

    • AAP

    • ACS

Evidence Based Medicine D.J. Van Durme, MD


Clinical evidence

Clinical Evidence

  • BMJ

  • Summaries of Evidence

  • Specific clinical questions: treatment

  • Makes specific recommendations

  • States when there is a lack of evidence

  • Free from United Health Foundation

Evidence Based Medicine D.J. Van Durme, MD


Clinical evidence1

Clinical Evidence

Evidence Based Medicine D.J. Van Durme, MD


Hands on with clinical evidence

Hands On with Clinical Evidence

  • Look up Stroke Prevention in Clinical Evidence

    • Beneficial – control BP and cholesterol and give aspirin

    • Unknown – other antiplatelet agents showed no benefit over aspirin

    • Ineffective or harmful – anticoagulant for those in sinus rhythm & carotid endarterectomy for those with <30% symptomatic stenosis

Evidence Based Medicine D.J. Van Durme, MD


Hands on possible example or use your own

Hands on (POSSIBLE example or use your own!)

  • Patient wants to know if Gingko biloba will help her mom’s Alzheimer’s

    • See InfoRetriever – dementia

      • Treatment – Complementary and alternative medicine

        • Mixed results in InfoPOEMS – some say maybe yes, some say no

        • Cochrane says – it seems safe, but studies are weak, we really do not know – more study is needed

    • See Clinical Evidence - dementia

Evidence Based Medicine D.J. Van Durme, MD


Acp journal club

ACP Journal Club

  • About 100 journals systematically surveyed

  • Highest-validity articles abstracted

  • Structured abstracts to guide critical appraisal

  • Clinical commentary

  • Included in our OVID subscription

Evidence Based Medicine D.J. Van Durme, MD


Acp journal club1

ACP Journal Club

  • Limitations

    • individual article summaries may not account for the “big picture”

    • may have to read multiple items

    • No “control” over what is covered

    • $78/year ?

Evidence Based Medicine D.J. Van Durme, MD


Need to read the key

Need to read the “key”

  • Levels of Evidence

    • Level 1: Highest

    • Level 2:

    • Level 3:

    • Level 4:

    • Level 5: Lowest—but still evidence

Evidence Based Medicine D.J. Van Durme, MD


Read the key

Read the “key”

  • Levels of Recommendation (USPSTF)

    • A – Highest – Strongly recommended (PAP smears)

    • B – Recommended (Mammograms age 40+)

    • C – no recommendation for or against (too close a balance between harm/benefit) (osteoporosis screening below age 60)

    • D – Recommend AGAINST (ovarian cancer)

    • I – insufficient evidence to make any recommendation for or against (Prostate cancer screening)

Evidence Based Medicine D.J. Van Durme, MD


Other guidelines

Other guidelines

  • A – good evidence

  • B – fair evidence

  • C – based on expert opinion and/or consensus

  • X – evidence of harm

Evidence Based Medicine D.J. Van Durme, MD


Essential principle

Essential principle

  • Be ready to “surrender” to a higher level of evidence when it becomes available

  • Do not become entrenched in what has been done for years

    • A bad idea done by a LOT of people for a LONG time, is still a bad idea

Evidence Based Medicine D.J. Van Durme, MD


Evidence based information recommendations reviews

Evidence based information, recommendations, reviews

  • Not all that claims to be “evidence based”, is really EBM

    • Should include explicit statements about search methods, findings, appraisal and level of evidence (or strength of recommendation)

  • High quality sources

    • Cochrane, AHRQ, USPSTF, ACP Journal Club, Clinical Evidence, InfoRetriever

  • Questionable sources

    • Developed by BOGSAT methodology

      • Bunch Of Guys Sitting Around a Table

      • Sometimes called “consensus”, argument may be won based on volume and stamina

Evidence Based Medicine D.J. Van Durme, MD


How does ebm really work2

How does EBM REALLY work?

  • Step 4: Implement information into practice

    • Integrate information with patients values and preferences

    • Patient-centered care

Evidence Based Medicine D.J. Van Durme, MD


How does ebm really work3

How does EBM REALLY work?

  • Step 4: Implement information into practice

    • Integrate information with patients values and preferences

    • Patient-centered care

      • Demographics, age, socioeconomics, fear, etc.

    • Evidence may point to surgery as better treatment but patient refuses

      • This does NOT mean EBM is out the window

      • Your job is to understand the magnitude of benefit and the level of evidence

        • Then translate into useable information for the patient

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • As patient participates in care decisions, you are practicing TRUE evidence based medicine

Evidence Based Medicine D.J. Van Durme, MD


Ok i am convinced how can i start to practice evidence based medicine

OK – I am convinced, how can I start to practice evidence based medicine?

  • Step 1 – Ask the questions

    • Use your clinical experiences to find 1-2 case scenarios every day that translate into clinical questions

      • Ask your student to help – he/she may REALLY appreciate that you explicitly tried to help find a REAL answer that would help an actual patient

    • PICO – population – intervention – comparison - outcome

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Use your growing clinical skills but do not be swayed by YUCK’s

    • Your Unsubstantiated Clinical Knowledge (and experience)

    • Regularly seek to find the best available evidence to guide you

    • Especially review common topics, you may be getting “stale” without realizing it

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Step 2 – Search for the evidence

  • When searching for background information

    • Critically appraise your texts for known problems/biases

      • Date of publication, references, source

    • Try to use systematic review articles

      • Explicit statements of how and where they searched, and statements of strength of recommendation of level of evidence

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Step 2 – searching (continued)

  • Locate and regularly use YODA’s

    • Your Own Data Analyzer

    • Let others do hard work for you

      • It is their full-time job, do you really have the time and expertise to do better?

    • Try InfoRetriever and Clinical Evidence a few times a week

      • Save your questions on a card and find answers over lunch or end of the day

      • Look at the Cochrane reports first

      • BUT even those may be dated!

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Step 3 – Critical Appraisal

    • Do not fall for three common myths

      • Newer article, by “bigger” name, and a “famous” journal, does NOT mean it is better

    • Use three quick tips

      • Is it relevant first?, don’t get overwhelmed by the stats, was it from YODA?

    • PRACTICE CRITICAL APPRAISAL of original research – if you do not use it, you will lose it

      • I often let headlines drive this – then I need to know NOW

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Step 4 – Integrate into patient care

    • Take your findings back to your patients

      • Sometimes this may be 2 minutes later or 2 weeks later

      • Discuss how to integrate this into care of your patient

        • Tell the patient that you have been “looking up the latest information” and they will appreciate it!

Evidence Based Medicine D.J. Van Durme, MD


Med fsu

  • Step 5 – Self evaluation – how did you do?

    • Learn to improve your . . .

      • Framing of the question

      • Search terms

      • Search locations

      • Critical appraisal skills

      • Patient understanding

      • Patient centered approach

Evidence Based Medicine D.J. Van Durme, MD


Questions

Questions?

Evidence Based Medicine D.J. Van Durme, MD


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