Finding and using best evidence
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Finding and Using Best Evidence. Rebecca Payne, MPH Laura Straw, MPH Health Analysis Department Navy and Marine Corps Public Health Center. Disclaimer.

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Finding and using best evidence

Finding and Using Best Evidence

Rebecca Payne, MPH

Laura Straw, MPH

Health Analysis Department

Navy and Marine Corps Public Health Center


Disclaimer

Disclaimer

  • The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

FOR OFFICIAL USE ONLY


Health analysis department

Health Analysis Department

  • Department within the Population Health Directorate of the Navy and Marine Corps Public Health Center, Portsmouth, VA

  • Highly trained team consisting of:

    • Epidemiologists

    • Program Manager

    • Technical Affairs Officer

    • Biostatistician

    • Physician Lead

    • Navy Tumor Registry Consultant

FOR OFFICIAL USE ONLY


Objectives

Objectives

  • Define “best evidence”

  • Describe how one would find best medical evidence

  • List the hierarchy of strength of evidence

  • List examples of best evidence in Navy Medicine

FOR OFFICIAL USE ONLY


Evidence based

“Evidence-Based…”?

  • Evidence-based medicine:

    • “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”1

  • Evidence-based clinical practice:

    • “Evidence-based clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option that suits the patient best” 2

  • Evidence-based practice in health care:

    • Evidence-based health care “takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information” 3

FOR OFFICIAL USE ONLY


Levels of evidence

Levels of Evidence

Filtered Information

Quality of evidence

Unfiltered Information

Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

FOR OFFICIAL USE ONLY


Background info expert opinion

Background Info/ Expert Opinion

  • Quick references

    • Medscape Reference

    • 5 Minute Clinical Consult

  • Textbooks

  • Internet

  • Colleagues/experts

FOR OFFICIAL USE ONLY


Example medscape reference

Example: Medscape Reference

FOR OFFICIAL USE ONLY


Levels of evidence1

Levels of Evidence

Filtered Information

Quality of evidence

Unfiltered Information

Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

FOR OFFICIAL USE ONLY


Unfiltered information

Unfiltered Information

  • Reports

  • Case series: Descriptive study of group with common exposures or outcomes

  • Case-controlled studies: People with a specific health outcome are matched with people who do not have the outcome to compare if the groups differ with respect to potential causes

  • Cohort studies: People exposed to a cause or a treatment are compared to those not exposed to determine if they differ with respect to risk of some outcome

FOR OFFICIAL USE ONLY


Unfiltered information1

Unfiltered Information

  • Randomized Controlled Trials

    • “Gold standard”

    • Experimental design

    • Participants are randomly assigned to a control condition or to an experimental condition

    • Minimizes bias

    • Drawbacks: Expensive and time consuming

FOR OFFICIAL USE ONLY


Unfiltered information resources

Unfiltered Information Resources

  • PubMed

  • http://www.ncbi.nlm.nih.gov/pubmed

  • Ovid MEDLINE http://www.ovid.com/site/catalog/DataBase/901.jsp

  • PsychINFO

  • www.apa.org/psycinfo/

FOR OFFICIAL USE ONLY


Example pubmed

Example: PubMed

FOR OFFICIAL USE ONLY


Example pubmed1

Example: PubMed

FOR OFFICIAL USE ONLY


Levels of evidence2

Levels of Evidence

Filtered Information

Quality of evidence

Unfiltered Information

Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

FOR OFFICIAL USE ONLY


Filtered evidence

Filtered Evidence

  • Critically Appraised Individual Articles

  • Synopsis and evaluation of individual research studies

  • Critically Appraised Topics

  • Synthesis and evaluation of multiple research studies

FOR OFFICIAL USE ONLY


Caia resources

CAIA Resources

  • ACP Journal Club

  • http://acpjc.acponline.org/

  • Evidence Updates- from the BMJ Evidence Center

  • http://plus.mcmaster.ca/evidenceupdates/

  • Any “Evidence-Based…” Journal series (i.e. Evidence-Based Nursing)

FOR OFFICIAL USE ONLY


Cat resources

CAT Resources

  • AHRQ National Guideline Clearinghousehttp://guideline.gov/index.aspx

  • Clinical Evidence

    • http://clinicalevidence.bmj.com/x/index.html

  • Essential Evidence Plus- POEMs

    • http://www.essentialevidenceplus.com/

FOR OFFICIAL USE ONLY


Example ahrq national guideline clearinghouse

Example: AHRQ National Guideline Clearinghouse

FOR OFFICIAL USE ONLY


Example ahrq national guideline clearinghouse1

Example: AHRQ National Guideline Clearinghouse

FOR OFFICIAL USE ONLY


Cat resources1

CAT Resources

  • The VHA/ MHS have their own Clinical Practice Guidelines

    • http://www.healthquality.va.gov/

    • VA/DoD Evidence-Based Practice Guideline Work Group (EBPWG) include representatives from all military branches and the VA

    • EBPWG selects topics based on cost, volume, risk, and feasibility.

FOR OFFICIAL USE ONLY


Example va dod cpgs

Example: VA/DoD CPGs

FOR OFFICIAL USE ONLY


Levels of evidence3

Levels of Evidence

Filtered Information

Quality of evidence

Unfiltered Information

Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

FOR OFFICIAL USE ONLY


Filtered information

Filtered Information

  • Systematic Review:

  • Searching for, recording, analyzing and interpreting the existing evidence 4

  • Meta-Analysis:

  • Applying a statistical formula to measure the effect, size, and

  • impact of treatment programs 4

  • Example From Cochrane:

  • Exercise or Exercise and Diet for preventing

  • type 2 diabetes7

    • 8 trials, with ~5,000 participants

    • Conclusion: Exercise and diet can decrease

    • type 2 diabetes

FOR OFFICIAL USE ONLY


Systematic review resources

Systematic Review Resources

  • Cochrane Database of Systematic Reviews

    • www.cochrane.org

  • The Database of Abstracts of Review of Effects (DARE)

    • http://www.ovid.com/site/products/ovidguide/daredb.htm

    • PUBMED

    • http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?otool=yalelib&dr=citation

  • Ovid MEDLINE

Source: http://www.ebmpyramid.org/samples/complicated.html

FOR OFFICIAL USE ONLY


Example uspstf

Example: USPSTF

  • US Preventive Services Task Force (USPSTF)

    • http://www.uspreventiveservicestaskforce.org/

  • Independent group of prevention and EBM experts that makes recommendations about clinical preventive services

FOR OFFICIAL USE ONLY


Example uspstf1

Example: USPSTF

FOR OFFICIAL USE ONLY


Evidence based applications and examples

Evidence Based Applications and Examples


The 5 minute clinical consult 2009 or uptodate

The 5-Minute Clinical Consult 2009OR UptoDate


Restless leg syndrome

Restless Leg Syndrome


Cervical cancer screening

Cervical Cancer Screening

  • What is the evidence for routine cervical caner screening in women?

  • US Preventive Services Task Force

Source: Whitlock, E.P., Vesco, K.K., Eder, M., Lin, J., Senger, C., Burda, B., Liquid Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cencer: A Systematic Review for the US Preventive Services Task Force. Annals of Internal Medicine. 2011. Vol 155 No 10. p 687-697

FOR OFFICIAL USE ONLY


Cervical cancer ctd

Cervical Cancer, Ctd

FOR OFFICIAL USE ONLY


Cervical cancer ctd1

Cervical Cancer, ctd.

  • Does everyone agree?

Source: http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf

FOR OFFICIAL USE ONLY


Finding and using best evidence

PTSD

  • What is the best evidence available about treatment for PTSD?

  • VA/DOD Clinical Practice Guideline:

Source: VA/DOD Clinical Practice Guideline: Management of Post Traumatic Stress Disorder and Acute Stress Reaction (2010). http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp

FOR OFFICIAL USE ONLY


Ptsd cont d

PTSD Cont’d

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Ptsd cont d1

PTSD Cont’d

  • Cochrane Review: PTSD

  • Psychological and psychosocial interventions

    • “Some types of psychological treatment (individual trauma-focused cognitive behavioural therapy/exposure therapy [TFCBT], eye movement desensitisation and reprocessing [EMDR], stress management, and group TFCBT) were effective in the treatment of PTSD, and individual TFCBT and EMDR appeared to be superior to stress management at two to five months. Insufficient evidence was available to determine whether psychological treatment is harmful, but there was greater drop-out in active treatment groups. Caution is needed in interpreting these results because of considerable unexplained heterogeneity, and the potential impact of publication bias”

  • Pharmacotherapy for post-traumatic stress disorder

    • “Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of selective serotonin reuptake inhibitors as first-line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.”

  • Source: http://www.thecochranelibrary.com/details/collection/1045825/Cochrane-Evidence-Aid-resources-for-post-traumatic-stress-disorder-following-nat.html

FOR OFFICIAL USE ONLY


Hedis

HEDIS

  • NCQA’s Health Effectiveness Data and Information Set (HEDIS)

  • Widely used set of health performance indicators

  • Desirable attributes for HEDIS measures are:

    • Relevance

    • Scientific Soundness –Clinical Evidence! (There should be evidence documenting the link between clinical processes and outcomes that measures address)

    • Feasibility

  • Source: HEDIS Technical Specification Manual

FOR OFFICIAL USE ONLY


Evidence applications

Evidence Applications

  • In Military Medicine: Population Health Navigator/CarePoint

FOR OFFICIAL USE ONLY


Analysis application

Analysis Application

  • How could we apply best evidence when measuring healthcare?

  • Look for best evidence: systematic reviews, CPGs, research

  • Assess evidence

  • Look for existing measures; if none exist, look for “measurable points” in evidence.

  • Ensure proposed measure is meaningful and feasible

  • Develop measure

FOR OFFICIAL USE ONLY


Application example mtbi metrics

Application Example: mTBI Metrics

  • Wounded, Ill, and Injured (WII) Program:

    • Navy Medicine effort to monitor and improve the care offered to wounded, ill, and injured service members and their families

  • mTBI Metrics

    • TBI Screening: Percent of Coded Head Injury/Trauma Patients Coded as Screened for TBI

    • Co-Occurring Conditions Screen: Percent of Coded mTBI Patients Coded as Screened for Co-Occurring Conditions

    • Six Week Follow Up Visit: Percent of Coded mTBI Patients with Follow-Up within Six Weeks


Mtbi metrics example cont d

mTBI Metrics Example (cont’d)

  • Metric Definitions:

    • The Department of Veterans Affairs (VA) and Department of Defense (DoD) Concussion and mTBI Clinical Practice Guideline (CPG)

  • Coding Guidance:

    • Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE PH/TBI)

    • Navy Medicine TBI subject matter experts (SMEs)


Finding and using best evidence

mTBI Metrics Example (cont’d)

General Coding Guidance & CPG Recommendation


Finding and using best evidence

mTBI Metrics (cont’d)

CPG Recommendation:

“Regardless of the time that has elapsed since injury, management should begin with the patient’s first presentation for treatment,” and head injury cases should be screened for TBI.

All Head Injury Cases: 5%

Active Duty Only: 7%

Not using codes?

Not screening for TBI?

Actual process different than recommendation?


References

References

  • Sackett,D., Richardson, W., Rosenberg, W., & Haynes, R. (1997). Evidence-based medicine: How to practice and the EBM. New York:Churchill Livingston.

  • Muir Gray, J.A. (1997) Evidence-based healthcare: How to make health policy and management decisions. London:Churchill Livingstone.

  • Hicks, N. (1997). Evidence based healthcare. Bandolier, 4(39),8.

  • Roberts, A., Yeager, K. (2004). Evidence-Based Practice Manual. New York, NY: Oxford University Press.

  • Whitlock, E.P., Vesco, K.K., Eder, M., Lin, J., Senger, C., Burda, B. (2011). Liquid Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cencer: A Systematic Review for the US Preventive Services Task Force. Annals of Internal Medicine. 155 (10),687-697.

  • Framingham Heart Study http://www.framinghamheartstudy.org/about/history.html

  • Orozco LJ, Buchleitner AM, Gimenez-Perez G, RoquéiFiguls M, Richter B, Mauricio D. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD003054. DOI: 10.1002/14651858.CD003054.pub3

FOR OFFICIAL USE ONLY


Navy and marine corps public health center health analysis

Navy and Marine Corps Public Health CenterHealth Analysis

CAPT Paul Rockswold, MD, MPH

Head, Health Analysis

P: 757-953-0690

Email: [email protected]

Rebecca Payne, MPH

P: 757-953-0620

Email: [email protected]

Laura Straw, MPH

P: 757-953-3776

Email: [email protected]

web: http://www-nehc.med.navy.mil/Data_Statistics/Health_Analysis/ha_overview.aspx

FOR OFFICIAL USE ONLY


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