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Training graduate students in EBP 43-year-old woman with 1-3 migraine headaches per week. Otherwise healthy. Stress is a significant trigger for her headaches, Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost.

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slide2
43-year-old woman with 1-3 migraine headaches per week.
  • Otherwise healthy.
  • Stress is a significant trigger for her headaches,
  • Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost.
  • She prefers “alternative” approaches
  • Has heard that acupuncture can help migraines.
she asks
She asks:
  • Should she pursue treatment with us or try an “alternative” approach such as acupuncture?
  • What do we think would be the most effective treatment for her?
based on the case scenario
Based on the case scenario…
  • STEP 1: Formulating EBP questions
background questions
Background Questions
  • What are the most effective treatments for chronic migraine headache?
  • Is acupuncture an effective treatment for migraine headache?
  • Are there any significant risks associated with acupuncture?
foreground questions
Foreground Questions

P = Patient Population or Problem

I = Intervention

C = Comparison

O = Outcome

foreground questions8
Foreground Questions

P = In middle aged women with migraine headaches

I =

C =

O =

foreground questions9
Foreground Questions

P = In middle aged women with migraine headaches

I = is there any evidence that acupuncture

C =

O =

foreground questions10
Foreground Questions

P = In middle aged women with migraine headaches

I = is there any evidence that acupuncture

C = compared to sham acupuncture, biofeedback, relaxation training and/or CBT

O =

foreground questions11
Foreground Questions

P = In middle aged women with migraine headaches

I = is there any evidence that acupuncture

C = compared to sham treatment, biofeedback, relaxation training, and cognitive-behavioral therapy

O = reduces the frequency, intensity, and/or duration of migraines?

operationalizing ebp
Operationalizing EBP:

STEP 1: Formulate a clear question.

STEP 2: Search for the best research evidence.

evidence
“Evidence”
  • What exactly are we looking for?
slide14

The Evidence Pyramid for

Effectiveness Questions

searching for the evidence how to access the secondary literature
Searching for the evidence: How to access the secondary literature

DATABASES:

  • PsycINFO
  • Medline

INTERFACES:

CSA Illumina, EBSCO, Ovid

Ovid, PubMed

foreground questions16
P =In middle aged women with migraine headaches

I = is there any evidence that acupuncture

C = compared to sham treatment, biofeedback, relaxation training, and cognitive-behavioral therapy

O = reduces the frequency, intensity, and/or duration of migraines?

Foreground Questions
searching medline
Searching Medline:
  • Select terms from the controlled vocabulary list
  • Search each term individually
  • Use AND / OR to combine the sets.
  • Limit to Humans and English
  • Limit to EBM reviews.
medline terms
Medline terms:
  • Controlled vocabulary
  • Trees of MeSH terms
  • Exploding
  • Scope notes
  • Combining and limiting
in ovid
In OVID:
  • EBM reviews limits to:
    • The Cochrane Database of Systematic Reviews (CDSR)
    • The Database of Abstracts of Reviews of Effects (DARE)
    • ACP Journal Club
    • Controlled Clinical Trials Registry (CCTR).
in pubmed
In PUBMED:
  • Clinical queries --systematic reviews limits using a specific methodological filter developed by PubMed.
operationalizing ebp23
Operationalizing EBP:
  • Formulate a clear question.
  • Search for the best research evidence.
  • Critically appraise the evidence.
  • Integrate with patient’s needs, preferences, circumstances, and values.
systematic reviews
Systematic reviews:
  • From the Cochrane Library:
    • “Acupuncture for ideopathic headache”
    • Two reviews on “Is acupuncture safe?”
  • Two evidence-based guidelines
    • AAN
    • Headache Consortium (behavioral and physical treatments)
slide27

Relaxation, BFT,

  • CBT: A
  • Behavioral therapy +
  • Med : B
  • Acupuncture: some evidence but inconclusive
  • More evidence for acupuncture than other “alternative” treatments
  • Acupuncture is low risk

Best research evidence

CD

Patient Characteristics, Values,

and Context

Clinical Expertise

slide28

Best research evidence

Prefers “alternative” treatments

Concerned about cost

No co-morbid conditions

Similar to pts in studies

Behavioral treatments feasible

Insight into the link between stress and headaches

Cost of acupuncture unknown at time of assessment

Not needle-phobic

CD

Patient Characteristics, Values,

and Context

Clinical Expertise

slide29

Best research evidence

CD

  • Assess the patient accurately
  • Communicate with the patient
  • Integrate the research and clinical evidence
  • Ability to deliver the txs of choice?

Patient Characteristics, Values,

and Context

Clinical Expertise

the clinical decision
The Clinical Decision:
  • Begin treatment with BFT and relaxation training
  • “Alternative” treatments
  • Affordable, feasible
  • Incorporate CBT
  • Reconsider acupuncture therapy
how do articles get tagged
How do articles get “tagged”?
  • Title
  • Author name
  • Keywords
  • Date of publication
  • Type of publication
  • etc
they also get tagged by concept
They also get tagged by CONCEPT
  • Controlled vocabulary
    • Medline: MeSH terms
    • PsycINFO: thesaurus
background vs foreground questions where do we look for answers
Background vs. Foreground Questions: Where do we look for answers?

Background questions  textbooks, UpToDate, etc. (well-established facts/basic info)

Foreground questions  MEDLINE search (usually new info)

recommended steps for performing a search
RECOMMENDED STEPS FOR PERFORMING A SEARCH
  • Formulate a clear question.
  • Background or foreground?
  • List the key words/terms
  • Decide WHERE to search
background questions36
Background questions:
  • Online textbooks (books@ovid)
  • Reviews in appropriate database (s)
foreground questions37
Foreground Questions:
  • Medline
  • PsycINFO
  • Other appropriate databases
recommended steps for performing a medline or psycinfo search
RECOMMENDED STEPS FOR PERFORMING A MEDLINE or PSYCINFO SEARCH
  • Formulate a clear question.
  • List the key words/terms
  • Decide WHERE to search
  • Select terms from the controlled vocabulary list (MeSH terms in Medline; thesaurus in PsycINFO)
  • You will use those terms to search
finding mesh terms for medline
Finding MeSH terms for Medline
  • Enter your term, click SEARCH
  • Read the SCOPE notes
  • Click on a subject heading term
  • Click on FULL TREE (scroll down to blue highlighted area)
  • Click on all the + signs to see the full tree
  • Decide which specific terms are best for your purposes.
finding thesaurus terms for psycinfo
Finding thesaurus terms for PsycINFO
  • Click on search tools
  • Choose the thesaurus tab
  • Browse thesaurus for…(check hierarchy)
  • Expand where you see a +
  • Choose the BEST terms for your concept
slide41

Present patients at evidence-based case conferences.

  • This will include the following in addition to the clinical data:
  • What were your foreground and background questions?
  • What search strategies did you use and what did you find?
  • What is your critical appraisal of the best evidence available?
  • How will/did you integrate this evidence with your particular patient’s circumstances, values, and situation?
  • What is your evidence-based treatment plan?
  • Should we create a CAT for this topic?
  • What research studies could be done that would improve your ability to care for patients similar to this one?