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: • 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… • STEP 1: Formulating EBP 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 P = Patient Population or Problem I = Intervention C = Comparison O = Outcome
Foreground Questions P = In middle aged women with migraine headaches I = C = O =
Foreground Questions P = In middle aged women with migraine headaches I = is there any evidence that acupuncture C = O =
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 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: STEP 1: Formulate a clear question. STEP 2: Search for the best research evidence.
“Evidence” • What exactly are we looking for?
The Evidence Pyramid for Effectiveness Questions
Searching for the evidence: How to access the secondary literature DATABASES: • PsycINFO • Medline INTERFACES: CSA Illumina, EBSCO, Ovid Ovid, PubMed
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: • 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: • Controlled vocabulary • Trees of MeSH terms • Exploding • Scope notes • Combining and limiting
Enter through your “library” site A demonstration : • http://www.iub.edu/
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: • Clinical queries --systematic reviews limits using a specific methodological filter developed by PubMed.
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: • 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)
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
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
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: • Begin treatment with BFT and relaxation training • “Alternative” treatments • Affordable, feasible • Incorporate CBT • Reconsider acupuncture therapy
How do articles get “tagged”? • Title • Author name • Keywords • Date of publication • Type of publication • etc
They also get tagged by CONCEPT • Controlled vocabulary • Medline: MeSH terms • PsycINFO: thesaurus
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 • Formulate a clear question. • Background or foreground? • List the key words/terms • Decide WHERE to search
Background questions: • Online textbooks (books@ovid) • Reviews in appropriate database (s)
Foreground Questions: • Medline • PsycINFO • Other appropriate databases
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 • 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 • 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
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?