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daniel_millan
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Training graduate students in EBP

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  1. Training graduate students in EBP

  2. 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.

  3. 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?

  4. Based on the case scenario… • STEP 1: Formulating EBP questions

  5. 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?

  6. Foreground Questions P = Patient Population or Problem I = Intervention C = Comparison O = Outcome

  7. Foreground Questions P = In middle aged women with migraine headaches I = C = O =

  8. Foreground Questions P = In middle aged women with migraine headaches I = is there any evidence that acupuncture C = O =

  9. 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 =

  10. 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?

  11. Operationalizing EBP: STEP 1: Formulate a clear question. STEP 2: Search for the best research evidence.

  12. “Evidence” • What exactly are we looking for?

  13. The Evidence Pyramid for Effectiveness Questions

  14. Searching for the evidence: How to access the secondary literature DATABASES: • PsycINFO • Medline INTERFACES: CSA Illumina, EBSCO, Ovid Ovid, PubMed

  15. 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

  16. EBP SEARCH PLANNING WORKSHEET

  17. 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.

  18. Medline terms: • Controlled vocabulary • Trees of MeSH terms • Exploding • Scope notes • Combining and limiting

  19. Enter through your “library” site A demonstration : • http://www.iub.edu/

  20. 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).

  21. In PUBMED: • Clinical queries --systematic reviews limits using a specific methodological filter developed by PubMed.

  22. 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.

  23. What did the search yield?

  24. 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)

  25. Step 4: Integrating the evidence

  26. 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

  27. 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

  28. 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

  29. The Clinical Decision: • Begin treatment with BFT and relaxation training • “Alternative” treatments • Affordable, feasible • Incorporate CBT • Reconsider acupuncture therapy

  30. How do articles get “tagged”? • Title • Author name • Keywords • Date of publication • Type of publication • etc

  31. They also get tagged by CONCEPT • Controlled vocabulary • Medline: MeSH terms • PsycINFO: thesaurus

  32. 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)

  33. RECOMMENDED STEPS FOR PERFORMING A SEARCH • Formulate a clear question. • Background or foreground? • List the key words/terms • Decide WHERE to search

  34. Background questions: • Online textbooks (books@ovid) • Reviews in appropriate database (s)

  35. Foreground Questions: • Medline • PsycINFO • Other appropriate databases

  36. 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

  37. 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.

  38. 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

  39. 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?