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Evidence Based Obstetric Medicine. Robert Hopkins, MD, FACP, FAAP UAMS Associate Professor of Medicine and Pediatrics. Outline. EBM Overview What is EBM Why is EBM important Basics of E-B medical practice Evidence Based Obstetrics 2005 Selected examples. Overcoming inertia….

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evidence based obstetric medicine

Evidence Based Obstetric Medicine

Robert Hopkins, MD, FACP, FAAP

UAMS Associate Professor of Medicine and Pediatrics

outline
Outline
  • EBM Overview
    • What is EBM
    • Why is EBM important
    • Basics of E-B medical practice
  • Evidence Based Obstetrics 2005
    • Selected examples
overcoming inertia
Overcoming inertia…
  • “Human nature: apply minimum work in order to complete the task at hand…”
  • “We need to learn not only HOW to read the literature---but also WHAT to read and WHEN to read it…”
  • “Usefulness = Validity * Relevance [of data]

Work (required to find data)”

what is ebm 1
What is EBM? [1]
  • Patient centered
  • Ask answerable questions
  • Search for best evidence
    • Can be time consuming… unless using E-B sources
  • Critical assessment of evidence
    • For validity and applicability
    • May be time consuming, as above
    • If we do not assess critically, our educated consumers/patients will go elsewhere…
what is ebm 2
What is EBM? [2]
  • Evaluate applicability [of search results]
    • Does the evidence apply to this patient?
    • Integrate evidence with clinical expertise
    • Is the intervention applicable to this specific person
    • ‘Guideline dilemma’: is this a replication of expert (egocentric) opinion or a compendium of evidence…
  • Critically assess the impact of change
    • To the patient
    • To the clinician
    • To ‘my medical practice’
so what is the problem
So… What is the problem?

Medical knowledge continues to grow

  • 3000 new papers published DAILY
  • 1000 new Medline article citations DAILY
  • 46 new RCT’s published DAILY

We do NOT read enough:

  • < ½ hour/week: 3 %
  • 1 hour/week: 46 %
  • 1-2 hr/week: 43%
  • 3+ hours/week: 8 %
but aren t we doing ok
BUT…Aren’t we doing OK???
  • Data re: practice variability (200+ studies)
    • [IM] Example: Determinants of need to Rx HTN
      • Level of BP
      • Patient age
      • Year MD awarded
      • End-organ damage
  • Can we realistically expect to provide the best care for 100+ patients/wk relying on memory and experience alone???
where does the data come from
Where does the data come from?
  • Print source
    • Texts: General/Subspecialty/PDR
    • Journals
    • Reprints
  • Human source
    • Consultations
    • CME Conferences
    • Pharmaceutical rep’s
  • Other:
    • Electronic: Best Evidence CD, UpToDate, PIER,…
    • Paper: Clinical Evidence [Updates]
    • Specialty Societies
the cme conundrum
The CME Conundrum
  • CME is a ‘growth industry’
  • Most presentations are ‘Fact’ oriented
  • Several RCT’s have demonstrated no improvement in clinical performance…

Freemantle N., et.al. Cochrane Database of Systematic Reviews 2000;2.

what are the answers
What are the answers?
  • Seek out and apply evidence others generated
  • Learn how to practice EBM ourselves

Ultimate goal is …to apply evidence-centered strategies to answer questions in our practice-- leading to refinement of our clinical behavior.

what evidence do we need
What evidence do we need?

Evidence about:

  • Predictive values and likelihood ratios for diagnostic tests
  • Power and specificity of prognostic markers
  • Comparative efficacy and safety of interventions
how often do we need ebm
How often do we need EBM?

Studies estimate at least:

  • 5 valid questions for every inpatient stay
  • 2 questions for every 3 outpatient visits

And yet

  • We get less than 1/3 of these answered…
to summarize why ebm
To summarize- Why EBM?
  • Too many patients
  • Too many questions
  • Too much information to glean all the PEARLS
  • No time to read
  • “Selection pressure” on the reading we do
    • Reading often focused on familiar source/topic
    • It is common practice to avoid difficult issues and focus on ‘quick answers’
what is the best evidence
What is the BEST evidence?

1989 Georgia [One man’s opinion]

  • ‘Old Professors’
  • Case series
  • Systematic Review
  • Randomized Controlled
  • Meta-Analysis
  • Case Control
  • Colleague/Consultant
  • Case report
structuring the question
Structuring the Question
  • Unstructured: Too many ‘hits’
    • Example: >13000 [Pregnancy + HTN] articles PubMed [1/15/05]
  • Structuring questions
    • Background: W5s and How
      • ‘W’ + Verb + Disease…
    • Foreground: most daily ‘clinical care’ issues
background questions
Background Questions
  • Who, What, When, Where, Why, How..
    • + [verb] + [DISease]
  • Results:
    • Often answered by textbooks, reviews
    • Most common when unfamiliar with a topic
foreground questions
Foreground Questions
  • Question Structure
    • Patient or problem
    • Intervention or exposure considered
    • Comparison intervention (If relevant)
    • Outcome of interest
cq example
CQ Example
  • In pregnant woman with severe HTN [>170/100] is Labetalol as effective as Hydralazine in reduction of BP and maternal morbidity?
    • Result: Cochrane DB Systematic Reviews: 2003

[Other than Diazoxide [more symptomatic hypotension], there are no clear differences in studied agents including Labetalol, Hydralazine, Nifedipine ER,…]

search for the evidence
Search for the Evidence

Database: Pub Med, Ovid and others

Search engines are highly sensitive…but they are not specific

(Specificity left to the questioner/searcher)

MeSH: Structured medical subject headings- freely available from NLM (topic map) allow targeting of search to topic

‘Related articles’ is useful if narrow topic evaluated

Limits: Clinical Trial OR Systematic Reviews

English(?) language

Human subjects

evaluating the evidence
Evaluating the Evidence

Some ‘pre-assessed’ sources for your use:

  • ACP Journal Club, Journal of Evidence-Based Medicine
  • NGC: http://www.guideline.gov
  • Cochrane database
  • Clinical Evidence (BMJ Publications)
  • UpToDate

JAMA Guide: EBM Working Group

  • Are the results valid?
  • What are the results?
  • Will the results help in my patients’ care?
  • http://medicine.ucsf.edu/resources/guidelines/users.html
data vs availability vs utility
Data vs. Availability vs. Utility

Data Source Access Quality

Experience Longitudinal Rapid Variable

Colleague Variable Variable Variable

Patients Rapid Rapid ???

Guidelines Variable Variable Variable

Texts Rapid Slow Good?

Research Slow Slow Good?

Journals Buried Variable Good

who are we
Who are we??
  • Evidence Users
  • Evidence Finders
  • Evidence Generators

[And I hope Never…]

  • Evidence Ignorers
what is our goal in ebm
What is our goal in EBM?

To NOT have to wade through 100+ papers

To NOT have to go through Medline

TO have evidence indexed by strength

TO have a brief (1 word ?) answer…

TO see questions that are already answered

i.e. ALL applicable knowledge in 15 seconds

…FLAT….

evidence based ob 2005
Evidence Based OB 2005

13043 “Pregnancy + HTN” articles

[Pubmed 1/18/05]

  • 207 when limited to Clinical trial, Human subjects, English language
evidence based ob 20051
Evidence Based OB 2005

15852 “Preeclampsia” articles in 2005 [Pubmed 1/13/05]

  • 263 articles when limited to: adults, human, English, published within 1 year
  • 170 articles with MeSH ‘major topic’ limit
  • 15 Clinical trials [Publication type]
  • 7 Randomized Controlled Trials
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