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Metropolitan Detroit Medical Library Group

Explore the importance and challenges of evidence-based medicine in clinical practice. Learn about tools and methods for efficient decision-making based on the best available evidence, impacting patient outcomes.

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Metropolitan Detroit Medical Library Group

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  1. Metropolitan Detroit Medical Library Group September 16, 2010 Larissa J. Lucas, MD Senior Deputy Editor, DynaMed

  2. Disclosure • Senior Deputy Editor, • DynaMed, EBSCO Publishing, Ipswich, MA • Clinical Instructor in Medicine • Harvard Medical School, Boston, MA

  3. Evidence Based Medicine • conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients • integrating individual clinical expertise with the best available external clinical evidence from systematic research Sackett DL BMJ. 1996 Jan 13;312(7023):71-2

  4. Clinical Expertise and Patient Preference Haynes RB ACP J Club. 2002 Mar-Apr;136(2):A11-4.

  5. Evidence Based Decision Making Tilburt JC. J Eval Clin Pract. 2008 Oct;14(5):721-5

  6. Why we need EBM tools • Barriers to answering clinical questions • Ebell MH. Am Fam Physician. 2009 Feb 15;79(4):293 • Time • Doubt • Culture • Access • Rising health care costs • Quality of care • Industry sponsored studies (BMJ. 2007 Dec 8;335(7631):1202)

  7. Answering clinical questions • 112 primary care physicians • 3,511 visits with 635 questions • 22.8% questions were investigated • 14% of questions investigated not answered • time to answer questions • 2 minutes during consultation • 32 minutes after consultation Ann Fam Med. 2007 Jul-Aug;5(4):345-52. • 48 primary care physicians • 1,062 questions • 55% questions investigated • doubt that answer existed for 11% questions • resource failure in 26% • 41% of answers were found easily • 31% found with difficulty J Am Med Inform Assoc. 2005 Mar-Apr;12(2):217-24

  8. How to ask a question • Cochrane systematic review • 4 trials • PICO training • PubMed searching training • Information seeking training • Question formulation training • Short-term benefits • Improved searching time • Improved question quality • Improved satisfaction with searching • Increased correct answers Cochrane Database Syst Rev. 2010 May 12;5:CD007335.

  9. Existing tools • Textbooks and handbooks • PubMed • Guidelines • Google • News services • Subscription online databases

  10. Types of Tools • Alerting “foraging” • Prompts clinicians to ask questions • Filtered for relevance and validity • Transparent evaluation and appraisal process • Evidence rating • Differentiate between “news” and practice changing outcomes • Finding “hunting” • Finding the answer to a clinical question • Transparent evidence rating criteria • Transparent reproducible methodology • Ease of use • Ease of access

  11. Relevance:Patient Oriented Outcomes • Symptoms • Functioning • Quality of Life • Lifespan

  12. Validity

  13. Validity • Use of appropriate criteria for appraisal • Randomized trials • Systematic reviews • Diagnostic studies • Prognostic studies • Criteria include patient oriented outcomes

  14. Effect on Patient-Oriented Outcomes • Symptoms (drivers license) • Functioning (visual loss) • Quality of Life (leg ulcers) • Lifespan SORT A SORT B • Effect on Disease Markers • Diabetes (Photocoagulation, GFR, NCV) • Arthritis (x-ray, sed rate) • Peptic Ulcer (endoscopic ulcer) SORT C Relevance of Outcome • Effect on Risk Factors for Disease • Improvement in markers (blood pressure, HBA1C, cholesterol) Uncontrolled Observations & Conjecture • Physiologic Research • Preliminary Clinical Research • Case reports • Observational studies • Highly Controlled Research • Randomized Controlled Trials • Systematic Reviews Validity of Evidence Adapted with permission from Slawson D. Evidence Based Medicine: Don’t We Need Information Management Instead?

  15. Defining Evidence-Based for a Clinical ReferenceEvidence-Based = conclusions based on best available evidence • Systematically identifying all applicable evidence • Systematically selecting the best available evidence from that identified • Systematically evaluating the selected evidence (critical appraisal) • Objectively reporting the relevant findings and quality of the evidence • Synthesizing multiple evidence reports • Deriving overall conclusions and recommendations from the evidence synthesis • Changing the conclusions when new evidence alters the best available evidence

  16. What clinicians need • Comprehensive • Valid • Systematic • Current • Synthesized

  17. Access • Desktop • Mobile • Electronic Health Record

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