Transcript IT Applications of EBM Principles

Selecting the Best EvidenceBased Medicine Resources
Daniel J. Van Durme, MD
Chairman, Dept. Family Medicine and Rural Health
Nancy Clark, MEd
Director of Medical Informatics Education
FSU College of Medicine
1
Objectives





What is EBM?
Formulate a clinical question
Apply levels of evidence to decision making
process including patient concerns
What are the major EBM databases
Search for evidence based information

Using EBM hunting tools
FSU College of Medicine
2
Handouts and Resources

EBM Tutorial online
www.med.fsu.edu/informatics/EBMTutorial.asp




EBM Resources handout
Clinical Question Worksheet
Cases
Slawson article on EBM
FSU College of Medicine
3
New Resource EBM Teaching Materials
FSU College of Medicine
4
What is EBM?

Evidence based medicine (EBM) was
originally defined as the conscientious,
explicit, and judicious use of current best
evidence in making decisions about the care of
individual patients.
(Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS.
Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-2)
FSU College of Medicine
5
What is EBM?

The revised and improved definition of evidencebased medicine is
“the integration of the
best research evidence
with clinical expertise
and patient values”

It reflects a systematic
approach to clinical problem solving.
(Sackett DL, Strauss SE, Richardson WS, et al. Evidence-based medicine: how to
practice and teach EBM. 2nd Ed. London: Churchill-Livingstone,2000)
6
What EBM skills do all practicing
clinicians really need?

Among other skills:



Information mastery: finding the best
evidence for every day practice
Have at fingertips “just in time’ information at
point of care for clinical decision making
 web based and/or PDA
Evaluate expert-based information, including
colleagues, CME, presentations, reviews and
guidelines
Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching
information management instead? Acad Med. 2005 Jul;80(7):685-9.
7
Advanced EBM Skills
Only a small percentage of clinicians need to be able to do the
following
 Critical Appraisal and Interpretation of Research on:


Critical Evaluation and Interpretation of:




Therapies, Diagnostic Tests, Prognosis
Systematic Reviews, Including Meta-analysis, Decision Analysis,
Practice Guidelines, Pharmaceutical Advertising, Including
Pharmaceutical Representatives
Assigning Levels of Evidence to Research Findings
Teaching Level 1 Skills
Produce written Communication of Research Findings


Physicians
Patients
(Slawson, et al)
FSU College of Medicine
8
Lifelong Learning


Old method: read a few journal articles per
week
Reality: Primary care docs would need over
17 hrs/day just to review reasonable and
pertinent material


Even in one narrow specialty would need 6+hrs/wk
Practicing docs (all specialties) average 1-1.5
hrs/wk
FSU College of Medicine
9
Lifelong Learning
from Day to Day Encounters


Reading the articles that happen to cross the
desk does not help MY PATIENTS TODAY
Finding evidence based optimal care for my
patients today helps them AND helps me to
stay current in my field and be an efficient
and effective lifelong learner
FSU College of Medicine
10
The EBM Process
“The practice of evidence-based medicine is a process of lifelong,
self-directed, problem-based learning in which caring for one's own
patients creates the need for clinically important information about
diagnosis, prognosis, therapy and other clinical and health care
issues.”
(Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for
clerkship education. Am J Med. 1997 May;102(5):427-32.)
FSU College of Medicine
11
The EBM Process
The patient
1. Start with the patient -- a clinical problem or question
arises out of the care of the patient
The question
2. Construct a well built clinical question derived from the
case
The resource
3. Select the appropriate resource(s) and conduct a search
The evaluation
4. Appraise that evidence for its validity (closeness to the
truth) and applicability (usefulness in clinical practice)
The patient
5. Return to the patient -- integrate that evidence with
clinical expertise, patient preferences and apply it to
practice
Self-evaluation
6. Evaluate your performance with this patient
FSU College of Medicine
12
Constructing A Clinical Question
P
I
C
O
patient
intervention
comparison
outcome
Who?
What?
Alternative
Intervention?
Outcomes
“How would I
describe a group
of patients
similar to this
particular
patient?”
”Which
treatment, test
or other
intervention?”
What is the
“Compared to what patient oriented
other treatment, test, outcome – better
or perhaps compared prognosis?
to doing nothing”
Higher rate of
cure? Etc.?”
FSU College of Medicine
13
Examples
P
Kids with acute otitis
media -2-4 y/o
I
C
Antibiotics
O
No treatment except
No pain after two
acetaminophen
days?
for pain/fever
Adult with
microhematuria
IVP
CT scan
Diagnostic accuracy
(Predictive value or
likelihood ratio)
Adult patients <70
TIA
No TIA
Rates of CVA within
90 days
Healthy adolescents
Routine
scoliosis
screen
No screening –
Pain, disability, need
evaluate only if
for intervention
problems
FSU College of Medicine
14
Types of Questions
Best Answered by EBM Resource

Therapy Question


Prognosis Question


In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis
with MRI as predictive of healing as an audible pulse on Doppler
examination?
Diagnosis Question


In patients with migraine headaches without auras, is Depakote more
effective than Inderal for prophylaxis of headaches?
In geriatric patients with suspected carotid stenosis, is duplex
ultrasound as good as magnetic resonance angiography in detecting
significant carotid stenosis?
Harm Question

For pregnant patients, does the consumption of large amounts of
coffee, (compared to non-coffee drinkers) increase the rate of
spontaneous abortion?
FSU College of Medicine
15
Question Worksheet




P - Who?
I - What?
C- Alternatively?
Outcome?

Type of Question




Therapy
Prognosis
Diagnosis
Harm/Etiology
Using the worksheet provided, construct a
clinical question from your own practice.
FSU College of Medicine
16
Assessing Validity

Definitions




Level of Evidence (LOE): usually one study
Strength of Recommendation (SOR):
recommendation based on multiple studies
A value of the confidence in the
recommendation based on the quality of
research
Assigned by experts using specific criteria
Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered
approach to grading evidence in the medical literature. Am Fam Physician. Feb 1 2004;69(3):548-556. 17
Levels of Evidence
Centre for Evidence-Based Medicine, Oxford





Level 1: Systematic Review (with metaanalysis) of Randomized Clinical Trials
Level 2: Cohort Studies
Level 3: Case-Control Studies
Level 4: Case-series
Level 5: Expert Opinion
FSU College of Medicine
18
Strength of Recommendation Taxonomy
A: There is good research-based evidence to support the
recommendation.
B: There is fair research-based evidence to support the
recommendation.
C: The recommendation is based on expert opinion and
panel consensus.
X: There is evidence of harm from this intervention.
FSU College of Medicine
19
Bottom Line on LOE or SOR





Level 1
Level 2
Level 3
Level 4
Level 5
A
Highest level
B
C
Lowest Level
But still evidence
FSU College of Medicine
20
Evidence Based Medicine
Databases (Foraging Tools)
People who do the heavy lifting
for you.
FSU College of Medicine
21
EBM Foraging Tools
A high-quality foraging tool employs a
transparent process that



Systematically searches and reviews literature
Identify useful, valuable, “quality” research
Synthesizes into “bottom line” recommendation



Patient oriented outcomes (POEM); not diseaseoriented outcomes (DOE)
Assign level of evidence
How to apply recommendations?
(Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be
teaching information management instead? Acad Med. Jul 2005;80(7):685-689.)
22
Major EBM Databases (Foraging Tools)








Cochrane
Clinical Evidence
DARE
ACP Journal Club
InfoPOEMS
Evidence Based _____
USPSTF
National Guidelines
Clearinghouse
FSU College of Medicine
23
Cochrane Library




The current resource with the highest
methodological rigor
For each clinical question, all of the English
literature meticulously searched for randomized
trials
Large systematic reviews with valid methods +
collaborative effort by Review Groups
Conclusions are based on all the evidence from valid
randomized trials (treatment and harm questions)
FSU College of Medicine
24
Cochrane Library



Full text at Cochrane Library at Wiley
Abstracts in InfoRetriever
Limitations





limited to English
only addresses questions amenable to
randomized trials
most of medicine has not been studied
enough to allow for conclusions
$235/year or abstracts only free
www.cochrane.org
FSU College of Medicine
25
26
ACP Journal Club

About 140 internal medicine journals systematically
surveyed

Highest-validity articles abstracted

Structured abstracts to guide critical appraisal

Clinical commentary

Web site acpjc.org

Also published in Annals of IM

Alerts available
FSU College of Medicine
27
ACP Journal Club

Limitations





Limited pediatrics
individual article summaries may not account for the “big
picture”
may have to read multiple items
No “control” over what is covered
$78/year ?
FSU College of Medicine
28
29
POEMS
InfoPOEMS







Patient Oriented Evidence that Matters
Journal of Family Practice and other specialty journals
Systematic surveillance of 100 journals
Reviews of recent research articles
Effect patient concerns – morbidity, mortality, quality of
life
Included in Essential Evidence Plus (formerly InfoRetriever)
Daily e-mail updates available
FSU College of Medicine
31
32
Evidence Based Practice



Summaries: structured search, critical
appraisal, authoritative recommendations,
clinical perspective, and rigorous peer review
FPIN.org – Family Physicians Inquiries
Network
Appear in PEPID
FSU College of Medicine
33
FSU College of Medicine
34
Guidelines.gov



Stored at National Guidelines Clearinghouse
Agency for Healthcare Research and Quality
1600 Guidelines may be





Explicit evidence-based
Evidence-based
Research-based (highly referenced)
“expert consensus”
Multiple guidelines on one condition
FSU College of Medicine
35
US Preventive Services Task Force





First convened by the U.S. Public Health Service in 1984
Since 1998 Agency for Healthcare Research and Quality
Leading independent panel of private-sector experts in
prevention and primary care
Conducts rigorous, impartial assessments of the scientific
evidence for effectiveness of broad range of clinical
preventive services, including screening, counseling, and
preventive medications
Its recommendations considered "gold standard" for clinical
preventive services
FSU College of Medicine
36
USPSTF Tool





Free PDA and online tool (ePSS)
Enter age, gender
Get recommendations
Filter level of recommendations
http://epss.ahrq.gov/PDA/
FSU College of Medicine
37
Hunting Tools
Most Bang for Your Buck
FSU College of Medicine
38
Drilling Down for Information
Grandage KK, Slawson DC, Shaughnessy AF. When less is more: a practical approach 39
to searching for evidence-based answers. J Med Libr Assoc. 2002 Jul;90(3):298-304.
EBM Hunting Tools
A high-quality Hunting tool employs a transparent
process that
 Searches multiple EBM databases (several
foraging tools)
 Organizes results to make them easy to find
 Provides levels of evidence
(Slawson, et al)
FSU College of Medicine
40
EBM Pyramid
InfoRetriever
DynaMed
5, C
MEDLINEFSU College of Medicine
41
Major EBM Hunting Tools
Web and PDA
Tools
Cochrane
Guidelines
USPSTF
LOE
ACP Pier (Web only)
  
   
Summaries

Summaries

PEPID
Summaries
Essential Evidence +
Dynamed
Clinical Evidence


ACP
Journal
Club
FSU College of Medicine
42
Clinical Evidence







Includes >250 conditions
Summaries of evidence
Specific clinical questions: treatment and prevention
Makes specific recommendations
States when there is a lack of evidence
Book Free from United Health Foundation
Web and PDA versions available
FSU College of Medicine
43
Clinical Evidence
FSU College of Medicine
44
Do Clinical Evidence Case
FSU College of Medicine
45
Essential Evidence Plus (EE+)

POEMS -- JFP







>104 journals surveyed
Over 3500 article synopses
Link out to PubMed
Cochrane abstracts
Selected evidence-based guidelines
Basic drug info
Clinical calculators/prediction rules
FSU College of Medicine
46
New Content

Essential Evidence summaries





Organized like disease quick reference
Bottom Line at top
Links to InfoPOEMs, Cochranes
Links to calculators and algorythms, images
Uses SORT for level of evidence
FSU College of Medicine
47
EE+ Features








Essential Evidence (replaces 5MCC)
EBM Guidelines
Pearls –PDA; Favorites on Desktop
Levels of Evidence explained
ICD-9 and E/M coding tools
Immunization Guide
USPSTF Guidelines
Derm Expert
FSU College of Medicine
48
Symbols
New 8/09
FSU College of Medicine
49
Essential Evidence Plus



Comes in web, desktop and PDA versions
Daily POEMS are available in mp3 podcast version
Limitations



individual article summaries may not account for the “big
picture”
may have to read multiple items
$79/year
FSU College of Medicine
50
Do EE+ Case
FSU College of Medicine
51
PEPID







FPIN summaries included in CRC module
Drug and disease reference, interaction tool
Clinical rotation aids for students with basic
principles
Lab manual, calculators, images
Compares favorably with Epocrates, 5MCC
PDA and Online
$199 for individual subscription
FSU College of Medicine
52
Using PEPID
FSU College of Medicine
53
Links to Evidence Based Summaries
FSU College of Medicine
54
DynaMed






Designed as entry point to information
Textbooks and Medline not efficient
Intuitive clinical organization
Brief summarized information presented
Links out to articles and reviews if more
details needed
ICD-9 codes and links to patient information
handouts
FSU College of Medicine
55
DynaMed Sources



Systematic surveillance of 18 primary
journals – e.g. BMJ, JAMA, Lancet, NEJM,
Pediatrics
12 major EBM resources – e.g. ACP Journal
Club, Cochrane Library, InfoPOEMs,
Alternative Therapies,
4 drug info sources – e.g. The Medical Letter,
FDA MedWatch
FSU College of Medicine
56
DynaMed Organization of Results

Description (including ICD-9
Codes)






Causes, Pathogenesis,
Likely risk factors, Possible
risk factors


CC, HPI, Meds, PMH, FH,
SH, ROS
Physical

Skin, HEENT, Neck,
Extremities, Neuro, Pelvic



Making the diagnosis,
Rule out, Tests to order,
Blood tests, Urine studies,
Imaging studies,
Pathology tests, Other
diagnostic testing
Prognosis
Treatment

Complications and
Associated Conditions
History

Diagnosis
Description, Also called,
ICD-9 Codes, Types,
Organs Involved, Who Is
Most Affected,
Incidence/Prevalence
Causes and Risk Factors


Treatment Overview, Diet,
Activity, Counseling,
Medications, Surgery,
Consultation and referral,
Other management,
Follow-up
Prevention and Screening
References (including
Reviews and Guidelines)
Patient Information
57
DynaMed

Limitations




variable quality if not Cochrane or review
areas with a lot of research can get hard to
navigate. Lot of information-slower to wade
through
Hard to navigate on PDA
$200/year or effort
FSU College of Medicine
58
Do DynaMed Case
Use CTRL-F to Find words in articles
FSU College of Medicine
59
ACP PIER





PIER: The Physicians' Information and Education
Resource.
Available online at ACP and PDA ($69/yr)
Modules on Disease, Screening and prevention,
complementary medicine, procedures, quality
measures and drug resource (Clinical Pharmacology)
Provide A-B-C levels of evidence
Excellent Tables summarize recommendations
FSU College of Medicine
60
Do ACP PIER Case
FSU College of Medicine
61
Searching All Resources at Once
WebFeat
In development,
but getting better all the time.
Web Only
FSU College of Medicine
62
Summary
Need
Treatment of common diagnosis
Need to create a presentation on a topic
Answers to clinical questions, use a
clinical decision support calculator,
ICD-9 code
Tabular summaries of diagnoses,
treatment, and follow-up of chronic or
acute illness
Broad and basic overview for med
students organized by rotation
CTRL-F
Resource
Clinical Evidence
DynaMed
Essential
Evidence Plus
ACP PIER
PEPID
63
Find the Answer to Your Question
Group exercise
FSU College of Medicine
64