Donna Windish, MD, MPH Associate Professor of Medicine <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> Evidence-Based Medicine: How to Effectively and Efficiently Search for the Answer to your Clinical Questions Donna Windish, MD, MPH Associate Professor of Medicine

What is the Importance of Answering Clinical Questions? Provide evidence-based care Teach patients and colleagues Lifelong self-directed learning

Yale trainees Knowledge Performance Outcomes Time since training → Choudhry NK, Ann Intern Med. 2005;142(4):260-273

Evidence-based practice Acquire (Appraise) Best evidence Preferences and actions Ask Apply Clinical expertise Clinical state and circumstances Haynes RB, ACPJC. 2002 Mar-Apr;136:A11

Epidemiology of clinical questions Studies of outpatient physicians For every 3 patients seen in the office, 2 clinical questions were generated1,2,3 Most questions involved therapy and diagnosis Majority of questions deemed clinically important 30% pursued, often using non-evidence-based sources Factors predicting pursuit of an answer patient expectation (OR = 2.3, p = 0.004) perceived malpractice liability (OR = 2.1, p = 0.05) 1Covell DG, Ann Intern Med. 1985;103(4):596-599 (practicing MDs) 2Gorman PN, Med Decis Making. 1995;15(2):113-119 (practicing MDs) 3Green ML, Am J Med. 2000;109(3):218-23 (internal medicine residents)

Clinical Scenario You are caring for a 64-year-old man who has just developed non-valvular atrial fibrillation. PMH includes hypertension, type 2 diabetes mellitus, and a remote history of an upper GI bleed. He has no history of stroke or TIA. An echocardiogram shows an EF of 50% and mildly dilated left atrium. Initial attempts at cardioversion were unsuccessful. You opt for a rate control strategy and consider the options for primary prevention of stroke (aspirin versus warfarin).

Step 1: Ask Identify information and translate this into answerable clinical questions

Background vs. Foreground Questions Background question Addresses general knowledge that would help clinicians better understand a particular disorder, health state, diagnostic test, treatment, or other aspect of health care What causes non-valvular afib? What left atrial size puts a patient at risk for afib? What are the recommendations for cardioversion in afib?

Background vs. Foreground Questions Addresses specific knowledge to inform clinical decisions or actions. P I C O

Background vs. Foreground Questions Addresses specific knowledge to inform clinical decisions or actions. Patient/ Population Intervention/Exposure Comparison Outcome

Background vs. Foreground Questions Addresses specific knowledge to inform clinical decisions or actions. Patient/ Population How would I describe a patient or group of patients similar to mine? Intervention/Exposure Which main intervention (exposure, finding, test, risk factor) am I considering? Comparison What is the main alternative to the intervention? Outcome What can I hope to accomplish? What could this exposure really affect?

Question Classification Intervention/ Exposure physical finding risk factor exposure diagnostic test treatment maneuver Question clinical exam prognosis harm diagnosis therapy prevention Arrow

Foreground Question (PICO) Therapy/Prevention Question In Action Patient Intervention Comparison Outcome

Foreground Question (PICO) Therapy/Prevention Question In Action Patient Intervention Comparison Outcome 64 y/o man Non-valvular afib Hypertension Diabetes GI bleed in past

Foreground Question (PICO) Therapy/Prevention Question In Action Patient Intervention Comparison Outcome 64 y/o man Non-valvular afib Hypertension Diabetes GI bleed in past aspirin

Foreground Question (PICO) Therapy/Prevention Question In Action Patient Intervention Comparison Outcome 64 y/o man Non-valvular afib Hypertension Diabetes GI bleed in past aspirin warfarin

Foreground Question (PICO) Therapy/Prevention Question In Action Patient Intervention Comparison Outcome 64 y/o man Non-valvular afib Hypertension Diabetes GI bleed in past aspirin warfarin primary prevention of stroke

Why Ask Clinical Questions So Specifically?

Why Ask Clinical Questions So Specifically? Use time wisely Search efficiently (sources and search terms) Know “when to stop” Integrate evidence with clinical context and patient preferences in decision-making Communicate clearly with other clinicians

Step 2: Acquire Efficiently acquire the best evidence

Critically appraise each article for it is validity and usefulness EBM 1992 Clinical question MEDLINE search for original clinical research studies Critically appraise each article for it is validity and usefulness Summarize results Customize for your patient Make a decision

EBM 2015 Ask Acquire Appraise Apply Ask Apply Acquire Appraise Appraisal mode (“Doer”) Summary mode (“User”) Ask Acquire Appraise Apply Ask Apply Acquire Appraise Guyatt GH, BMJ. 2000;320(7240):954-5 Haynes RB, ACPJC 2001;134(2):A11-A13 McColl A, BMJ 1998;316:361-5 Straus, Evidence-based Medicine, 2005 Akl EA, Med Teach. 2006;28(2):192-194

Hierarchy of EBM Resources Full integration (CDSS) EMR and POE push technology patient specific info systems Clinical Evidence ACP Smart Medicine UpToDate EBM guidelines All questions for condition summaries DARE health-evidence.ca ACPJC, EBM journal synopses of syntheses Systematic reviews Cochrane library SRs in journals SRs in guidelines Single focused question syntheses ACPJC on line EBM Journal synopses of studies Medline or PubMed (clinical queries) BMJ Updates ACPJC plus studies DiCenso A, Bayley L, Haynes RB. Editorial: Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. Ann Intern Med. 2009;151(6):JC3-2-

“Specialized” EBM Summaries JAMA Rational Clinical Exam (clinical findings) USPSTF Guide (screening, counseling, immunizations, chemoprophylaxis)

Summaries Explicit and preferably exhaustive search strategy Explicit criteria for inclusion of articles Explicit and preferably accepted appraisal criteria Inferences and recommendation based on highest level of evidence (and include citations) Revised and updated regularly

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Practice “In a 64 year-old man with non-valvular a-fib, hypertension, diabetes and a past GI bleed, is the use of aspirin as effective as wafarin in the primary prevention of stroke?” Studies PubMed www.pubmed.gov Syntheses Cochrane www.thecochranelibrary.com Summaries Clinical Evidence www.clinicalevidence.com National Guidelines Clearninghouse www.guidelines.gov UpToDate www.uptodate.com PubMed4Hh App ACP Smart Medicine Guideline Central App

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