EBM Searching: A Refresher Ob/Gyn Clerkship 2011 Sally Birch MAppSc AHIP Information Services Librarian Amani Magid MLIS AHIP Information Services Librarian

Goals: At the end of this session, you will be able to: 1. Review of the Evidence Based Practice process 2. Convert information needs about diagnosis, therapy, prognosis and etiology into answerable questions 3. Understand how to formulate clinical questions using PICO methodology 4. Track down the best evidence using evidence-based tools

What is Evidence Based Practice?

Why is EBM important? Studies have shown that when clinicians have access to information, it changes their patient care management decisions.  Video: Why We Need Evidence Based Healthcare  =related =related

Ask for general knowledge & has two essential components:  A question root (who, what, when, etc.) with a verb  A disorder, test, treatment, or other aspect of healthcare  Example: How does the new medication Prandin® work? Or Is childbirth at home still practiced in developed nations? Background Questions

Why formulate questions clearly?  Assists in focusing on directly relevant evidence which saves time.  Achieve high yield search strategies  Helps in communicating more clearly with colleagues

PICO  Patient, or Population or Problem  What are the characteristics (eg. age group, gender, comorbidity)?  What is the condition or disease you are interested in?  Intervention  What do you want to do with this patient (e.g. treat, diagnose, observe, surgery)?  Comparison  What is the alternative to the intervention (e.g. placebo, different drug or therapy or surgery)?  Outcome  What are the relevant outcomes (e.g. morbidity, death, complications)?

A 45-year-old G2P2, LMP 21 days ago, presents with heavy menstrual bleeding. Prior to 6 months ago her cycles came every days, lasted for 6 days, and were associated with cramps that were relieved by ibuprofen. In the last 6 months there has been a change with menses coming every days, lasting 7-10 days and associated with cramps not relieved by ibuprofen, passing clots and using 2 boxes of maxi pads each cycle. She is worried about losing her job if the bleeding is not better controlled. She denies dizziness, but complains of feeling weak and fatigued. Her weight has not changed in the last year. She denies any bleeding disorders or reproductive cancers in the family. She uses condoms for contraception. She takes no daily medications and has no other medical problems. She is married and works in a factory. On exam, BP=130/88; P= 100; Ht=5’6’; Wt=150 pounds. She appears pale. Pelvic exam shows normal vulva, vagina and cervix: normal size, mildly tender, mobile uterus; non-tender adnexae without palpable masses. The chief resident thinks she has a uterine fibroid. You think she has a uterine polyp. You are thinking of doing a pelvic ultrasound.

PICO P – patient or problem uterine fibroids AND polyps middle aged female I - Intervention ultrasound C- Comparison O- Outcome diagnosis

PICO Formulated Clinical Question For a middle aged female with uterine fibroids and polyps is ultrasound an effective diagnostic tool? For a middle aged female with uterine fibroids and polyps is ultrasound an effective diagnostic tool? For/in patient with [Patient/ Problem] Is/does [Intervention] or [Comparison, if any] affect [Outcome]

Type of QuestionSuggested Best Type of Study TherapyRCT > cohort > case control > case series DiagnosisProspective, blind comparison to gold standard Etiology / HarmRCT > cohort > case control > case series PrognosisCohort study > case control > case series PreventionRCT > cohort study > case control > case series Clinical ExamProspective, blind comparison to gold standard CostEconomic analysis Questions of therapy, etiology and prevention which can best be answered by RCT can also be answered by a meta-analysis or systematic review.

Clinical Queries  PubMed provides pre-designed search queries that will give results of the standard required for evidence-based analysis  Eg. choose the therapy filter and you will get RCT’s  Other Recommended Resources  Course Support site  Evidence-Based Medicine Subject Guide  Trip Database

Clinical Scenario A 20 yr old female presents with abdominal pain. She describes gradual onset of pain 24 hrs previously, persistent in the lower abdomen. She developed nausea shortly after the onset of pain. She denies diarrhea, dysuria, or previous abdominal symptoms. Her last menstrual period was 7 days ago with no abnormal patterns in her menses. Her temperature is 38.2C with normal blood pressure, pulse, and respiration rate. Her abdomen is soft, with tenderness to palpation in the right lower quadrant and suprapubic region. No peritoneal irritation or masses are detected. A rectal examination reveals right side tenderness. Pelvic examination reveals no purulent discharge; however, her right adnexa region is tender. Laboratory studies reveal WBC count of 14,600/mm 3, normal hemoglobin and hematocrit values, and normal electrolyte and amylase levels. Urinalysis reveals concentrated urine with 3 to 5 RBCs per hpf, 5 to 10 WBCs per hpf, and negative results for leukocyte esterase. The results from a serum pregnancy test are negative. You begin to suspect acute appendicitis, but are unsure whether to order CT imaging/ultrasonography, which could rule in appendectomy but not other conditions, or diagnostic laparoscopy, which allows accurate assessment of pathology but is more invasive.

Components to include:  Case Scenario  Background Questions; including answers and references  PICO  Clinical Query  Type of Question & best study needed  Search engine used  Search terms & # results  Evaluate selected paper. INCLUDE paper used and CAT.  Outline what you would communicate to your patient, integrating the evidence found with your clinical expertise and patient preferences.