Online Resources for Evidence- Based Clinical Care Elizabeth Eckstrom, MD, MPH Oregon Health & Science University Carol Howe, MD, MLS University of Arizona

Today we will: v v Discuss levels of evidence and how to efficiently find the highest level of evidence for your question v v Differentiate foreground and background questions and find the best evidence for each v v Practice using some of these resources

Mr. Drake v v Mr. Drake is a 72 year old new patient to your practice. He has a history of HTN and CAD, both medically managed and stable. He exercises regularly, and is enjoying retirement; doing lots of travel with his wife. He wants to plan well for his wife’s future, so is wondering what is his risk of having a heart attack in the next five years? v v He has never had a pneumovax, so you recommend one today. He states he has read the literature and doesn’t think he needs one. You have always followed the recommendation to vaccinate your patients over 65, but decide to review the evidence yourself so you can show him why he needs vaccination.

Foreground vs Background questions v 5 year prognosis for patients with stable HTN and CAD v Pneumonia risk reduction with pneumovax in a fairly healthy 72 year old

What is the best evidence you could find to answer these questions? pyramid modified from: Navigating the Maze, University of Virginia, Health Sciences Library. From The University of Washington

Background Questions v Background questions tend to be general questions about a disease such as – typical clinical presentation –epidemiology – natural history – treatment.

For Background questions…. v Textbooks v Textbook databases : Stat!Ref; MD Consult; AccessMedicine v UptoDate - essentially a continuously updated online textbook v Clinics of North America-quarterly journal of review articles v eMedicine- part of Medscape-regularly updated point of care reference. (FREE For health care providers) v Other resources you find useful and reliable?

Foreground Questions v Foreground questions are much more focused, targeted questions. v PICO is an ideal mnemonic for helping to build an answerable question. v The nature of the question will help you determine the best strategy for how to answer it.

PICO v P-patient, population or problem v I-Intervention (diagnostic test, exposure, prognostic factor, therapy) v C-Comparison- (population without that disease, placebo drug, comparison drug) v O-outcome-Measurable outcome such as improvement in symptoms, adverse effects, mortality.

Clinical questions usually fall into these categories: v Etiology (can also include Cause and Harm) v Diagnosis v Therapy (also includes Prevention) v Prognosis

What is the best evidence you could find to answer these questions? pyramid modified from: Navigating the Maze, University of Virginia, Health Sciences Library. From The University of Washington

Type Of QuestionSuggested best type of study Diagnosisprospective, blind comparison to a gold standard TherapyRCT > cohort > case control > case series Prognosiscohort study > case control > case series Harm/EtiologyRCT > cohort > case control > case series PreventionRCT > cohort > case control > case series Clinical Examprospective, blind comparison to a gold standard Cost Benefiteconomic analysis From Introduction to Evidence-Based Practice, Duke university Medical Center Library and Health Sciences Library, UNC-Chapel Hill

For most foreground questions: v Look in first in “filtered” or “pre- appraised sources” such as the Cochrane Library,ACP Medicine (available also from Stat!Ref), or BMJ Clinical Evidence (to name just a few!) v If there is no recent review, PubMed has some excellent options —which we will spend most of the rest of our time reviewing

Sources for further exploration: v Introduction to Evidence-Based Practice, Duke university Medical Center Library and Health Sciences Library, UNC-Chapel Hill. Fifth Edition. (updated July 2010) v University of Illinois: Evidence Based Medicine: Finding the Best Clinical Literature. Last updated v SUNY Downstate Medical Center Evidence Based Tutorial (last updated 2004) v Centre for Evidence-Based Medicine Toronto v Buckingham J, Fisher B, Saunders D. Evidence-Based Medicine: mini manual. Based in part on the Evidence-Based Medicine Toolkit, Last updated July, manual2009.pdf manual2009.pdf manual2009.pdf