Evidence-based medicine: a hands-on workshop Presented by Chris Maloney, MD Director, Medical Student Education in Pediatrics Venus Wilke, MD Assistant Clerkship Director for Pediatrics University of Utah Salt Lake City, Utah Here we can introduce ourselves and make a statement of how we became interested in EBM, how we were “taught” EBM practices and how we have integrated EBM into our practice of medicine and our teaching.

Objectives and Priorities Pediatrics Topics Session 1 and 2 Formulate a clinical question relative to a patient’s problem. Conduct an effective search of the medical literature. Critically read the pediatric literature and apply the information in developing a differential diagnosis, diagnostic plan, or management plan.

Clinical judgment and experience Best research evidence EBM Patient values

Evidence-based medicine Defined David L. Sacket Evidence-based Medicine How to practice and teach EBM The integration of best research evidence with clinical expertise and patient values

EBM: Defined Best research evidence – clinically relevant research . . . into the accuracy and precision of diagnostic tests, the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative and preventive regimens. Clinical expertise – the ability to use clinical skills and past experience to rapidly identify each patient’s health state and diagnosis, their individual risks and benefits of potential interventions. Patient’s values – the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.

barriers between research and practice slide 4.2 barriers between research and practice 30 kg of guidelines per family doctor per year 25000 biomedical journals in print 8000 articles published per day 95% of studies cannot reliably guide clinical decisions 2001 Bazian Ltd

The steps toward the practice of EBM Step 1: Converting the need for information to an answerable question. Step 2: Tracking down the best evidence with which to answer the question. Step 3: Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice). Step 4: Integrating the critical appraisal with our clinical expertise and with our patients unique biology, values and circumstances. Step 5: Evaluating our effectiveness and efficiency at achieving steps 1-4 and seeking new ways to improve them both for next time.

How evidence changed clinical practice 32. Failure of extracranial-intracranial arterial bypass to reduce the risk of Ischemic stroke. Results of an international randomized trial. The EC/IC Bypass Study Group. New England Journal of Medicine 1985; 313: 1191 – 1200. 31. Extracranial to intracranial vascular anastomosis for occlusive Cerebrovascular disease: experience in 110 patients. Surgery 1977; 82: 648-654.

systematic review of RCTs slide 7.1 hierarchy of major study designs systematic review of RCTs interventional RCT observational cohort case control validity 2001 Bazian Ltd

Formulating a Question Foreground Background A B C Novice Experience with the condition Expert

Formulating a Question: “Background Information” Ask for general knowledge about a disorder This question has 2 essential components A question root with a verb (who, what, where, when, how or why) A disorder or an aspect of a disorder

Formulating a Question: “Foreground Information” Ask for specific information about managing a patient with a specific disorder This question has 3 or 4 essential components P – Patient/Population/Problem I – Intervention/Exposure C – Control/Comparison (if relevant) O – Outcome

Evidence-based Resources ACP Journal Club -- http://www.acpjc.org/index.html articles report original studies and systematic reviews that warrant immediate attention by physicians attempting to keep pace with important advances in internal medicine Clinical Evidence -- http://www.clinicalevidence.org from the BMJ Publishing Group; an international source of the best available evidence for effective health care Guidelines -- http://www.guidelines.gov a public resource for evidence-based clinical practice guidelines Evidence-based Reviews http://www.ovid.com Contains ACP Evidence-based Medicine reviews and Cochrane Library databases Centre for EBM -- http://www.cebm.utoronto.ca this website helps develop, disseminate, and evaluate resources that can be used to practice and teach EBM

Major Electronic Resources (available from Eccles Library) Access Medicine http://www.accessmedicine.com/ home.aspx A collection of textbooks, hot topics and self-assessment tools: Harrison’s, Goodman and Gilman, etc. Cochrane Library http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME A database of systematic reviews and more DynaMed http://www.dynamicmedical.com/ 1,800 clinical topic summaries; designed for use at point of care, providing best available evidence; updated daily

Major Electronic Resources (available from Eccles Library) PubMed/MEDLINE with LinkOut http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=uutahlib Buttons indicate if material is available in print or electronic formats STAT!Ref – ACP’s PIER http://online.statref.com/Splash.aspx?SessionId=4C78EFPGJWMMVSYS Physicians' Information and Education Resource Plus 23 other textbooks for background information UpToDate http://www.utdol.com/enterprise.asp?bhcp=1 Author evaluated review of the best evidence FreeMedicalJournals http://www.freemedicaljournals.com Promoting free access to medical journals

Searching PubMed URL – http://pubmed.gov With LinkOut (indicates if library has print or electronic copies) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=uutahlib

Searching PubMed MESH Database Ease of use Mapping of many terms Explode capability Hierarchical arrangement of terms Ability to limit to the major focus area Can use to broaden a search Can limit to age

Searching PubMed MESH Database

Searching PubMed MESH Database

Searching PubMed Clinical Queries Limits to clinical trials Therapy Diagnosis Prevention Prognosis Systematic Reviews

Searching PubMed

Searching PubMed Limits article type age of subjects entrez date publication date language human or animal subjects subsets gender

Searching PubMed

Searching PubMed External Linking

Searching PubMed Use of quotes vs. no quotes 'brca 1' vs brca 1 Use of wildcards chemotherap* y, ies, eutic with synonyms eradicat* OR cur* OR eliminat* (Note: Use of quotes and wildcard turns off automatic mapping) Use of AND OR NOT e.g. Bronchiolitis AND RSV NOT Influenza [MESH]

Levels of Evidence

Levels of Evidence

General areas covered today Therapy Harm/Etiology Diagnosis Prognosis

One approach to critically selecting an article 1. What is the Authors reputation? 2. What is the Institutions reputation? 3. What is the Type of study? i.e RCT, review 4. What is the Population and how do they compare with my situation? 5. Regardless of the outcome will it change my practice? 6. What are the Methods? 7. What are the Results?

Some Statistical Information

design features that increase validity slide 8.1 design features that increase validity 2001 Bazian Ltd

Event Rate and Number Needed to Treat

Likelihood Ratios

Confidence Intervals

Group Exercise 1. Working in groups of 2 - 4 2. Identify a question preferably a foreground question 3. Determine a search strategy 4. Perform the search and obtain an article 5. Critically review the article(s) using the worksheets 6. Share your question, strategy and results

References How to practice and teach EBM. Sackett DL, Straus SE, Richardson WS, Rosenberg W, and Haynes RB. Churchill Livingstone. Second Ed. 2000. Users guide to the medical literature. A manual for evidence- Based clinical practice. Guyatt G and Rennie D. AMA Press. 2001.

Worksheets http://www.med.ualberta.ca/ebm/ebm.htm