KSOM Y2 Evidence-Based Medicine: Background & Resources Emily Brennan, MLIS Eileen Eandi, MLS Joe Pozdol, MLIS Evans Whitaker, MD, MLIS Norris Medical Library, Rm Zonal Ave. Los Angeles, CA

Introduction We are… Personal Librarians for KSOM Y2: –Last Name: Ahn-FechtPamela Corley Fernandez-LeeEileen Eandi Leong-PenmanEmily Brennan (replacing Adrian Follette) Perrin-YasmehEvans Whitaker Ask questions! Please fill out evaluation forms at the end of class…

Context and Outline Class today -- an extension of Dr. Samet’s lecture of August 7, 2009 Assignment given today and posted on library student portal –Due date: August 28, 2009 to Curriculum Office Objectives of today’s session I.EBM Background A. Briefly review study types pertinent to EBM B. Introduce evidence pyramid C. Introduce levels of evidence D. Introduce PICO and searchable clinical questions II. EBM Resources A. Introduce major sources of evidence-based information at USC B. Provide search tips to promote maximally efficient searching

EBM BACKGROUND

EBM Defined Simple concept –Use the best available evidence to make clinical decisions… EBM process… –Begins and ends with the patient –Weighs 3 factors to make clinical decisions Best available clinical research Experience of individual clinician Patient preferences/characteristics

One Aspect of EBM “EBM encourages a healthy skepticism of every practice in medicine and promotes a culture of inquiry.” – Sloane, P.D., Slatt, L.M., Ebell, M.H., Jacques, L.B., Smith, M.A. (2008). Essentials of family medicine (5 th ed.). Philadelphia: Wolters, pp. 40.

Best available clinical evidence Clinician experience Patient needs, desires, resources Patient-Doctor Dyad – Not really changed through time The point at which effecting Doctor-Patient communication and planning is informed by the best evidence Three Interacting Realms of EBM

Stages of EBM Process 1.Formulate search (based on patient interaction) 2.Perform search 3.Assess search results Relevance (does it apply to my patient?) Validity (are the findings of the articles true?) 4.Apply results to your patient 5.Reassess your patient  Repeat process as needed You will see variations in the above depending on the author and the field in which they work

Study Types Study types of most relevance to EBM –Randomized Control Trial (primary literature) Participants are assigned randomly to treatment and control groups Groups are compared over time –Systematic Review (secondary literature) Reproducible methods used to locate and select articles Inclusion/exclusion criteria –Meta analysis (secondary literature) Numerical data from separate studies combined using statistical/mathematical methods

Evidence Pyramid Source:

Levels of Evidence (LOE) Another way to look at same idea… Confusing as… –There are several systems –None are universal –All use a-d OR 1-5 OR some combination (e.g., 1a) Essential Evidence Plus collects some of these LOE systems

Levels of Evidence (LOE) Common finding in all LOE systems… –Randomized controlled trial (RCT), Systematic review, Meta analysis are considered “best evidence” Reduce the chance of author bias… However… –Many questions have little or no evidence… Use the best evidence that exists May mean case reports!

A Heart Failure Scenario 65 yo male with history of hospitalization for congestive heart failure one year ago beginning care with you today. Medications: diuretic, angiotensin converting enzyme (ACE) inhibitor, and a statin. Physical exam: BP of 124/78 in the right arm, sitting. His pulse is 85 and regular. His weight is 80 kg which he states is his normal weight. He has clear lung fields and no pretibial edema. You order lab work, a chest x ray, a resting oximetry, and an echocardiogram. –His lab work is all within normal limits. –His CXR show clear lung fields, borderline cardiomegaly, and flattened diaphragms. –His room air, resting oximetry is 95%. –His echocardiogram shows a mildly dilated left ventricle, an ejection fraction of 30%, and evidence of his previous myocardial injury. Your question: Should I start this patient with chronic CHF on beta blockers, specifically carvedilol?

Developing a Searchable Question Clinical question: –“For a 65 yo man with congestive heart failure and systolic dysfunction, should carvedilol be prescribed? –You might consider several outcomes (e.g., improved QOL, decreased hospitalization, decreased mortality) Searchable clinical question: –“Is carvedilol an effective treatment for congestive heart failure?” Concepts to use while searching for information: –Congestive heart failure, carvedilol

PICO PICO – a structure used to formulate evidence- based questions –Example for today uses congestive heart failure PProblem/PatientCongestive heart failure (CHF) IInterventionBeta blocker (carvedilol) CComparison (optional)None (might consider metoprolol) OOutcomeVarious things you might measure: --Quality of life --Mortality --Hospitalization --Cost

EBM INFORMATION RESOURCES

Background Resources Clinical Information Tools –Essential Evidence Plus –ACP Pier –UpToDate –Clinical Evidence

EBM Databases From Ovid: Cochrane Database of Systematic Reviews o Mentioned by Dr. Samet o A collection of Systematic Reviews created by the Cochrane Collaboration ACP Journal Club o Selected “original studies and systematic reviews” o “Warrant immediate attention by physicians” o What you see is an abstract of the article and commentary “by clinical experts ” o Evaluate methodology and results Database of Abstracts of Reviews of Effects (DARE) o “DARE …systematically identifies and quality assesses reviews from around the world.” “Change database” and “Open and Re-execute” allow rapid search of all three sources

MEDLINE (OvidSP) –MEDLINE with filters Systematic review “subject subset” Meta analysis “limit” RCT “limit” Cohort “MeSH” Case control “MeSH”

EBM Aggregator and Guidelines –TRIPdatabase –Sources of guidelines National Guideline Clearinghouse -- (US) National Institute for Health and Clinical Excellence (NICE) – (UK) – mentioned by Dr. Samet

Conclusion We have touched on: –the EBM process –Evidence pyramid and Levels of Evidence –PICO –Places to find evidence-based information Background resources EBM databases MEDLINE with EBM “filters” TRIP and sources for guidelines

Last Slide All materials from this session will be posted on Year 2 KSOM library portal page Please fill out class evaluations Contact your personal librarian (or any of us) for questions about any of this Thanks!