EBM for the busy Clinician Gil C. Grimes, MD EBM Working Group, Department Family Medicine Scott & White

Objectives EBM curriculum outline Levels of Evidence DOE vs. POEMs Sources for Evidence Use of clinical query in PubMed

First a few Questions I am familiar with Evidence Based Medicine? Databases and sites that I routinely use to obtain information?

What is EBM? Simply put it is the integration of research evidence with clinical expertise and patient values. EBM will allow us to do more good than harm Patients want to know the following “Will it make me live better” “Will it make me live longer”

Levels of Evidence This is a method for grading journal articles, guidelines etc. This is not “universal” AAFP uses Level A, B, C Centre for EBM Oxford uses 1,2,3 Focuses on the type of article and quality Therapy/Prevention/Etiology/Harm, Diagnosis, Prognosis Either way is just fine

Where’s the beef? Levels of evidence are good…. What I want to know is how this will work for me. Friends the path requires moving from DOE to POE…

Disease Oriented Evidence Most common type of evidence found in research journals Important to our understanding of disease Responsible for many therapeutic advances Intended for a research audience Pathophysiology Pharmacology Etiology

Patient Oriented Evidence Uncommon in most journals Outcomes patients care about Mortality Morbidity Quality of Life Cost Harm

POEMs Patient-Oriented Evidence that Matters Addresses a clinical problem encountered by primary care physicians Uses patient-oriented outcomes Potential to change our practice if valid and applicable

DOES vs. POEMs The Numbers…. 6 month survey of 90 journals 8,047 articles 213 POEMs 97% DOEs and other material 2.6% POEMs

So where do I find this? You could search the literature Yeah like you have that much time! You could ask you colleagues Expert opinion Level C You could familiarize yourself with one or two good sources That sounds pretty good…

Usefulness equation Usefulness= relevance x validity work Go for sources that have done the work for you

Systematic Reviews Summarized Evidence- Referenced Resources Research Articles Other Sources

Cochrane It is an international organization that aims to help people make well informed decisions about health care by preparing, maintaining and ensuring the accessibility of systematic reviews of the effects of health care interventions.

Cochrane The Collaboration is built on ten principles: collaboration building on the enthusiasm of individuals avoiding duplication minimizing bias keeping up to date striving for relevance promoting access ensuring quality continuity enabling wide participation

Cochrane Focus is on therapy Excellent resource Solid source Degree of scrutiny limits some applicability Let’s look

Clinical Evidence Published by BMJ Collects evidence on a wide variety of topics If you receive their book, you should have free access to their web site

InfoRetriever Founded by three Family Physicians, a PharmD and a Psychologist Goal to improve the health and lives of people by providing patient- oriented evidence that matters in a rapid and accessible form I use this database daily Let’s Look

TRIP Database TRIP was created in 1997 to bring together all the 'evidence-based' healthcare resources available on the Internet. Excellent resource Allows focused PubMed search if all else fails Tracks your usage for educational purposes Let’s Look

PubMed Clinical Queries PubMed is a Huge database Typical searches are tough Clinical Queries makes that easier Let’s Look

DynaMed Created by Brian Alper, MD Evolved form his ‘black book of facts’ Background information Better for review than Up-to-date (level 5) Discusses diagnosis, treatment, etc. Evidence based Peer reviewed Let’s Look

Journal Sources Journal of Family Practice Journal Watch from NEJM InfoPOEMs ACP-Journal Club Relevance before Validity

Relevance Slice the bedside stack Is this something that is common to my practice? Is it an outcome my patients would care about? If the outcome is true would I have to change my practice? If relevant then examine for validity

Clinical Questions Foreground questions Four components Patient population/Problem Intervention Comparison intervention Outcome

Mentoring Every Question is a teachable moment If you look up two questions with the student they will learnb It should not slow you down

My Experience New MSIII on his second rotation Lot’s of questions InfoRetriever answered 90% We discussed outcomes No one had discussed outcomes with him to that point It added 15 minutes to my morning and afternoon He reports that he continues to utilize the EBM tools demonstrated

Pharma Interactions Modeling behavior for students Demonstrating the sales methods being utilized Real life scenarios

Handhelds This is the key to just in time information InfoRetriever can run off Palm or Microsoft handheld Very functional Gives you decision tools in your hand when you need them

Handouts List of useful websites Password for InfoRetriever for TAMU Worksheets for reviewing articles Worksheet for pharm reps My contact information

Questions?