1. Donna Windish, MD, MPH Associate Professor of Medicine
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Evidence-Based Medicine: How to Effectively and Efficiently Search for the Answer to your Clinical Questions
Donna Windish, MD, MPH
Associate Professor of Medicine

2. What is the Importance of Answering Clinical Questions?
Provide evidence-based care
Teach patients and colleagues
Lifelong self-directed learning

3. Yale trainees Knowledge Performance Outcomes Time since training →
Choudhry NK, Ann Intern Med. 2005;142(4):

4. Evidence-based practice
Acquire
(Appraise)
Best
evidence
Preferences
and actions
Ask
Apply
Clinical expertise
Clinical state and
circumstances
Haynes RB, ACPJC Mar-Apr;136:A11

5. Epidemiology of clinical questions
Studies of outpatient physicians
For every 3 patients seen in the office, 2 clinical questions were generated1,2,3
Most questions involved therapy and diagnosis
Majority of questions deemed clinically important
30% pursued, often using non-evidence-based sources
Factors predicting pursuit of an answer
patient expectation (OR = 2.3, p = 0.004)
perceived malpractice liability (OR = 2.1, p = 0.05)
1Covell DG, Ann Intern Med. 1985;103(4): (practicing MDs)
2Gorman PN, Med Decis Making. 1995;15(2): (practicing MDs)
3Green ML, Am J Med. 2000;109(3): (internal medicine residents)

6. Clinical Scenario
You are caring for a 64-year-old man who has just developed non-valvular atrial fibrillation. PMH includes hypertension, type 2 diabetes mellitus, and a remote history of an upper GI bleed. He has no history of stroke or TIA.
An echocardiogram shows an EF of 50% and mildly dilated left atrium. Initial attempts at cardioversion were unsuccessful. You opt for a rate control strategy and consider the options for primary prevention of stroke (aspirin versus warfarin).

7. Step 1: Ask
Identify information and translate this into answerable clinical questions

8. Background vs. Foreground Questions
Background question
Addresses general knowledge that would help clinicians better understand a particular disorder, health state, diagnostic test, treatment, or other aspect of health care
What causes non-valvular afib?
What left atrial size puts a patient at risk for afib?
What are the recommendations for cardioversion in afib?

9. Background vs. Foreground Questions
Addresses specific knowledge to inform clinical decisions or actions. P I C O

10. Background vs. Foreground Questions
Addresses specific knowledge to inform clinical decisions or actions.
Patient/
Population
Intervention/Exposure
Comparison
Outcome

11. Background vs. Foreground Questions
Addresses specific knowledge to inform clinical decisions or actions.
Patient/
Population
How would I describe a patient or group of patients similar to mine?
Intervention/Exposure
Which main intervention (exposure, finding, test, risk factor) am I considering?
Comparison
What is the main alternative to the intervention?
Outcome
What can I hope to accomplish?
What could this exposure really affect?

12. Question Classification
Intervention/
Exposure
physical finding
risk factor
exposure
diagnostic test
treatment
maneuver
Question
clinical exam
prognosis
harm
diagnosis
therapy
prevention
Arrow

13. Foreground Question (PICO)
Therapy/Prevention Question In Action
Patient
Intervention
Comparison
Outcome

14. Foreground Question (PICO)
Therapy/Prevention Question In Action
Patient
Intervention
Comparison
Outcome
64 y/o man
Non-valvular afib
Hypertension
Diabetes
GI bleed in past

15. Foreground Question (PICO)
Therapy/Prevention Question In Action
Patient
Intervention
Comparison
Outcome
64 y/o man
Non-valvular afib
Hypertension
Diabetes
GI bleed in past
aspirin

16. Foreground Question (PICO)
Therapy/Prevention Question In Action
Patient
Intervention
Comparison
Outcome
64 y/o man
Non-valvular afib
Hypertension
Diabetes
GI bleed in past
aspirin
warfarin

17. Foreground Question (PICO)
Therapy/Prevention Question In Action
Patient
Intervention
Comparison
Outcome
64 y/o man
Non-valvular afib
Hypertension
Diabetes
GI bleed in past
aspirin
warfarin
primary prevention of stroke

18. Why Ask Clinical Questions So Specifically?

19. Why Ask Clinical Questions So Specifically?
Use time wisely
Search efficiently (sources and search terms)
Know “when to stop”
Integrate evidence with clinical context and patient preferences in decision-making
Communicate clearly with other clinicians

20. Step 2: Acquire
Efficiently acquire the best evidence

21. Critically appraise each article for it is validity and usefulness
EBM 1992
Clinical question
MEDLINE search for original clinical research studies
Critically appraise each article for it is validity and usefulness
Summarize results
Customize for your patient
Make a decision

22. EBM 2015 Ask Acquire Appraise Apply Ask Apply Acquire Appraise
Appraisal mode (“Doer”)
Summary mode (“User”)
Ask Acquire Appraise Apply
Ask Apply
Acquire Appraise
Guyatt GH, BMJ. 2000;320(7240):954-5
Haynes RB, ACPJC 2001;134(2):A11-A13
McColl A, BMJ 1998;316:361-5
Straus, Evidence-based Medicine, 2005
Akl EA, Med Teach. 2006;28(2):

23. Hierarchy of EBM Resources
Full integration (CDSS)
EMR and POE
push technology
patient specific info
systems
Clinical Evidence
ACP Smart Medicine
UpToDate
EBM guidelines
All questions for condition
summaries
DARE
health-evidence.ca
ACPJC, EBM journal
synopses of syntheses
Systematic reviews
Cochrane library
SRs in journals
SRs in guidelines
Single focused question
syntheses
ACPJC on line
EBM Journal
synopses of studies
Medline or PubMed (clinical queries)
BMJ Updates
ACPJC plus
studies
DiCenso A, Bayley L, Haynes RB. Editorial: Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. Ann Intern Med. 2009;151(6):JC3-2-

24. “Specialized” EBM Summaries
JAMA Rational Clinical Exam (clinical findings)
USPSTF Guide (screening, counseling, immunizations, chemoprophylaxis)

25. Summaries Explicit and preferably exhaustive search strategy
Explicit criteria for inclusion of articles
Explicit and preferably accepted appraisal criteria
Inferences and recommendation based on highest level of evidence (and include citations)
Revised and updated regularly

26. Yes, There’s an App for That iPhone

27. Yes, There’s an App for That iPhone

28. Yes, There’s an App for That iPhone

29. Yes, There’s an App for That iPhone

30. Practice
“In a 64 year-old man with non-valvular a-fib, hypertension, diabetes and a past GI bleed, is the use of aspirin as effective as wafarin in the primary prevention of stroke?”
Studies
PubMed
Syntheses
Cochrane
Summaries Clinical Evidence
National Guidelines Clearninghouse
UpToDate
PubMed4Hh App
ACP Smart Medicine
Guideline Central App

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