2. Existing knowledge can prevent…
Waste
Errors
Poor quality clinical care
Poor patient experience
Adoption of interventions of low value
Failure to adopt interventions of high value
Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health Service. Quoted on

3. Learning Objectives At the end of the presentation, learners will:
be able to define evidence based medicine (also referred to as evidence based practice, evidence based eye care, etc.)
be able to utilize a well-built clinical question to facilitate an efficient search
understand the 4S approach to organizing medical evidence

4. What is EBM?
Evidence Based Medicine (EBM) is defined as the practice of medicine that ‘requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances’.
Source: Straus SE, Richardson, WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd ed. New York: Elsevier Churchill Livingstone, 2005.

5. Definitions Best research evidence: Clinical expertise:
‘Valid and clinically relevant research’.
Clinical expertise:
‘Ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal circumstances and expectations ‘.

6. Focused Approach Saves Time
You will not have time to read all of the important articles in the literature
500,000 new medical articles published each year
You will be expected to quickly make increasingly complex decisions
Sorting the valid information from the less useful takes time away from decision making
You will be expected to “standardize” your practice
Standard of care critical in health care reform and legal issues

7. New Skills Efficient literature searching
Evaluate the literature according to formal rules of evidence

8. Information Retrieval for Evidence Based Patient Care
Using research findings versus conducting research
Retrieving and evaluating information that has direct application to specific patient care problems
Selecting resources that are current, valid, and available at point of care
Developing search strategies that are feasible within time constraints of clinical practice

9. Steps to Practice EBM
Convert information need into answerable clinical question
Track down the best evidence to answer the question
Critically appraise the evidence for its validity (closeness to truth) , impact (size of the effect), and applicability (usefulness in practice)
Integrate appraisal with clinical expertise and with patient’s unique values and circumstances

10. ©Sandra A. Martin
Source: Martin, S. A., Shreeve, S. & Prislin, M. (1999). Development of a longitudinal patient-care oriented informatics curriculum featuring web-based instructional and assessment tools.  Association of American Medical Colleges Annual Meeting.

11. Improvements in EBM Practice
Development of efficient search strategies to retrieve the evidence, e.g., clinical queries in Ovid MEDLINE
Creation of systematic reviews
Development of new clinical decision support tools
Future: Systems that integrate and summarize relevant research evidence about specific clinical problems and link through the EMR to a specific patient’s circumstances

12. “Using” EBM versus Doing EBM
Rapidly develop and practice EBM with limited time and resources
Use the 4S approach to locate critically appraised content

13. 4S Hierarchy

14. Information Pyramid Up-to-date, Dynamed, FIRSTConsult, ACP PIER
ACP Journal Club
Evidence Based Ophthalmology
Cochrane and other Systematic Reviews (OVID EBMR)
MEDLINE Searches with Clinical Queries
SOURCE: Haynes, R. B. (2001). Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence. Evidence-Based Medicine, 6 (2), Retrieved from

15. Critically Appraised Content

16. Appraisal Required by User

17. Steps to Using EBM
Convert information need into answerable clinical question
Track down the best evidence to answer the question
Use the 4S approach to locate critically appraised content

18. Is the Evidence Available?
For many common, clinical issues in Optometry and Ophthalmology, there are few acceptable sources to guide decision making
Implementation of evidence-based practice in optometry, p. 240

19. Using EBM – Step 1 Frame the well built clinical question
Arises from the clinical encounter
Used to initiate search for evidence
Four basic types of clinical questions
Therapy/prevention
Diagnosis
Etiology
Prognosis

20. Selecting the Question
Begin with the patient encounter
Which question
is most important to the patient’s well being
fills gaps in your clinical knowledge
is feasible to answer in the time available

21. Foreground Clinical Questions
Deal with patient management issues
Contain elements of PICO format
Patient/Population
Intervention
Comparison Intervention (if useful)
Outcome
Facilitate an efficient search

22. Example – Therapy Question
In patients with open angle glaucoma (POAG), does IOP lowering treatment (medical or surgical) versus no treatment delay visual field loss?

23. Search Terms Therapy Question
In patients with open angle glaucoma (POAG) [Patient/Population], does IOP (intraocular pressure) lowering treatment (medical or surgical) [Intervention] versus no treatment [Comparison Intervention], delay visual field loss [Outcome]?
Search Terms: open angle glaucoma, POAG, IOP, intraocular pressure, visual field loss

24. Type of question leads to type of study to best answer the question
Type of Studies
Therapy
Select treatments that do more good than harm, worth the effort and costs
Diagnosis
Select and interpret diagnostic tests against the gold standard
Prognosis
Estimate the patient’s clinical course
Etiology/Harm
Identify causes and risk factors

25. Randomized controlled trials are considered the best studies for assessing therapeutic interventions.
Source:  Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

26. Evidence Pyramid
Number of studies fewer at higher levels of the pyramid, but of higher quality and relevance to clinical practice

27. Best Study Design for Type of Question
Therapy
Randomized controlled trials
Diagnosis
Prospective cohort, blind comparison to a gold standard
Prognosis
Cohort, Case Control, Case Series
Etiology/Harm

28. Using EBM – Steps 2 & 3 Track down the evidence to answer the question
Use the 4S approach to select the most likely resource
Start with the highest level resource available

29. Critically Appraised Content

30. Systems Dynamed Summaries for more than 3000 topics
Monitors >500 medical journals and systematic review databases
Updated daily
Each article evaluated for clinical relevance and scientific validity

31. Databases

32. Databases
1:39

33. Synopses A step down from Systems
Useful when no answer can be found in the Systems
Summary of individual studies and reviews
Faster than reviewing the individual studies
Examples: ACP Journal Club, Evidence Based Ophthalmology

34. Synopses ACP Journal Club 1991-2009 archive of cumulative content
Periodically thinned
Selected from >100 journals
Published monthly
“Structured abstracts”, critically appraised
Commentaries on context, methods, and clinical applications by expert clinicians
IM focus (Tx, Px, Harm, and Dx)

35. ACP Journal Club

36. Synopses Evidence Based Ophthalmology
Quarterly journal includes reviews of 24 critically relevant articles from ocular literature
Editorial board comprised of practicing physicians with expertise in epidemiology and clinical trials
Search NSU

37. Evidence Based Ophthalmology

38. Syntheses Systematic reviews Supplement Synopses with more detail
Compare findings
Cochrane Database of Systematic Reviews is the premiere example

39. Syntheses Cochrane Database of Systematic Reviews
Part of the Cochrane Library (1996)
916 completed reviews, 1905 protocols
Among the highest level of evidence upon which to base treatment decisions
Includes Dx since 2008
Eyes & Vision Research Group
Contains 136 reviews

40. Systematic Review
Analyzes data from several primary studies to answer a specific clinical question
Provides search strategies and resources used to locate studies
Includes specific inclusion and exclusion criteria (results in less bias)
Meta-Analysis (subclass) statistically summarizes results of several individual studies
Access through OVID

41. Cochrane Database
:15

42. Syntheses All Evidence Based Medicine Reviews
Database of seven EBM Resources
ACP Journal Club (synopsis)
Database of Abstracts of Reviews of Effects (DARE) (synthesis)
Cochrane Database of Systematic Reviews (synthesis)
Access through Ovid
Expands search for summaries/reviews

43. Appraisal Required by User

44. Original Studies
Synopses and syntheses take 6 months to years to appear
If the other “S’s” don’t provide the answer, search for studies
Must critically appraise the evidence yourself. Understand and apply measures of internal/external validity
Least efficient (in terms of time) for clinical questions

45. Primary (Original) Studies
Articles that report results of original research investigations
Conclusions supported by data and reproducible methodology
Good Source: MEDLINE (OVID)

46. Databases
MEDLINE
Premiere biomedical database from the NLM (National Library of Medicine)
Covers 1950-present
Indexes >4000 international biomedical journals
Full text available for many articles
Access through Ovid

47. MEDLINE Searches Limit search results to study type
Randomized controlled trials
Clinical trials
In OVID, limit by Clinical Queries
Appraise study for validity and relevance

48. Levels of Evidence
Grade the quality of evidence based on the design of the clinical study
Variety of hierarchies in use

49. American Academy of Family Physicians Rating System Level A
Systematic reviews of randomized controlled trials including meta-analyses
Good-quality randomized controlled trials
Level B
Good-quality nonrandomized clinical trials
Systematic reviews not in Level A
Lower-quality randomized controlled trials not in Level A
Other types of study: case control studies, clinical cohort studies, cross sectional studies, retrospective studies, and uncontrolled studies
Level C
Evidence-based consensus statements and expert guidelines

50. Dynamed

51. Take Home Points Foreground question reveals your search terms
Start your search at top of 4S hierarchy and work down
Be aware of the filter
Look at more than one resource in the hierarchy. Findings may differ.
Practice makes perfect

53. Evidence Based Medicine Lecture NSUOCO Residency Journal Club
Sandra A. Martin, M.L.I.S.
Health Sciences Resource Coordinator
Optometry Subject Librarian
John Vaughan Library Room 305B –