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 http://www.nks.nhs.uk/.

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, 3 rd ed. New York: Elsevier Churchill Livingstone, 2005.

5. Definitions Best research evidence: ‘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 1. Convert information need into answerable clinical question 2. Track down the best evidence to answer the question 3. Critically appraise the evidence for its validity (closeness to truth), impact (size of the effect), and applicability (usefulness in practice) 4. Integrate appraisal with clinical expertise and with patient’s unique values and circumstances

11. Improvements in EBM Practice 1. Development of efficient search strategies to retrieve the evidence, e.g., clinical queries in Ovid MEDLINE 2. Creation of systematic reviews 3. Development of new clinical decision support tools 4. 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), 36-38. Retrieved 2-07-07 from http://ebm.bmj.com/cgi/reprint/6/2/36 http://ebm.bmj.com/cgi/reprint/6/2/36

15. Critically Appraised Content

16. Appraisal Required by User

17. Steps to Using EBM 1. Convert information need into answerable clinical question 2. Track down the best evidence to answer the question 3. 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 QuestionType of Studies TherapySelect treatments that do more good than harm, worth the effort and costs DiagnosisSelect and interpret diagnostic tests against the gold standard PrognosisEstimate the patient’s clinical course Etiology/HarmIdentify 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 Type of QuestionStudy Design TherapyRandomized controlled trials DiagnosisProspective cohort, blind comparison to a gold standard PrognosisCohort, Case Control, Case Series Etiology/HarmCohort, Case Control, Case Series

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. 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 Journals@Ovid

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

48. MEDLINE Indexing

50. Search Query

51. Boolean Connectors

52. MEDLINE Search Limits Limit search results to study type –Randomized controlled trials –Clinical trials In OVID, limit by “Clinical Queries” Appraise study for validity and relevance

53. Ovid MEDLINE Clinical Queries

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

56. 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

57. Dynamed

58. Take Home Points Foreground question (PICO) 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

60. 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 marti004@nsuok.edu – 918-444-3263