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MBE en dermatología






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  • Evidence-Based Dermatology

MBE en dermatología MBE en dermatología Presentation Transcript

  • Using the Internet to Practice Evidence-Based Dermatology David A. Barzilai, M.D., Ph.D. Brown University Department of Dermatology Presentation Home: http://ebderm.org Last Update: 1.9.07 ( check http://ebderm.org for latest updates )
  • Presentation Objectives
    • This Presentation Addresses:
    • What is Evidence-Based Medicine (EBM)?
    • How does one practice EBM?
    • What tools are available to practice EBM?
      • Emphasis on internet tools (available at http://ebderm.org )
      • Special resources of dermatological interest will be highlighted
  • Evidence-Based Medicine
    • "the conscientious, explicit, and judicious use of current best evidence in making clinical decisions about the care of individual patients."
      • Dr. David Sackett, “father” of EBM
    • EBM is not “cookbook medicine”
    • Evidence is thoughtfully integrated w/:
      • Patient preferences
      • Provider expertise (including knowledge what makes this patient unique)
  • Setting
    • The Goal: Providing exemplary care for our patients, using the current best evidence
    • The Challenge:
      • Minutes per patient encounter to seek out best evidence
      • Minutes to hours per week of reading to “stay current”
      • Research data is accruing faster than our ability to read!
    • The Issue: how do we best make use of our limited time for:
      • Information retrieval and “reading time”
      • Information management
      • Evidence-based medical practice
  • Overview : EBM Search Algorithm
    • Formulating a well-built clinical question
    • Finding the current best evidence *
    • Critically appraising the evidence for validity
    • Application of this evidence, integrating the data with patient values and clinical expertise .
    • Storing the data and evaluating performance of steps 1-4 for continuous quality improvement
    * We emphasize step 2 in this brief presentation
  • The Well-Built Clinical Question
    • Includes the following (P.I.C.O.):
      • A P atient or population
      • An I ntervention or “exposure”
      • A C omparison intervention (if appropriate)
      • A clinical O utcome (diagnosis/screening, prognosis, therapy, event, harm, or prevention)
  • Well-Built Clinical Question (WBCQ) – an Example
    • “ In a 22 year old woman with mild non-comedonal acne (Patient), does monthly use of salicylic acid (Intervention) or benzoyl peroxide (Comparison) prevent more acneiform lesions from developing (Outcome)?” Resources to facilitate WBCQ’s
  • The WBCQ- Resources
    • Anatomy of a well-built clinical question (University of Sheffield)
    • Contstruct a well-built clinical question using PICO (University of Washington)
    • Further reading on well-built clinical question , from University of Medicine and Denistry of New Jersey.
    • Sackett et. al (see References)
    • When you have created your well-built clinical question, consider using this as the basis for contributing a Critically Appraised Topic to ebderm.org, which is a practice-based learning tool for conducing evidence-based searches and evaluations.  
  • What Kind of Study to Answer my Question?
    • Keep in mind the Hierarchy of Evidence :
      • Systematic review of RCTs > RCT>Cohort>x-sectional >case report> anecdote (“ rule of thumb” )
      • However , a good observational study beats a poorly conducted Randomized Controlled Trial (RCT).
    • Also, the best design varies by the question:
      • Prognosis, harm: Cross Sectional or Cohort Study
      • Natural history, Diagnosis: Cohort Study
      • Therapy & prevention, other interventions: RCT’s
  • Critically Examine All Sources
    • Foundation is epidemiology and biostatistics
      • Is this study important?
      • Is this study valid?
      • Does this study apply to my patient population?
    • Learn Critical Appraisal Skills ( free ):
      • Synopsis of JAMA review of EBM
      • University of Alberta EBM Toolkit
      • Basic Biostatistics 1 and Basic Biostatistics 2 (BMJ)
  • Seeking the Evidence (overview)
    • Evidence-Based Resources:
      • Evidence-Based Systematic Review Databases
      • Secondary journals
      • EBM textbooks and guidelines
      • Medline / electronic databases
    • Consult Medline first for very latest research
  • What About Consulting Colleagues and Experts??...
    • Image source: http://www.askanexpert.com/
  • Least Reliable Sources of Evidence
    • Colleagues, experts, & “throw-away” journals
      • Convenient and fast
      • Often invalid , incomplete, and biased information
    • Textbooks (usually)
      • Generally not systematically researched
      • Usually based on “expert opinion”
      • Most are out of date - check for recent citations
      • Great exception (explicit protocols):
  • 1. Evidence-Based Systematic Review Databases
    • Traditional narrative reviews are often expert-based, biased, and incomplete (unreliable).
    • Systematic reviews are characterized by:
      • Clear and focused study question
      • Explicit definition of study criteria to be included
      • A priori protocol for collating the evidence
      • Exhaustive search, including“hand-searching” and unpublished studies
      • Explicit or implicit factoring of study quality
    • Most comprehensive resource for therapy Q’s
  • Systematic Review Databases
    • The Cochrane Library :
      • Best source for structured, systematic reviews
      • Explicit search & quality criteria ( free abstracts)
    • Database of Abstracts of Reviews of Effectiveness (DARE)
      • Structured abstracts of systematic reviews meeting highest quality standards
      • A ( free ) part of the Cochrane Library
    • Evidence-Based Medicine Reviews (EBMR) integrates the above with secondary journal content:
      • ACP Journal Club / Best Evidence
      • Medline searching and some full-text journals.
  • 2. Secondary Journals
    • Evidence-Based “secondary journals” provide structured abstracts with balanced commentary
    • Selected from high quality publications
    • Can be best resource to start with when investigating rare clinical conditions (saves time).
    • E.g.’s-
      • Evidence-Based Medicine , ACP Journal Club (free)
      • Specialty-specific resources: Evidence-Based Dermatology section of Archives of Dermatology
      • Bandolier (free) brief EBM summaries of summaries
    • Journal Watch Dermatology ,  a product of the publishers of the New England Journal of Medicine, provides month summaries with expert commentary for 13-15 manuscripts.
  • 3. EBM Textbooks
    • Most efficient source for simple clinical queries, but most quickly outdated
      • Evidence-Based Dermatology the definitive book on evidence-based dermatology ( link to review ).
      • Clinical Evidence , by BMJ Publishing Group and ACP, meets the highest evidence-based medicine standards.
      • UpToDate  meets a high standard of evidence-based content and periodically updated.
      • ACP Medicine , developed from WebMD Scientific American® Medicine   available online by subscription.
  • Evidence-Based Guidelines
    • The best sources rate the strength of evidence
    • Always consider external validity to your patient
      • The National Guideline Clearinghouse   is the most well known of the high quality clinical guideline databases  (free).
      • The Guide to Clinical Preventative Services includes the latest clinical prevention recommendations by the U.S. Preventive Services Task Force  ( free )
      • The UK National Electronic Library for Health Guidelines has over 2000 guidelines produced in the United KIngdom ( free ).
      • The Guidelines International Network permits guideline searches with a more international focus with membership.
      • For skin-related guideilnes developed through by two large dermatology associations, you can visit the American Academy of Dermatology guidelines and the British Association of Dermatologists guidelines.
  • 4. Medline
    • If the Cochrane Library has not addressed our question, next try Medline…
    • The largest biomedical literature database, but :
      • Misses some journal articles, misclassifies others
      • Can be overwhelming if not searching selectively
    • PubMed is a free Medline service with Boolean and other search capabilities.
    • Sample PubMed queries can be found at Sample Clinical Query (from the New York Academy of Medicine) (free)
    • Clinical query filter facilitates clinical searches
    • Medline searching tips from the New York Academy of Medicine helps you take advantage of the power of Medline (free)
  • Meta-Search Engines
    • Permit integrated multi-source searches
      • Evidence Based Medicine Reviews , by Ovid: searches Cochrane, DARE, ACP Journal Club, and Medline.
      • Tripdatabase: Cochrane Library, DARE, the National Guideline Clearinghouse, clinical questions answering services, online books, and Medline
        • Quality more variable
      • SUMSearch: Cochrane, National Guide Clearinghouse and other sources
        • Incorporates data quality in results.
  • Critically Appraised Topics (CATs)
    • Practice-based learning of EBM
    • Results vary by author, source
      • Ebderm.org will host an international CAT bank specific to skin disease. 
      • Spanish Language dermatology CAT bank available at dermatoscopio . cl
      •   BestBets
      • The CAT Bank
      • CAT Crawler is a search engine for CATs from multiple sources, but currently does not search ebderm.org or dermatoscopio.cl for skin-related CATs.
  • Information Management
    • Use Science Citation Index to search for newer articles that cited an older classic paper of interest.
    • EMBASE is a Medline alternative
      • More extensive European journal representation
      • Wider array of health science disciplines represented
    • Invest in a citation manager program such as EndNote :
      • Download abstracts from Medline
      • Label abstracts for quick searches later
      • Effortless reference resorting
  • Guidelines for Reading
    • Choose 2-3 gold standard journals relevant to your patients for weekly reading
    • Devote weekly protected time for reading
    • Subscribe to e-mail TOC’s of 1-3 other high quality journals (e.g. Lancet , JAMA ).
    • Consider specialty-specific services:
      • Dermlinx ( www.mdlinx.com )
      • Medscape Dermatology ( www.medscape.com )
  • Selected Comprehensive Web-Based EBD Resources
    • Evidence-Based Dermatology
    • Centre for Evidence-Based Dermatology
    • Netting the Evidence
    • Centre For Evidence Based Medicine
    • Evidence-Based Medicine Resource Center
  • Some Final Suggestions
    • The most effective way to learn evidence-based dermatology is to practice it:
      • Consider creating a Critically Appraised Topic ( CAT ) on ebderm .org
    • Consider joining IDEA (International DermatoEpidemiology Network)
    • Get involved with the Cochrane Skin Group
  • Distribution Statement
    • You may distribute freely, provided that this presentation is preserved in its entirety without changes
    • Questions / comments:
      • David A. Barzilai , MD PhD ( skinresearch .org )
      • For presentation updates see: ebderm .org
  • References
    • Arndt KA: Information excess in medicine. Overview, relevance to dermatology, and strategies for coping. Arch Dermatol 128:1249-1256, 1992
    • Barzilai DA, Freiman A, Dellavalle RP, Weinstock MA, Mostow: Dermatoepidemiology . J Am Acad Dermatol. 2005 Apr;52(4):559-73; quiz 574-8 [CME Review].
    • Bigby M: Evidence-based medicine in dermatology . Dermatol Clin 18:261-276, 2000 (much like the above – choose one)
    • The Challenge of Dermato-epidemiology by Hywell Williams (Book)
    • Cook DJ, Meade MO, Fink MP: How to keep up with the critical care literature and avoid being buried alive. Crit Care Med 24:1757-1768, 1996
    • Evidence-Based Medicine: How to Practice and Teach EBM by David Sackett
    • How to Read a Paper: The Basics of evidence based medicine by Trisha Greenhalgh
    • Studying a Study and Testing a Test by Richard Riegelman and Robert Hirsch