Introduction to EBM

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  • Thank you for this opportunity to talk with you about the American Academy of Pediatrics and the Resident Section.
    Membership in the AAP has value on many different levels. In short, AAP membership can help you succeed in the field of Pediatrics.
  • Introduction to EBM

    1. 1. Rani S. Gereige, M.D., MPH Associate Professor University of South Florida Introduction to Evidence-Based Medicine (EBM)
    2. 2. Learning Objectives What is EBM? – Definition Why is EBM becoming important? Introduction to EBM – 5 steps of EBM Advantages and Limitations of EBM EBM Resources
    3. 3. What is Evidence-Based Medicine? Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values Sackett DL, Straus SE, Richardson WS, Rosenberg W, and Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd Ed, Churchill Livingstone, London, 2000
    4. 4. Why is EBM becoming Important??
    5. 5. Why Is EBM Important? 1. Need for valid information daily on Diagnosis, treatment, prognosis and prevention (5x per inpatient, 3x per 3 outpatients) 2. Inadequate traditional sources: Outdated (Textbooks) Frequently wrong (Expert opinions) Ineffective (Didactics/CME) Too overwhelming in volume and variable in validity (Medical Journals)
    6. 6. Journals on Aging in 1994: 95Journals on Aging in 1974: 28 Information Explosion 1948- 4,700 scientific journals in publication 1990- More than 100,000 scientific journals (90% of all major scientific advances are in 150 of those)
    7. 7. Why Is EBM Important? (Cont’ed) 3. Time constraints in clinical practice Primary care docs would need over 17 hours/day just to review reasonable pertinent material Specialists in one narrow field would need 6+ hrs/week Practicing docs average around 1-1.5 hrs/wk 4. Diagnostic skills and clinical judgment versus up-to-date knowledge and performance
    8. 8. What is Driving EBM to the Forefront? More informed patients/families The internet – Not always accurate information Insurance companies Hospitals Accrediting bodies Medico-legal factors Research Medical education
    9. 9. Introducing EBM – 5 Steps “Frame” the patient care answerable question Search and find the best evidence Appraise critically the evidence Integrate the critical appraisal with expertise and patient’s unique values Evaluate the effectiveness and efficiency of steps 1-4
    10. 10. Framing the question - Tips P = Patient/Problem/Population: Ask “how would I describe a group of patients similar to mine?” Balance precision with brevity I = Intervention: Ask “which main intervention am I considering?” (cause, prognostic factor, treatment, etc..) C = Comparison/Control: Ask “which is the main alternative to compare with the intervention?” again, be specific O = Outcome: Ask “what can I hope to accomplish?” or “what could this exposure really affect?” again, be specific.
    11. 11. Best Research Evidence Where to find it? How to know that it is the BEST available evidence? Is it clinically relevant? Is it patient-centered? Hierarchy of evidence – 4 S Studies Systematic Reviews Synopses Systems – Guideline and pathways
    12. 12. Quest for the Current Best Evidence CURRENT BEST Evidence Keep in mind that Last year’s best might not be this year’s best
    13. 13. How to Learn About Best Information Resources? From librarians (hands-on training) From experts in medical informatics Courses/ Tutorials
    14. 14. Ideal, still theoretical, links EMR to best research evidence, always updated, drills down Provide enough information to support a clinical action More details, summaries based on exhaustive search for evidence, explicit scientific reviews, and systematic assembly of evidence When all above fails, more recent or not reviewed topics
    15. 15. Systems Clinical Evidence (BMJ) URL: http://www.clinicalevidence.com Contains limited range of clinical questions PIER (the Physician’s Information and Education Resource) by ACP URL: http://pier.acponline.org Only for members UpToDate® URL: http://www.uptodate.com Updated quarterly Extensively referenced ACP Medicine (Formerly Scientific American Medicine) URL: http://www.acpmedicine.com
    16. 16. Systems (Cont’ed) Harrison’s Principles of Internal Medicine URL: http://www.harrisonsmed.com Only updated every 3 years Evidence Based on Call URL: http://www.eboncall.org/content.jsp.htm Evidence-Based Pediatrics and Child Health URL: http://www.evidbasedpediatrics.com Evidence Based Cardiology URL: http://www.evidencebasedcardiology.com/ OVID includes and links EBMR (Cochrane, ACP Journal Club, the Database of Abstracts of Reviews of Evidence (DARE), and Medline
    17. 17. Criteria to evaluate systems Look for Systems that: Are revised at least once a year: Date of revision should be listed Select and appraise the evidence in an explicit way (Introduction) Site evidence to support clinical care declarations
    18. 18. Synopses ACP Journal Club http://www.acpjc.org/ Give you the summary and links you to the evidence Ex: “Low Molecular Weight Heparin is Effective and Safe in the Acute Coronary Syndromes”
    19. 19. Syntheses Cochrane Library URL: http://www.cochranelibrary.com/ OVID’s EBMR (Includes ACP Journal Club, Cochrane Database of Systematic Reviews (CDSR), and DARE)
    20. 20. Studies Specialized ACP Journal Club: www.acpjc.org Evidence Based Medicine: www.ebm.bmjjournals.co m Evidence Based Nursing: www.ebn.bmjjournals.com Evidence Based Mental Health: www.ebmh.bmjjournals.co m General Cochrane Central Register of Controlled Trials (Therapy) MEDLINE: http://www.ncbi.nlm.nih. gov/PubMed/ Using the Clinical Queries Search ASK MEDLINE http://askmedline.nlm.ni h.gov/ask/ask.php Make use of your Library and Institutional subscriptions
    21. 21. When all fails it
    22. 22. Evidence that Finds You Cancel your full-text journal subscriptions You need to read 86-107 articles (top 5 full-text journals) to find one that meets the basic criteria for quality and relevance This is 3 hours (at 2 minutes per article) PubMed has also the feature of “related articles”, and “Links”
    23. 23. Evidence that Finds You Invest in evidence-based journals and online services (see synopses). Synopses are linked to full text articles With synopses you can set it up to: Be alerted when new articles cite this review Be connected to similar synopses on similar articles in the publisher’s other journals E-mail the item to a friend or colleague Download the synopsis
    24. 24. Evidence that Finds You Can have the current contents of a certain journal in your specialty sent to you Other specialty-based services: PedsCCM Evidence Based Journal Club http://pedsccm.wustl.edu/EBJournal_club.h tml Family Practice Journal Club (POEMS) http://www.infopoems.com/ Critical Care http://ahsn.lhsc.on.ca
    25. 25. If You are on Your Own PubMed BioMed Central (Open access journals) http://www.biomedcentral.com Public Library of Science http://www.publiclibraryofscience.org/ SCHARR http://www.shef.ac.uk/~scharr/ir/netting/
    26. 26. Top Five Used Resources In a Survey of commonly used resources, the top 5 resources used: 1. Clinical Evidence 2. UpToDate® 3. DynaMed® 4. ACP PIER
    27. 27. Textbooks are only useful for “background questions” (Pathophysiology of clinical problems)
    28. 28. Background Knowledge General knowledge related to question at hand What bacteria cause acute otitis media? What are the symptoms of meningitis? What antibiotics are effective in treating otitis media? What are the risk factors for recurrent otitis media?
    29. 29. Study Pyramid Best Worst
    30. 30. Systematic Reviews &Meta- analyses
    31. 31. Randomized Controlled Studies
    32. 32. The Double Blind Method
    33. 33. Cohort Studies
    34. 34. Case Control Studies
    35. 35. Case Series & Case Reports
    36. 36. Elements of a CAT Topic Title Name of Reviewer, date. Patient Story Answerable Clinical Question (PICO) The Search The Study Citation Methods Issues of Validity Results & results recalculated with Intention to Treat Applicability/ Limitations Resolution of Patient Story Clinical Bottom Line
    37. 37. Advantages of EBM Helps us stay up to date Improves morbidity and mortality (saves lives) Helps us improve diagnostic certainty and do the right thing for our patients Saves time (Cannot possibly keep up) Helps dispel the myths and avoid the Ping-Pong between “experts”
    38. 38. Other Advantages Reinforces communication skills, compassion, and listening skills Skills in finding and appraising evidence Provides a framework for self-directed lifelong learning Provides material for future research Common language Physician still needs clinical/diagnostic skills and insight
    39. 39. Limitations and criticism of EBM Needs new skills in searching and appraisal Time limitation for busy clinicians Late and slow evidence that EBM works Is it cookbook medicine?
    40. 40. So What is “The Truth”? A probability statement… that what we do for patients does more good than harm
    41. 41. EBM in Teaching
    42. 42. So….. Why EBM??!!
    43. 43. Because Patients Do Not Come With Instructions!!!
    44. 44. EBM Web Resources EBM Home page (McMaster): www.hiru.hirunet.mcmaster.ca/ebm/ Users' guide to the literature: www.hiru.mcmaster.ca/ebm/userguid/1_map.htm USA Cochrane Collaboration Home Page: www.cochrane.org Journal of Family Practice Journal Club: www.infopoems.com/ Center for Evidence Based Medicine: www.cebm.jr2.ox.ac.uk/ University of Michigan Pediatric EBM site: www.ped.med.umich.edu/ebm Evidence Based Medicine Review (EBMR): www.ovid.com Clinical Evidence: www.clinicalevidence.org/IpBinCE/Ipext.dll?f =templates&fn=main-h.htm&2.0 DARE: Database of Abstracts of Reviews of Effectiveness: nhscrd.york.ac.uk/darehp.htm EBM online: http://ebm.bmjjournals.com/misc/about/shtml
    45. 45. EBM Resources Journals: Bandolier : www.jr2.ox.ac.uk/Bandolier British Medical Journal: www.bmj.com Journal of Family Practice: www.jfp.denver.co.us/ New England Journal of Medicine: www.nejm.org/ Clinical "stuff": Guide to Clinical Preventive Services, 2nd Ed: www.ahcpr.gov/clinic AHCPR Guidelines: www.ahcpr.gov/clinic CDC Home Page: www.cdc.gov/ National Guideline Clearinghouse: www.Guideline.gov

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