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Evidence-Based Medicine for Obstetrics & Gynecology
 

Evidence-Based Medicine for Obstetrics & Gynecology

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Lecture given to obstetrics and gynecology residents at McGill University on August 7, 2013

Lecture given to obstetrics and gynecology residents at McGill University on August 7, 2013

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    Evidence-Based Medicine for Obstetrics & Gynecology Evidence-Based Medicine for Obstetrics & Gynecology Presentation Transcript

    • Evidence-Based Medicine for Obstetrics and Gynecology L I F E S C I E N C E S L I B R A R Y Summer 2013 Robin Featherstone, MLIS http://www.slideshare.net/featherr
    • Why EBM?
    • Workshop - Objectives By the end of the workshop, you will be able to: 1. Describe the five stages of the EBM process 2. Differentiate background from foreground questions 3. Develop a well-formed PICO question 4. Categorize questions and identify the best studies to answer each question type 5. Select appropriate sources to search for evidence to best answer your questions 6. Identify three fundamental questions to ask when appraising a published study
    • EBM for Obstetrics & Gynecology  Based on Hematology pilot EBM program for specialist residents  Focused on real-life clinical questions  Aimed to integrate EBM principles into journal clubs, everyday practice
    • EBM Process Appraising the Evidence Incorporating evidence into decision-making Evaluating the Process Formulating the clinical question Searching the Evidence Your patient for whom you are uncertain about therapy, diagnosis, or prognosis ASK ACQUIRE APPRAISE APPLY ASSESS
    • Guyatt G, Rennie D, Cook D. Users' Guides to the Medical Literature : A Manual for Evidence-Based Clinical Practice (2nd Edition). New York, NY, USA: McGraw-Hill Professional Publishing; 2008. [1.] What are the reported incidences of paraovarian cysts? What are risk factors for pelvic inflammatory disease? Should a left atrial mobile mass in an elderly woman with a previous uterine sarcoma be removed?
    • [1.] Sources for Background Questions • Textbooks • Handbooks • Manuals • Encyclopedias • etc Background Questions
    • Patient Scenario You are following a 35 year-old pregnant female for low platelets thought to be due to immune thrombocytopenia as she had thrombocytopenia prior to her pregnancy. During the pregnancy, her platelets fluctuated quite a bit, ranging from her pre-pregnant baseline of 120 to as low as 60. When she presented to hospital in labour, her platelets count was 75 preventing her from getting an epidural, but ensuring a safe delivery. She undergoes a spontaneous vaginal delivery without complications. She and the baby are medically ready to leave the hospital 48 hours later. Her platelet count has risen to 110. She asked if she should be concerned for her newborn, knowing that her antibodies, the same that are causing her immune thrombocytopenia, are passed along to baby. Should a blood test be done to check the baby’s platelet count. If so, when?
    • Formulating a Clinical Question Patient, population, or problem Intervention, prognostic factor, or exposure Comparison or intervention Outcomes to measure or be achieved
    • What’s the PICO? You are following a 35 year-old pregnant female for low platelets thought to be due to immune thrombocytopenia as she had thrombocytopenia prior to her pregnancy. During the pregnancy, her platelets fluctuated quite a bit, ranging from her pre-pregnant baseline of 120 to as low as 60. When she presented to hospital in labour, her platelets count was 75 preventing her from getting an epidural, but ensuring a safe delivery. She undergoes a spontaneous vaginal delivery without complications. She and the baby are medically ready to leave the hospital 48 hours later. Her platelet count has risen to 110. She asked if she should be concerned for her newborn, knowing that her antibodies, the same that are causing her immune thrombocytopenia, are passed along to baby. Should a blood test be done to check the baby’s platelet count. If so, when?
    • PICO P: Newborns born to mothers with immune thrombocytopenia I: Blood test to check platelet count C: No blood test O: Diagnosis of immune thrombocytopenia
    • Clinical Question In newborn patients with suspected immune thrombocytopenia, is a blood test to determine platelet count recommended to diagnose immune thrombocytopenia?
    • What is the “evidence”? Systematic Reviews Randomized control trials Cohort studies Case-control studies Case reports Editorials Animal research All types of articles found in PubMed
    • Question Best Evidence Cost •Cost-effectiveness study Diagnosis •Diagnostic validation studies •Prospective studies / blind comparison to a gold standard Etiology/Harm •Cohort study •Case control study Prognosis •Cohort study •Case control study Quality of life •Qualitative studies Therapy •Systematic review of Randomized Controlled Trials (RCTs) •Single RCT 1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006. 2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
    • Levels of Evidence for Therapy Question Level of Evidence Type of Study 1a Systematic reviews of randomized controlled trials (RCTs) 1b Individual RCTs with narrow confidence interval 2a Systematic reviews of cohort studies 2b Individual cohort studies and low-quality RCTs 3a Systematic reviews of case-control studies 3b Case-control studies 4 Case series and poor quality cohort and case-control studies 5 Expert opinion 15 Levels of evidence (2001). Centre for Evidence Based Medicine. Retrieved 26 Aug 2008 from http://www.cebm.net/index.aspx?o=1025
    • Unfiltered Filtered 2a 2b 54 3b 4 1b1b 2a 5 2b 3b Summaries Information Sources for Diagnosis Question Synopsis of synthesis
    • 1. Soundness of evidence-based approach 2. Comprehensiveness and specificity 3. Ease of use 4. Availability See also: http://www.jgh.ca/en/hslinteractivepyramid Criteria for Selecting an Information Source
    • Filtered Information Sources some examples } includes: • Cochrane Database of Systematic Reviews • DARE (Database of Abstracts of Reviews of Effects)
    • Filtered Information Sources some examples
    • Filtered Information Sources some examples Unfiltered
    • Information Sources some examples Unfiltered Expert Opinion
    • Unfiltered Filtered Information Sources some examples
    • Unfiltered Expert Opinion Filtered
    • What’s the PICO? A 27-year-old presented for her initial prenatal visit at 10 weeks’ gestation. Her family and medical histories were unremarkable and she reported healthy behaviours. Her BMI was 22. She has been vegan for the previous 5 years. Her initial prenatal labs revealed mild anemia (hematocrit, 32%; hemoglobin, 10.8 g/dL ). She was asked to bring a 3-day diet history so that her food choices could be evaluated. Evaluation of her diet revealed a deficiency of iron-rich foods and insufficient intake of foods high in folate. You discussed iron supplementation with the patient and she expressed concern over the impact on the health of the baby. Penney, et. al. (2008). Nutritional Counseling for Vegetarians During Pregnancy and Lactation. Journal of Midwifery & Women’s Health. Vol 53. Issue 1. pg 37-44. Retrieved July 23, 2013 from http://dx.doi.org/10.1016/j.jmwh.2007.07.003
    • Possible PICO 1 P: 27 year old female with prenatal anaemia I: Iron supplementation C: No iron supplementation O: Adverse pregnancy outcomes
    • Possible PICO 2 P: 27 year old female with prenatal anaemia I: Diet modification to include iron enriched vegetarian foods C: No diet modification O: Improvement in haemoglobin concentration
    • Possible PICO 3 P: 27 year old female with prenatal anaemia I: Iron supplementation C: Diet modification to include iron enriched vegetarian foods O: Adverse pregnancy outcomes
    • Possible PICO 4 P: 27 year old female with prenatal anaemia I: Iron supplementation C: Diet modification to include iron enriched vegetarian foods O: Improvement in haemoglobin concentration
    • For a patient with prenatal anemia, does iron supplementation increase the risk of adverse pregnancy outcomes? What kind of a question is this?
    • Question Best Evidence Cost •Cost-effectiveness study Diagnosis •Diagnostic validation studies •Prospective studies / blind comparison to a gold standard Etiology/Harm •Cohort study •Case control study Prognosis •Cohort study •Case control study Quality of life •Qualitative studies Therapy •Systematic review of Randomized Controlled Trials (RCTs) •Single RCT 1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006. 2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
    • Unfiltered Expert Opinion Filtered Where are you going to look?
    • * Links to all of these resources: http://www.mcgill.ca/library/library- findinfo/subjects/health/medicine Search strategies* Cochrane (anemia OR anaemia) AND pregnan* AND iron UpToDate (anemia OR anaemia) AND pregnan* AND iron > Treatment of the adult with iron deficiency anemia > Pregnancy PubMed Clinical Queries (anemia OR anaemia) pregnancy iron TRIP Database (anemia OR anaemia) AND pregnan* AND iron Google Scholar allintext: (anemia OR anaemia) ~pregnancy iron
    • EBM Process Appraising the Evidence Incorporating evidence into decision-making Evaluating the Process Formulating the clinical question Searching the Evidence Your patient for whom you are uncertain about therapy, diagnosis, or prognosis ASK ACQUIRE APPRAISE APPLY ASSESS
    • Summarizing the Evidence (Systematic Reviews)* 1. Are the results valid? A. Did the review explicitly address a sensible clinical question? B. Was the search for relevant studies detailed and exhaustive?  Were sources of evidence and search strategies specified in sufficient detail for replication  Was the likelihood and direction of publication bias considered? C. Were the primary studies of high methodologic quality? D. Were selection and assessments of studies reproducible? *. http://jamaevidence.com/criticalAppraisalWorksheet/26
    • Summarizing the Evidence (Systematic Reviews), cont. 2. What are the results? A. Were the results similar from study to study? B. What are the overall results of the review? C. How precise were the results?
    • Summarizing the Evidence (Systematic Reviews), cont. 3. How can I apply the results to patient care? A. Were all patient-important outcomes considered? B. Are any postulated subgroup effects credible? C. What is the overall quality of the evidence? D. Are the benefits worth the costs and potential risks?
    • 1. UpToDate is a _______ resource. And EMBASE is a ________ resource. 2. The 5 stages in the EBM process are _______. 3. The best evidence to answer a diagnosis question is _______. 4. To find systematic reviews of RCTs use _______. 5. PICO stands for ________. 6. The three questions to ask to appraise ANY study are _______, ________, and ________. Summary Quiz
    • Next steps Some suggestions for your journal clubs (next one: August 21)  Start with a patient case  Develop a PICO question  Search for best available evidence  Appraise the article using standard questions for that study design  Slides available: http://www.slideshare.net/featherr