MBE en dermatología

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  • Evidence-Based Dermatology
  • MBE en dermatología

    1. 1. Using the Internet to Practice Evidence-Using the Internet to Practice Evidence- Based DermatologyBased Dermatology David A. Barzilai, M.D., Ph.D.David A. Barzilai, M.D., Ph.D. Brown UniversityBrown University Department of DermatologyDepartment of Dermatology Presentation Home:Presentation Home: http://ebderm.orghttp://ebderm.org Last Update: 1.9.07Last Update: 1.9.07 ((checkcheck http://ebderm.orghttp://ebderm.org for latest updatesfor latest updates))
    2. 2. Presentation ObjectivesPresentation Objectives This Presentation Addresses:This Presentation Addresses: What is Evidence-Based Medicine (EBM)?What is Evidence-Based Medicine (EBM)? How does one practice EBM?How does one practice EBM? What tools are available to practice EBM?What tools are available to practice EBM? – Emphasis on internet tools (available atEmphasis on internet tools (available at http://ebderm.orghttp://ebderm.org)) – Special resources of dermatological interest will be highlightedSpecial resources of dermatological interest will be highlighted
    3. 3. Evidence-Based MedicineEvidence-Based Medicine "the conscientious, explicit, and judicious use of"the conscientious, explicit, and judicious use of current best evidence in making clinicalcurrent best evidence in making clinical decisions about the care of individual patients."decisions about the care of individual patients." – Dr. David Sackett, “father” of EBMDr. David Sackett, “father” of EBM EBM is not “cookbook medicine”EBM is not “cookbook medicine” Evidence isEvidence is thoughtfullythoughtfully integrated w/:integrated w/: – Patient preferencesPatient preferences – Provider expertise (including knowledge what makesProvider expertise (including knowledge what makes this patient unique)this patient unique)
    4. 4. SettingSetting The Goal: Providing exemplary care for our patients,The Goal: Providing exemplary care for our patients, using the current best evidenceusing the current best evidence The Challenge:The Challenge: – Minutes per patient encounter to seek out best evidenceMinutes per patient encounter to seek out best evidence – Minutes to hours per week of reading to “stay current”Minutes to hours per week of reading to “stay current” – Research data is accruing faster than our ability to read!Research data is accruing faster than our ability to read! The Issue: how do we best make use of our limitedThe Issue: how do we best make use of our limited time for:time for: – Information retrieval and “reading time”Information retrieval and “reading time” – Information managementInformation management – Evidence-based medical practiceEvidence-based medical practice
    5. 5. OverviewOverview: EBM Search Algorithm: EBM Search Algorithm 1.1. Formulating a well-built clinical questionFormulating a well-built clinical question 2.2. Finding the currentFinding the current bestbest evidenceevidence** 3.3. Critically appraising the evidence for validityCritically appraising the evidence for validity 4.4. Application of this evidence,Application of this evidence, integratingintegrating the data withthe data with patient valuespatient values andand clinical expertiseclinical expertise.. 5.5. Storing the data andStoring the data and evaluating performanceevaluating performance of steps 1-of steps 1- 4 for continuous quality improvement4 for continuous quality improvement * We emphasize step 2 in this brief presentation
    6. 6. The Well-Built Clinical QuestionThe Well-Built Clinical Question Includes the following (P.I.C.O.):Includes the following (P.I.C.O.): 1.1. AA PPatient or populationatient or population 2.2. AnAn IIntervention or “exposure”ntervention or “exposure” 3.3. AA CComparison intervention (if appropriate)omparison intervention (if appropriate) 4.4. A clinicalA clinical OOutcome (diagnosis/screening, prognosis,utcome (diagnosis/screening, prognosis, therapy, event, harm, or prevention)therapy, event, harm, or prevention)
    7. 7. Well-Built Clinical Question (WBCQ) – anWell-Built Clinical Question (WBCQ) – an ExampleExample ““In a 22 year old woman with mild non-In a 22 year old woman with mild non- comedonal acne (Patient), does monthly use ofcomedonal acne (Patient), does monthly use of salicylic acid (Intervention) or benzoyl peroxidesalicylic acid (Intervention) or benzoyl peroxide (Comparison) prevent more acneiform lesions(Comparison) prevent more acneiform lesions from developing (Outcome)?” Resources tofrom developing (Outcome)?” Resources to facilitate WBCQ’sfacilitate WBCQ’s
    8. 8. The WBCQ- ResourcesThe WBCQ- Resources Anatomy of a well-built clinical questionAnatomy of a well-built clinical question (University of Sheffield)(University of Sheffield) ContstructContstruct a well-built clinical question using PICOa well-built clinical question using PICO (University of(University of Washington)Washington) Further reading on well-built clinical questionFurther reading on well-built clinical question, from University of, from University of Medicine and Denistry of New Jersey.Medicine and Denistry of New Jersey. Sackett et. al (see References)Sackett et. al (see References) When you have created your well-built clinical question, considerWhen you have created your well-built clinical question, consider using this as the basis for contributing ausing this as the basis for contributing a Critically Appraised TopicCritically Appraised Topic toto ebderm.org, which is a practice-based learning tool for conducingebderm.org, which is a practice-based learning tool for conducing evidence-based searches and evaluations.evidence-based searches and evaluations.
    9. 9. What Kind of Study to Answer myWhat Kind of Study to Answer my Question?Question? Keep in mind theKeep in mind the Hierarchy of EvidenceHierarchy of Evidence:: – Systematic review of RCTs > RCT>Cohort>x-Systematic review of RCTs > RCT>Cohort>x- sectional >case report> anecdote (“sectional >case report> anecdote (“rule of thumb”rule of thumb”)) – HoweverHowever, a good observational study beats a poorly, a good observational study beats a poorly conducted Randomized Controlled Trial (RCT).conducted Randomized Controlled Trial (RCT). Also, the best design varies by the question:Also, the best design varies by the question: – Prognosis, harm: Cross Sectional orPrognosis, harm: Cross Sectional or Cohort StudyCohort Study – Natural history, Diagnosis: Cohort StudyNatural history, Diagnosis: Cohort Study – Therapy & prevention, other interventions: RCT’sTherapy & prevention, other interventions: RCT’s
    10. 10. Critically Examine All SourcesCritically Examine All Sources Foundation is epidemiology and biostatisticsFoundation is epidemiology and biostatistics – Is this study important?Is this study important? – Is this study valid?Is this study valid? – Does this study apply to my patient population?Does this study apply to my patient population? Learn Critical Appraisal Skills (Learn Critical Appraisal Skills (freefree):): – Synopsis of JAMA review of EBMSynopsis of JAMA review of EBM – University of Alberta EBM ToolkitUniversity of Alberta EBM Toolkit – Basic Biostatistics 1Basic Biostatistics 1 andand Basic Biostatistics 2Basic Biostatistics 2 (BMJ)(BMJ)
    11. 11. Seeking the Evidence (overview)Seeking the Evidence (overview) Evidence-Based Resources:Evidence-Based Resources: 1.1. Evidence-Based Systematic Review DatabasesEvidence-Based Systematic Review Databases 2.2. Secondary journalsSecondary journals 3.3. EBM textbooks and guidelinesEBM textbooks and guidelines 4.4. Medline / electronic databasesMedline / electronic databases Consult Medline first for very latest researchConsult Medline first for very latest research
    12. 12. What About Consulting Colleagues andWhat About Consulting Colleagues and Experts??...Experts??... Image source:Image source: http://www.askanexpert.com/http://www.askanexpert.com/
    13. 13. LeastLeast Reliable Sources of EvidenceReliable Sources of Evidence Colleagues, experts, & “throw-away” journalsColleagues, experts, & “throw-away” journals – Convenient and fastConvenient and fast – Often invalid , incomplete, and biased informationOften invalid , incomplete, and biased information Textbooks (usually)Textbooks (usually) – Generally not systematically researchedGenerally not systematically researched – Usually based on “expert opinion”Usually based on “expert opinion” – Most are out of date - check for recent citationsMost are out of date - check for recent citations – GreatGreat exception (explicit protocols):exception (explicit protocols):
    14. 14. 1. Evidence-Based Systematic Review1. Evidence-Based Systematic Review DatabasesDatabases TraditionalTraditional narrative reviewsnarrative reviews are often expert-based,are often expert-based, biased, and incomplete (unreliable).biased, and incomplete (unreliable). Systematic reviewsSystematic reviews are characterized by:are characterized by: – Clear and focused study questionClear and focused study question – Explicit definition of study criteria to be includedExplicit definition of study criteria to be included – A priori protocol for collating the evidenceA priori protocol for collating the evidence – Exhaustive search, including“hand-searching” andExhaustive search, including“hand-searching” and unpublished studiesunpublished studies – Explicit or implicit factoring of study qualityExplicit or implicit factoring of study quality Most comprehensive resource for therapy Q’sMost comprehensive resource for therapy Q’s
    15. 15. Systematic Review DatabasesSystematic Review Databases The Cochrane LibraryThe Cochrane Library :: – Best source for structured,Best source for structured, systematicsystematic reviewsreviews – Explicit search & quality criteria (Explicit search & quality criteria (free abstracts)free abstracts) Database of Abstracts of Reviews of EffectivenessDatabase of Abstracts of Reviews of Effectiveness (DARE)(DARE) – Structured abstracts of systematic reviews meeting highestStructured abstracts of systematic reviews meeting highest quality standardsquality standards – A (A (freefree) part of the Cochrane Library) part of the Cochrane Library Evidence-Based Medicine ReviewsEvidence-Based Medicine Reviews (EBMR) integrates(EBMR) integrates the above with secondary journal content:the above with secondary journal content: – ACP Journal ClubACP Journal Club // Best EvidenceBest Evidence – Medline searching and some full-text journals.Medline searching and some full-text journals.
    16. 16. 2. Secondary Journals2. Secondary Journals Evidence-Based “secondary journals” provide structuredEvidence-Based “secondary journals” provide structured abstracts with balanced commentaryabstracts with balanced commentary Selected from high quality publicationsSelected from high quality publications Can be best resource to start with when investigatingCan be best resource to start with when investigating rarerare clinical conditions (saves time).clinical conditions (saves time). E.g.’s-E.g.’s- – Evidence-Based MedicineEvidence-Based Medicine,, ACP Journal ClubACP Journal Club (free)(free) – Specialty-specific resources:Specialty-specific resources: Evidence-Based DermatologyEvidence-Based Dermatology section ofsection of Archives of DermatologyArchives of Dermatology – BandolierBandolier (free)(free) brief EBM summaries of summariesbrief EBM summaries of summaries Journal Watch DermatologyJournal Watch Dermatology,, a product of the publishers ofa product of the publishers of the New England Journal of Medicine, provides monththe New England Journal of Medicine, provides month summaries with expert commentary for 13-15summaries with expert commentary for 13-15 manuscripts.manuscripts.
    17. 17. 3. EBM Textbooks3. EBM Textbooks Most efficient source for simple clinical queries, butMost efficient source for simple clinical queries, but most quickly outdatedmost quickly outdated – Evidence-Based DermatologyEvidence-Based Dermatology the definitive book on evidence-basedthe definitive book on evidence-based dermatology (dermatology (link to reviewlink to review).). – Clinical EvidenceClinical Evidence, by BMJ Publishing Group and ACP, meets the highest, by BMJ Publishing Group and ACP, meets the highest evidence-based medicine standards.evidence-based medicine standards. – UpToDateUpToDate meets a high standard of evidence-based content andmeets a high standard of evidence-based content and periodically updated.periodically updated. – ACP MedicineACP Medicine, developed from, developed from WebMD Scientific American® MedicineWebMD Scientific American® Medicine available online by subscription.available online by subscription.
    18. 18. Evidence-Based GuidelinesEvidence-Based Guidelines The best sources rate theThe best sources rate the strengthstrength of evidenceof evidence Always consider external validity toAlways consider external validity to youryour patientpatient – TheThe National Guideline ClearinghouseNational Guideline Clearinghouse is the most well known of the highis the most well known of the high quality clinical guideline databasesquality clinical guideline databases (free).(free). – TheThe Guide to Clinical Preventative ServicesGuide to Clinical Preventative Services includes the latest clinicalincludes the latest clinical prevention recommendations by theprevention recommendations by the U.S. Preventive Services Task ForceU.S. Preventive Services Task Force ((freefree)) – TheThe UK National Electronic Library for Health GuidelinesUK National Electronic Library for Health Guidelines has over 2000has over 2000 guidelines produced in the United KIngdom (guidelines produced in the United KIngdom (freefree).). – TheThe Guidelines International NetworkGuidelines International Network permits guideline searches with apermits guideline searches with a more international focus with membership.more international focus with membership. – For skin-related guideilnes developed through by two large dermatologyFor skin-related guideilnes developed through by two large dermatology associations, you can visit theassociations, you can visit the American Academy of DermatologyAmerican Academy of Dermatology guidelines and theguidelines and the British Association of DermatologistsBritish Association of Dermatologists guidelines.guidelines.
    19. 19. 4. Medline4. Medline If the Cochrane Library has not addressed our question, next tryIf the Cochrane Library has not addressed our question, next try Medline…Medline… The largest biomedical literature database,The largest biomedical literature database, butbut:: – Misses some journal articles, misclassifies othersMisses some journal articles, misclassifies others – Can be overwhelming if not searchingCan be overwhelming if not searching selectivelyselectively PubMedPubMed is a free Medline service with Boolean and otheris a free Medline service with Boolean and other search capabilities.search capabilities. Sample PubMed queries can be found atSample PubMed queries can be found at Sample Clinical QuerySample Clinical Query (from the New York Academy of Medicine)(from the New York Academy of Medicine) (free)(free) Clinical query filterClinical query filter facilitates clinical searchesfacilitates clinical searches Medline searching tipsMedline searching tips from the New York Academy of Medicinefrom the New York Academy of Medicine helps you take advantage of the power of Medlinehelps you take advantage of the power of Medline (free)(free)
    20. 20. Meta-Search EnginesMeta-Search Engines Permit integrated multi-source searchesPermit integrated multi-source searches – Evidence Based Medicine ReviewsEvidence Based Medicine Reviews, by Ovid:, by Ovid: searches Cochrane, DARE, ACP Journal Club, andsearches Cochrane, DARE, ACP Journal Club, and Medline.Medline. – Tripdatabase: Cochrane Library, DARE, the NationalTripdatabase: Cochrane Library, DARE, the National Guideline Clearinghouse, clinical questions answeringGuideline Clearinghouse, clinical questions answering services, online books, and Medlineservices, online books, and Medline Quality more variableQuality more variable – SUMSearch: Cochrane, National GuideSUMSearch: Cochrane, National Guide Clearinghouse and other sourcesClearinghouse and other sources Incorporates data quality in results.Incorporates data quality in results.
    21. 21. Critically Appraised Topics (CATs)Critically Appraised Topics (CATs) Practice-based learning of EBMPractice-based learning of EBM Results vary by author, sourceResults vary by author, source – Ebderm.org will host anEbderm.org will host an international CAT bankinternational CAT bank specific to skinspecific to skin disease.disease. – Spanish Language dermatology CAT bank available atSpanish Language dermatology CAT bank available at dermatoscopiodermatoscopio..clcl – BestBetsBestBets – The CAT BankThe CAT Bank – CAT CrawlerCAT Crawler is a search engine for CATs fromis a search engine for CATs from multiplemultiple sources,sources, but currently does not search ebderm.org or dermatoscopio.clbut currently does not search ebderm.org or dermatoscopio.cl for skin-related CATs.for skin-related CATs.
    22. 22. Information ManagementInformation Management UseUse Science Citation IndexScience Citation Index to search forto search for newernewer articles that cited an older classic paper of interest.articles that cited an older classic paper of interest. EMBASEEMBASE is a Medline alternativeis a Medline alternative – More extensive European journal representationMore extensive European journal representation – Wider array of health science disciplines representedWider array of health science disciplines represented Invest in a citation manager program such asInvest in a citation manager program such as EndNoteEndNote:: – Download abstracts from MedlineDownload abstracts from Medline – Label abstracts for quick searches laterLabel abstracts for quick searches later – Effortless reference resortingEffortless reference resorting
    23. 23. Guidelines for ReadingGuidelines for Reading Choose 2-3 gold standard journals relevant toChoose 2-3 gold standard journals relevant to your patients for weekly readingyour patients for weekly reading Devote weeklyDevote weekly protected timeprotected time for readingfor reading Subscribe to e-mail TOC’s of 1-3 otherSubscribe to e-mail TOC’s of 1-3 other high quality journalshigh quality journals (e.g.(e.g. LancetLancet,, JAMAJAMA).). Consider specialty-specific services:Consider specialty-specific services: – DermlinxDermlinx ((www.mdlinx.comwww.mdlinx.com)) – Medscape DermatologyMedscape Dermatology ((www.medscape.comwww.medscape.com))
    24. 24. Selected Comprehensive Web-Based EBDSelected Comprehensive Web-Based EBD ResourcesResources Evidence-Based DermatologyEvidence-Based Dermatology Centre for Evidence-Based DermatologyCentre for Evidence-Based Dermatology Netting the EvidenceNetting the Evidence Centre For Evidence Based MedicineCentre For Evidence Based Medicine Evidence-Based Medicine Resource CenterEvidence-Based Medicine Resource Center
    25. 25. Some Final SuggestionsSome Final Suggestions The most effective way to learn evidence-The most effective way to learn evidence- based dermatology is to practice it:based dermatology is to practice it: – Consider creating a Critically Appraised Topic (Consider creating a Critically Appraised Topic ( CATCAT) on) on ebdermebderm.org.org Consider joiningConsider joining IDEAIDEA (International(International DermatoEpidemiology Network)DermatoEpidemiology Network) Get involved with theGet involved with the Cochrane Skin GroupCochrane Skin Group
    26. 26. Distribution StatementDistribution Statement You may distribute freely, provided thatYou may distribute freely, provided that this presentation is preserved in itsthis presentation is preserved in its entirety without changesentirety without changes Questions / comments:Questions / comments: – David A. Barzilai, MD PhD (skinresearch.org)David A. Barzilai, MD PhD (skinresearch.org) – For presentation updates see:For presentation updates see: ebderm.orgebderm.org
    27. 27. ReferencesReferences Arndt KA: Information excess in medicine. Overview, relevance toArndt KA: Information excess in medicine. Overview, relevance to dermatology, and strategies for coping.dermatology, and strategies for coping. Arch DermatolArch Dermatol 128:1249-1256, 1992128:1249-1256, 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].[CME Review]. Bigby M: Evidence-based medicine in dermatology.Bigby M: Evidence-based medicine in dermatology. Dermatol ClinDermatol Clin 18:261-18:261- 276, 2000 (much like the above – choose one)276, 2000 (much like the above – choose one) The Challenge of Dermato-epidemiology by Hywell Williams (Book)The Challenge of Dermato-epidemiology by Hywell Williams (Book) Cook DJ, Meade MO, Fink MP: How to keep up with the critical careCook DJ, Meade MO, Fink MP: How to keep up with the critical care literature and avoid being buried alive.literature and avoid being buried alive. Crit Care MedCrit Care Med 24:1757-1768, 199624:1757-1768, 1996 Evidence-Based Medicine:Evidence-Based Medicine: How to Practice and Teach EBMHow to Practice and Teach EBM by Davidby David SackettSackett How to Read a Paper: The Basics of evidence based medicineHow to Read a Paper: The Basics of evidence based medicine by Trishaby Trisha GreenhalghGreenhalgh Studying a Study and Testing a TestStudying a Study and Testing a Test by Richard Riegelman and Robertby Richard Riegelman and Robert HirschHirsch

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