1. Lecture 3Finding the Answer for Your PICO Question? Dr. SohailBajammal October 3, 2011

2. Acknowledgment Some slides from Shaughnessy & Slawson’s “Information Mastery” Workshop Tufts University

3. Outline Review of the previous assignment PICO (POE & DOE) The category of your question will determine what type of study you would expect

4. Previous Assignment Background versus Foreground Questions PICO Questions MOST of you got it perfect Some had issues with the structure of the question This will affect your search strategy

5. Relevance: Type of Evidence POE: Patient-oriented evidence Mortality, morbidity, quality of life Live longer and/or better DOE: Disease-oriented evidence Pathophysiology, pharmacology, etiology Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.

6. Steps of Evidence-Based Dentistry ✔

9. Most of your questions Which is better to treat, drug A or drug B? Which is better to treat, oral or IV? Which is better to treat, chemo or radio?

10. Class Activity 10 minutes A group of 4 You are a group of researchers. You want to compare drug A with drug B in treating patients with tongue cancer to see which leads to better survival. How would you do that? Suggest a research design

11. Pyramid of Evidence http://servers.medlib.hscbklyn.edu/ebm/2100.htm

12. Case Report A descriptive study of one patient Detailed profile of a “rare” presentation or treatment Helpful in developing hypothesis to be tested later using analytic study

13. Case Series A descriptive study of multiple patients “Rare” phenomenon occurring multiple times Detailed profile of patients’ presentation and outcome Helpful in developing hypothesis

14. Disadvantages ofCase Report & Case Series Retrospective (looking back in time) Selection bias Recall bias Small sample size That’s why at the bottom of the pyramid

15. Case-Control Studies(for risk factors) Cases (e.g., Tongue Cancer) Shisha Smokers GO BACK IN TIME NOT Shisha Smokers Ask patients Read files Control (e.g., NO Tongue Cancer) Shisha Smokers GO BACK IN TIME NOT Shisha Smokers

16. Cohort Study Cohort: Roman word for “a group of soldiers that marched into battle together” A group of people followed up with time to see whether an outcome of interest develops Prospective or Retrospective

17. Prospective Cohort Drug A Die Early F/U Die Late Patients with Tongue Cancer Drug B Die Early F/U Die Late

18. Randomized Controlled Trial (RCT) Drug A F/U Outcomes Patients with Tongue Cancer RANDOM Drug B F/U Outcomes

19. Primary Sources Case report Case series Case-control Cohort Randomized controlled trial

20. Not all studies are good quality After you asked the PICO question You need to find the information Then, you need to “appraise” the quality of each relevant study you find

21. Where to search for evidence?

22. Searching for evidence Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

23. Searching for evidence Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

24. Searching for evidence Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

25. Searching for evidence Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

26. Searching for evidence Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

27. Searching for evidence Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

28. Systematic Review Ask a research question (PICO) Set up the studies inclusion & exclusion criteria Literature search: Systematically & thoroughly Keywords & MeSH terms Multiple databases & multiple sources Select the studies & assess their quality Summarize the findings Done in a pair

29. Meta-analysis All the previous steps Statistical pooling of the results of all studies

30. Searching for evidence Secondary Primary Case report, Case series, Case-Control, Cohort, Randomized Trial DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009

31. The Usefulness Equation Usefulness = Relevance x Validity of any source Work Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.

32. Relevance: Type of Evidence POE: Patient-oriented evidence mortality, morbidity, quality of life Live longer and/or better DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.

33. Validity The hard part of Information Mastery Technique: EBM working group Guyatt G, Rennie D, ed. Users’ guides to the medical literature. A manual for evidence-based clinical practice. Chicago: AMA, 2002. Did the researchers find what they think they found? Do the results apply to your patients? Self vs delegation- Take responsibility

34. Work Not all information sources are created equal Two type of information sources “Just-in-case” sources: high work “Just-in-time” sources: low work

35. Street Smart!

36. Coming weeks Next lecture on secondary sources (but the rest of your career) Rest of the course on primary sources and critical appraisal

37. Terms We Talked about Today POE versus DOE Primary Sources versus Secondary Sources Primary: Case report, Case series, Case-Control, Cohort Study, Randomized controlled trial Secondary: Systematic reviews, Synopses, Summary, Systems