Part 1 Introduction to EBM Lit Ser

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Information about Part 1 Introduction to EBM Lit Ser
Science-Technology

Published on March 1, 2014

Author: imadhassan

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Introduction to EBM Resources : Introduction to EBM Resources Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS Consultant Physician & Pulmonologist Chairman, Knowledge Translation Committee Department of Medicine KAMC Riyadh Kingdom of Saudi Arabia imadsahassan@gmail.com What is Evidence-based Medicine: What is Evidence-based Medicine “ Evidence-based medicine is the integration of: best available research evidence with clinical expertise and patient values ” Sackett , et al 2001 Three Pronged Approach: 3 Clinically relevant research, the literature Practitioner’s knowledge & experience Patient’s characteristics, preferences & values Three Pronged Approach 3 Integrates Evidence With: Integrates Evidence With Clinical expertise Experience Judgment Patient values and preferences Quality of life Costs Other important factors PowerPoint Presentation: Best Available Evidence Clinical Expertise Patient Values and Preferences Quality of Life Cost/ Availability What is Evidence-based Practice: What is Evidence-based Practice EBP is about asking questions and searching for answers in the body of medical research, and having found a likely source of information appraising the paper for its scientific validity and then applying the result to your problem. PowerPoint Presentation: Evidence-based Practice A sk clinical Questions A cquire the best evidence A ppraise the evidence A pply evidence to your patient 5A’s !! Assess effectiveness, efficiency of EBM process PowerPoint Presentation: Evidence-based Practice A sk clinical Questions: PICO A cquire the best evidence: Literature Searching A ppraise the evidence: Critical Appraisal A pply evidence to your patient: Knowledge Translation (Implementation) 5A’s !! Assess effectiveness, efficiency of EBM process Self-Education & Training in EBM: Self-Education & Training in EBM EBM Resources:  http://guides.mclibrary.duke.edu/content.php?pid=274373&sid=2262393 http://www.med.yale.edu/library/education/guides/feature/finditfast  CEBM Website:  http://www.youtube.com/user/cebmed , http://www.cebm.net/index.aspx?o=1965 YouTube: http://www.youtube.com/watch?v=odfo9CQGi0c Objectives : Objectives Why do Healthcare Professionals need to be competent in Literature Searching? Who should be competent in Literature Searching? Prerequisites for completing a successful Literature Searching exercise. PowerPoint Presentation: Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London 5,000? per day 1,400 per day 55 per day PowerPoint Presentation: The Decline in Knowledge and Patient Outcomes Competency in Literature Searching for Professionals:  Competency in Literature Searching for Professionals Dealing with the daily “challenge” to one’s knowledge. Life-long learning. Evidence-based practice Valuable employee. PowerPoint Presentation: For Whom? PowerPoint Presentation: Chairman Nursing Manager Resident Clinical Director Quality Nurse Competency in Literature Searching: For Whom?: Competency in Literature Searching: For Whom? Healthcare Professionals Including Policymakers etc Patients! Competency in Literature Searching for Patients:  Competency in Literature Searching for Patients For successful incorporation of: 1. Values and Preferences 2. Patient-centered Care The 6 Prerequisites for successful Literature Searching: The 6 Prerequisites for successful Literature Searching PowerPoint Presentation: Know how to use a computer/electronic device. Prerequisites for successful Literature Searching: Prerequisites for successful Literature Searching Know how to use a computer/electronic device. Computer Literacy Prerequisites for successful Literature Searching: Prerequisites for successful Literature Searching Know the Internet Jargon of Terms e.g. What is a Website? What is a Database? What is a Search Engine? What is a Meta-search Engine? PowerPoint Presentation: What is a Website? An internet site and an information resource on the World Wide Web. Websites may provide information on any topic. A collection of files that are arranged on the World Wide Web under a common address and allows retrieval via a browser . Examples: Pubmed, Yahoo, Guidelines Websites etc PowerPoint Presentation: What is a Database? A Database is an organized collection of information records that can be accessed electronically e.g. Medline (Pubmed), Cochrane etc PowerPoint Presentation: What is a Search Engine? A web-based computer-program that allows users to electronically search and retrieve specific information online. It searches documents and databases for specified keywords and returns a list of the documents where the keywords were found. Internet search engines help users find web pages on a given subject . General: e.g. Google, Yahoo etc Specialized: Google Scholar, Pubmed PowerPoint Presentation: What is a Meta-search Engine? A search engine that queries other search engines and then combines the results that are received from all. In effect , the user is not using just one search engine but a combination of many search engines at once to optimize Web searching . General: dogpile Specialized: TRIP, SumSearch . PowerPoint Presentation: “turning research into practice” Prerequisites for successful Literature Searching: Prerequisites for successful Literature Searching Know the EBM Jargon of Terms. PowerPoint Presentation: EBM Terminology Knowledge: Foreground/Background Types of Literature Articles: Primary (Original)/Secondary (Pre-appraised) Clinical Outcomes: Patient-oriented vs Disease Oriented Outcomes Reviews : Systematic/Non-systematic (Narrative ) CAT : Critically Appraised Topic Clinical Practice Guidelines Levels of Evidence: Hierarchy Pyramid Sources of Evidence: Point-of-care etc Knowledge Translation Resources PowerPoint Presentation: A sk clinical question Background /Foreground questions Background Question Asks for general knowledge about a disorder. Textbooks are good for answering background questions Foreground Question Asks for specific knowledge about managing patients with a disorder; consists of three or four components (PICO ): Diagnosis, Therapy, Prognosis etc Journal articles are good for answering foreground questions. Background versus Foreground Information: Background versus Foreground Information Case discussion: 27 year old woman with right lower quadrant (RLQ) abdominal pain Background information available from textbooks- What typically presents as RLQ pain What is the clinical course/complications of the different diagnoses Specifically, what is typical presentation of appendicitis Foreground information How good is a CT scan for appendicitis? PowerPoint Presentation: A sk clinical question novice expert Foreground questions Background question Types of Literature: Types of Literature Primary (Original) Secondary (Pre-appraised) Types of Literature: Types of Literature Primary (Original) Research publications e.g. in Pubmed Embase CINAHL PowerPoint Presentation:  The Pre-appraised Literature Pre-appraised = The Secondary Literature Useful for point-of-care searches Databases with pre-appraised evidence will give you the highest quality information in the shortest amount of time. Two types of pre-appraised databases Those with pre-appraised Synthesis of studies e.g. Guidelines and Systematic Reviews Those with pre-appraised Individual studies: Critically appraised Topics CATs Important Outcomes: Important Outcomes Patient Oriented Outcomes: PO Evidence outcomes patients actually care about Death (overall or disease-specific) Heart attacks, strokes, amputations, bed sores, broken hips, renal failure, etc. Ability to perform activities of daily living Versus Disease oriented outcomes: DO Evidence Biochemical, physiologic, pharmacologic, or laboratory measures Comparing DOE and POE: Comparing DOE and POE Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60. Example Disease-Oriented Evidence Patient-Oriented Evidence that Matters Comment Anti-arrhythmic Therapy Drug X  PVCs on ECG Drug X increases mortality POE contradicts DOE Type 2 Diabetes Aggressive Tx with insulin or oral agents can keep BS low Aggressive Tx does not reduce mortality or prevent most complications POE contradicts standard teaching Prostate Screening PSA screening detects prostate cancer early Does PSA screening  mortality? DOE exists, but POE is unknown PowerPoint Presentation: What is a Systematic Review? Systematic Reviews (SRs) Use a systematic methodology to identify, critically appraise, and synthesize relevant studies Individual studies assessed for validity Differ from traditional review articles (Narrative Reviews) in that conclusions are evidence-based rather than commentary What is a Systematic Review? Comparison Chart Systematic vs. Narrative Review: Comparison Chart Systematic vs. Narrative Review Systematic Review Article Review Article Narrow focus, answers foreground questions Broad focus, answers background questions Systematic scientific approach to finding, evaluating and summarizing the evidence Depends on the author’s inclination Comprehensive search for relevant articles Author gets to pick using any criteria Explicit methods of appraisal and synthesis Methods usually not specified Meta-analysis may be used to combine data Vote count or narrative summary PowerPoint Presentation: What is a Meta-analysis? Meta-analyses Uses studies from a Systematic Review and applies statistical techniques for combining quantitative data. A systematic review that uses quantitative methods to summarize the results. PowerPoint Presentation:  Evidence-based Practice Guidelines Systematically gather and “grade” evidence on a topic Developed by professional groups, government agencies, local practices etc PowerPoint Presentation: What is a Clinical Practice Guideline? Level of evidence/Grades of Recommendations: Level of evidence/Grades of Recommendations Ia II III IV V Oxford Centre of EBM Systematic reviews (meta-analyses) of RCTs Cohort studies Case-control-studies Case-series Expert opinion Grades of Recommendations Ib Randomized controlled trials Bias Bias Bias Bias Bias Bias Validity/Strength of Inference What is Critical Appraisal?: What is Critical Appraisal? Critical Appraisal: The process of assessing and interpreting the evidence by systematically considering its validity , results and relevance to the area of work considered. It answers 3 important questions: How well is this study performed? What does it show? Can I use it? PowerPoint Presentation: What is a Critically Appraisal Topic? A standardized one-page summary of the evidence. It consists of a declarative title , clinical bottom line , the clinical question (PICO ), search terms , a summary of the study methods, a table summarizing the key results and additional comments ( Sackett ). Critically-Appraised Topic (CAT): PowerPoint Presentation: What is the Best Evidence? Hierarchy of Levels of Evidence PowerPoint Presentation: What is a Randomised Controlled Trial? A group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables/outcomes of interest. Randomized Controlled Clinical Trial (RCT) Prerequisites for successful Literature Searching: Prerequisites for successful Literature Searching Know how to formulate your question. PowerPoint Presentation: Evidence-based Practice A sk clinical questions A cquire the best evidence A ppraise the evidence A pply evidence to Your patient 5A’s !! Assess effectiveness, efficiency of EBM process PowerPoint Presentation: Evidence-based Practice A sk clinical questions PICO Ask : Refine ability to convert need for information (e.g., therapy, prevention, diagnosis, prognosis) into an answerable question. PICO format for foreground questions. PowerPoint Presentation: A sk clinical question PowerPoint Presentation: Ask Clinical Questions: PICO Patient/ Population Outcome Intervention/ Exposure Comparison Components of Clinical Questions In patients with acute MI In post- menopausal women In women with suspected coronary disease does early treat- ment with a statin what is the accuracy of exercise ECHO does hormone replacement therapy compared to placebo compared to exercise ECG compared to no HRT decrease cardio- vascular mortality ? for diagnosing significant CAD? increase the risk of breast cancer? Prerequisites for successful Literature Searching: Prerequisites for successful Literature Searching Know where to go. PowerPoint Presentation: Evidence-based Practice Acquire the best evidence Literature Search Acquire: Select “best evidence” resources to answer clinical questions using criteria of: Validity – Can I trust the evidence? Relevance – Does the evidence apply to my patient? Time efficiency – Can I get the evidence fast? PowerPoint Presentation: Types of Resources Characteristics of a Good Resource: Characteristics of a Good Resource “Finding Evidence”: Sources : “Finding Evidence”: Sources Primary: PubMed , EmBase , Cinahl , Pyschlit Primary Resources: Primary Resources Primary Resources: Primary Resources “Finding Evidence”: Sources : “Finding Evidence”: Sources Secondary: Systematic Reviews: Cochrane Library, PubMed Guidelines websites: Guidelines Clearinghouse, Guidelines International Network CATS: BestBets , ACP Journal Club Point of Care: Clinical Evidence, EvidencePlus , UpToDate etc Secondary Resources: Secondary Resources Secondary Resources: Secondary Resources Secondary Resources: Secondary Resources “Finding Evidence”: Sources : “Finding Evidence”: Sources Tertiary resources (meta search engines, databases of databases): TRIP+ (Translating Research Into Practice) SumSearch Tertiary Resources: Tertiary Resources PowerPoint Presentation: Know what to do when you get there: the site’s technical language/know-how. PowerPoint Presentation: Resources For EBM Knowledge Translation DynaMed Essential Evidence Plus First Consult UpToDate Clinical Evidence ACP PIERS  Mc Master Plus: STAT REF BMJ Evidence Updates/ Alerts ACP Journal Club Open Clinical Dxplain Emergency Medicine on the Web Clinical Decision Making Calculators EBM toolbox CATmaker Evidence based medicine toolkit EBM Calculator National Guidelines Clearinghouse   NHS Evidence   ICSI Institute for Clinical Systems Improvements AHRQ Institute for Healthcare Improvement Knowledge Translation Clearinghouse NICE Advanced EBM Skills EBM Hunting Tools Types of Resources: Types of Resources Point of Care Clinical Resources/Decision Support Systems Up-Dates & New Evidence Evidence-Based Guidelines, Policies and Protocols Evidence-Based Quality Improvement Critical Appraisal Tools EBM Audiovisual Training Innovations Exchange for New Ideas of Care Portals to All PowerPoint Presentation: Resources For EBM Literature Searching PowerPoint Presentation: Resources For EBM Literature Searching PowerPoint Presentation: 2009 NCKUFM-YCY Systematic Review Cochrane reviews Evidence based journals EBM, EBN, EBMH, ACP J club Computerized Decision Support System (CDSS) 5S Information Resources: Information in top 4 are used Original articles: BMJUpdates, PubMed Clinical Queries Evidence based textbooks : UpTo Date, DynaMed , ACP PIER, BMJ Clinical Evidence Studies Syntheses Synopses Summaries Systems Haynes, R. (2006, November). Of studies, syntheses, synopses, summaries, and systems: the 5S evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8-A9. POCRaTs

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