CAGS Evidence Based Reviews in Surgery EBRS

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Evidence Based Reviews in Surgery A Joint
Program of The Canadian Association of General
Surgeons Lassociation Canadienne des Chirurgiens
Généraux and the American College of Surgery
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Evidence Based Medicine
The conscientious and judicious use of the best
current evidence from clinical care research in
the management of individual patients Sackett
et al
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Components of Evidence Based Medicine

• Produce the best evidence
• Disseminate and access the best evidence
• Critically appraise the best evidence
• Apply the best evidence to individual patients
• Audit ones own results

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Critical Appraisal Skills

• Skills that enable one to apply certain rules of
  evidence and the laws of logic to clinical
  investigative and published data in order to
  estimate their validity, reliability, credibility
  and utility
• Requires some knowledge of research design,
  statistics, economic analysis, decision analysis
  and clinical knowledge

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Issues

• Treatment effectiveness
• Natural history (prognosis)
• Causation / risk
• Measurement
• Diagnostic tests
• Early diagnosis / screening
• Practice guidelines, decision analysis, economic
  analysis, meta-analysis, outcomes studies

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Evidence Based Reviews in Surgery

• Internet based journal club designed to teach
  critical appraisal skills to practicing general
  surgeons and residents
• EBRS initiated by the Canadian Association of
  General Surgeons in 1999
• Interest in Canada in EBRS because
• critical appraisal skills must be taught as part
  of the residency curriculum
• RCPSC instituted the Maintenance of Certification
  Program

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Evidence Based Reviews in Surgery

• 8 packages per year
• Each package consists of the following
• clinical article
• methodological article
• clinical scenario
• questions stimulating evaluation of the
  methodology
• clinical and methodological critiques
• All articles and reviews available
  electronically

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October 2002 Topics Clinical Rectal Cancer
Methodological Treatment Effectiveness
Questions Related to Methodological and
Clinical Articles - October 2002 Articles Kaiteij
n E, Marijnen CAM, Nagtegaal ID, et al
Preoperative Radiotherapy Combined with Total
Mesorectal for Resectable Rectal Cancer. NEJM
2001 345(9) 638-46 Urschel JD, Goldsmith CH,
Tandan VR, Miller JD for the Evidence-Based
Surgery Working Group. Users' Guide to
Evidence-Based Surgery How to Use an Article
Evaluating Surgical Interventions. CJS 2001
44(2) 95-100 Reviewers Clinical - Dr. Terry
Phang UBC Methodological - Dr. Carole Richard
Univ. of Mont.
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Please read the above articles and be prepared to
discuss the following 1. What is the clinical
question being addressed? 2. Was the assignment
of patients to treatment randomized and
concealed? 3. Were all patients who entered the
trial properly accounted for? 4. Were patients,
their clinicians and study personnel blind to
treatment? 5. Were the groups similar at the
start of the trial? 6. Aside from the
experimental intervention, were the groups
treated equally? 7. How large and precise was
the treatment effect? 8. Were the study patients
similar to my patients? 9. Were the measured
outcomes clinically relevant? 10. Were all
clinically important outcomes considered? 11. Are
my surgical skills similar to those of the study
surgeons? 12. State the conclusion. Have the
authors addressed the question? 13. Does the
evidence support the conclusion?
The CAGS Evidence Based Reviews in Surgery is
supported by an unrestricted educational grant
from
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Clinical Scenario
A well informed 52 year old male presents with a
T2 rectal cancer. He questions the need for
radiotherapy because he has been on the internet
and learned that functional results are worse
following radiotherapy. What is your advice?
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Topics for 2005 - 2006
Methodological 1. Rx effectiveness 2. Q of
Life 3. Meta-analysis 4. Decision analysis 5.
Decision Aids 6. Teaching Surgical Procedures 7.
Prognosis 8. Equivalence
Clinical Hyperparathyroidism Laparoscopic
Colectomy Drains in GI surgery Diverticulitis Brea
st Cancer Breast Cancer Melanoma Occult
Pneumothorax



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Other Topics Covered in Past Years

• Decision analysis on bariatric surgery vs. diet
• FAST as a diagnostic tool in the trauma setting
• Management of CBD stones
• Practice Guidelines for gastric cancer, DCIS,
  splenic trauma in children
• Diagnostic tests MRCP, CT angiography,
  colonography
• Management of inguinal and ventral hernias

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Status of EBRS

• RCT which was designed to test whether this
  method of teaching critical appraisal skills to
  practicing general surgeons is effective
• 82 CAGS members participated
• Participants randomized to
• received clinical article only
• received EBRS packages (1 year)
• Outcome validated test assessing critical
  appraisal skills
• 70/82 surgeons completed the study
• Surgeons in the intervention group did
  significantly better than those in the control
  group on a valid critical appraisal test

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Status of EBRS

• Since 1999, EBRS has been made available to all
  general surgery training programs in Canada
• 13 of the 16 general surgery programs in Canada
  use it consistently for teaching critical
  appraisal skills as part of their Journal Club

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Current status of EBRS

• CAGS and the ACS signed an agreement in 2004 so
  EBRS is a joint project
• EBRS is now available to members of the ACS via
  the ACS website
• facs.org
• Click on Division of Education
• EBRS banner will come up
• password required

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Current status of EBRS

• Steering committee includes Canadian and American
  surgeons
• representatives from the Canadian Program
  Directors and APDS
• resident representatives from Canadian and
  American general surgery programs
• The administrative center is in Toronto
• administrative assistant is Marg McKenzie

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Current Status of EBRS

• Methodological reviews are completed by the
  Steering Committee members
• Clinical reviews are completed by Canadian and
  American experts
• Separate listserves with experts
• Main Cert and CME Credits are available to
  participants

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Current Status of EBRS

• EBRS has a library of approximately 50 past
  articles and reviews which may be accessed at any
  time using an index based on clinical and
  methodological topics
• Subscriptions to approximately 10 medical and
  surgical journals are maintained and may be
  accessed for personal use by members
• Reviews are published in the Canadian Journal of
  Surgery and Journal of the American College of
  Surgery (4 in each journal each year)
• To date, 18 articles have been published

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Evidence Based Reviews in Surgery

• EBRS is available for use by general surgery
  programs in the USA
• go to the ACS website and download articles and
  reviews
• contact our administrative assistant
  (mmckenzie_at_mtsinai.on.ca) to receive a package of
  materials for the academic year
• Format is left up to the programs
• part of existing journal club
• used exclusively in a journal club
• residents can review the material on their own

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Accessing EBRS

• Via the ACS website
• facs.org
• Click on Division of Education
• EBRS banner
• password required
• contact our administrative assistant Marg
  McKenzie (mmckenzie_at_mtsinai.on.ca) to receive a
  package of materials for the academic year
• Look for the EBRS booth in the Exhibit Area

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Evidence Based Reviews in Surgery

• EBRS is supported by an unrestricted educational
  grant from Ethicon Ethicon Endosurgery (Canada)
  and Ethicon and Ethicon Endosurgery (USA) and by
  the American College of Surgery
• EBRS is available at no cost to all members of
  CAGS and the ACS
• EBRS is available to all general surgery training
  program in Canada and the USA