Intro to Evidence Based Medicine Resources

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Intro to Evidence Based Medicine Resources

• Nancy Clark
• FSU College of Medicine

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Objectives

• Students will
• Formulate a clinical question
• Identify and utilize EBM online resources to
  answer their questions
• EBM Databases
• Guidelines
• Apply rules for levels of evidence to make
  clinical decisions

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Assessment

• Triple Jump Exam, 2nd yr
• Have a simulated patient or paper case
• Go to your computer, the web or your Palm for
  pertinent information
• Present patient and information collected to
  attending

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The EBM Process
EMB LLL
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The EBM Process
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Types of Questions

• Therapy/prevention Question
• Prognosis Question
• Diagnosis Question
• Harm Question

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Elements of a Good Question

• Who?
• What?
• Alternately?
• Outcome?

• Write the question
• Type of question?
• Type of Study?

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Summary
http//www.hsl.unc.edu/lm/ebm/Supplements/Question
Supplement.htm
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Evidence Pyramid
Type of Study



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Levels of Evidence

• Level 1 Randomized Clinical Trials
• Level 2 Head to Head Trial or
  Systematic Review of Cohort Studies
• Level 3 Case-Control Studies
• Level 4 Case-series
• Level 5 Expert Opinion

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Levels of Evidence

• Level 1 Highest
• Level 2
• Level 3
• Level 4
• Level 5 Lowestbut still evidence

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Purpose-specific resources

• CDC Travel
• Drug information resources
• Patient Education handouts
• Diagnostic Testing ARUP
• Medical Search engines
• Textbooks
• Journals

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EBM Databases

• Systematic Literature Searches
• Cochrane Library (OVID)
• Clinical Evidence
• Systematic Literature Surveillance
• ACP Journal Club (OVID)
• DARE
• DynaMed
• Medical InfoRetriever
• EMB Search Engine
• TRIP Database

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Today

• National Guidelines Clearinghouse (AHRQ)
• Cochrane
• ACP Journal Club
• Dynamed
• First Consult
• InfoRetriever

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Guidelines

• What is a guideline?
• Guidelines may be
• Explicit evidence-based
• Evidence-based
• Research-based (highly referenced)
• Opinion-based
• expert consensus

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Guidelines

• National Guideline Clearinghouse
• Primary Care Clinical Practice Guidelines
• Agency/Association sites
• AAFP
• APA
• AAP

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Cochrane Library

• The current resource with the highest
  methodological rigor
• For each clinical question, all of the English
  literature meticulously searched for randomized
  trials
• Large systematic reviews with valid methods
  collaborative effort
• Conclusions are based on all the evidence from
  valid randomized trials

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Cochrane Library

• Included in OVID subscription
• Limitations
• limited to English
• only addresses questions amenable to randomized
  trials
• most of medicine has not been studied enough to
  allow for conclusions
• 235/year or abstracts only

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ACP Journal Club

• About 100 journals systematically surveyed
• Highest-validity articles abstracted
• Structured abstracts to guide critical appraisal
• Clinical commentary
• Included in our OVID subscription

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ACP Journal Club

• Limitations
• individual article summaries may not account for
  the big picture
• may have to read multiple items
• No control over what is covered
• 78/year ?

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DynaMed

• Designed as entry point to information
• Textbooks and Medline not efficient
• Intuitive clinical organization
• Brief summarized information presented
• Links and references if more details needed
• ICD-9 codes and links to patient information
  handouts

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DynaMed format

• Description
• Etiology
• Increased Risks
• Associated Conditions
• Complications
• History (cc, HPI, etc.)
• Physical
• Diagnostic (including Rule out, Tests to order)

• Prognosis
• Treatment
• Prevention
• Screening
• References
• Patient Information

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DynaMed Sources

• 18 primary journals e.g. BMJ, JAMA, Lancet,
  NEJM, Pediatrics
• 12 secondary literature sources e.g.
  Alternative Therapies, ACP Journal Club, Cochrane
  Library, InfoPOEMs
• 4 drug info sources e.g. The Medical Letter,
  FDA MedWatch

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DynaMed

• Limitations
• variable quality
• areas with a lot of research can get hard to
  navigate
• 200/year or effort

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First Consult/PDxMD

• By MDConsult
• Differential Diagnosis
• Disease Information
• Patient Education Handouts

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PDxMD
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Medical InfoRetriever

• 104 journals surveyed for Evidence-Based Practice
  Newsletter
• Over 1300 article synopses/ POEMS
• Cochrane abstracts
• Selected evidence-based guidelines
• Basic drug info
• Clinical calculators/prediction rules

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Symbols
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InfoRetriever

• Comes in web, desktop and PDA versions
• Limitations
• individual article summaries may not account for
  the big picture
• may have to read multiple items
• 249/year
• Optimized for use with Internet Explorer 5.x or
  Netscape 6.x

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Hands-On Experience