EVIDENCE-BASED MEDICINE AT ST. BARNABAS HOSPITAL Hai Jung Helen Rhim, MD, MPHSt. Barnabas Hospital, Bronx, NY Director, Inpatient Pediatrics September

EVIDENCE-BASED MEDICINE AT ST. BARNABAS HOSPITALHai Jung Helen Rhim, MD, MPH St. Barnabas Hospital, Bronx, NY

Director, Inpatient Pediatrics September 24, 2009

Objectives

Define Evidence-Based Medicine (EBM) Discuss the need for and the benefits of EBM Present the Evidence-based Information Cycle Introduce the PICO format for clinical questions Decide what types of studies address the

question Determine which studies are most valid and

reliable Describe the new inpatient EBM curriculum Practice EBM format with a sample case

Questions for the Audience… Have you ever had a clinical question? Have you been able to find an answer every

time? Do you have a good & systematic way to

find it?

Don’t worry, you’re not alone.

It turns out that…

For every 10 patients seen, clinicians generate 0.7 to 18.5 questions1,2

66% of those questions are investigated but not resolved or never queried at all3,4

But almost all unanswered questions could be answered if only for a better system for searching2

Therefore we need a better system…

Evidence Based Medicine

We need…

What is Evidence-Based Medicine? EBM is:

"the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients"1

1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2.

What is EBM? (cont.)

The Practice of EBM is: “integrating individual clinical expertise

with the best available external clinical evidence from systematic research"1

is a method of solving clinical problems that stresses the examination of clinical research rather than relying on intuition and clinical experience alone2

1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2.2. Guyatt Gordon; Drummond Rennie. Users' guides to the medical literature : a manual for evidence-based clinical practice. Chicago: AMA Press; 2002. 706 p.

Decision Making in Clinical Practice

EBM is the practice of medicine in which the physician finds, assesses, and implements methods of diagnosis and treatment on the basis of the best available current research, their clinical expertise, and the needs and preferences of the patient. 3

3. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Why Do We Need EBM?

Need to keep up to date New discoveries everyday Must stay current with changing therapies

Life long learner Assessing the medical literature Curiosity/Self-directed learning

Teaching others Trainees/Students Patients

Clinical Questions

What are the Benefits of EBM? Recognizes that it is impossible to know

everything But you need to know how to find the

information if and when you need it4

“A detailed and exact knowledge of the outcomes of different interventions, derived from the research, can often save lives”4

“Offers the surest and most objective way to determine and maintain consistently high quality and safety standards in medical practice”5

4. http://library.downstate.edu/EBM2/intro.htm5. http://www.openclinical.org/ebm.html

So how do we do it?

Evidence-based Information Cycle

The

Five

A’s

www.cche.net

The 5 A’s

ASSESS clinical or policy problems and identify key issues;ASK well-built questions that can be answered using evidence-based resources;ACQUIRE evidence using selected, pre-appraised resources;APPRAISE the validity, importance and applicability of evidence that has been retrieved;APPLY evidence to clinical or policy problems.

www.cche.net

Identify an issue

Step 1: ASSESS

You are on rounds…

Presenting the H&P on a 3 month old baby who was admitted overnight with RSV+ bronchiolitis. The night float started the patient on oral steroids but is unsure if they are making a difference. You have noticed that not all patients with bronchiolitis get started on oral steroids…You mention this and your attending asks you to see what you can find in the literature in terms of efficacy of oral steroid therapy…

Now What???

Formulate a clinical question

Step 2: ASK

Formulating a Clinical Question It is CRITICAL to formulate a specific

question so that you don’t end up with 21,354 articles to evaluate! Makes the search for evidence easier Identifies the search terms needed to enter

into whichever searching service you choose

P I C O

How do we ask a specific question?

is your best friend for quick formulation of a clinical question

P for population

I for intervention

C for comparison

O for outcome

Formulating a Specific Question

P: Patient Population

(Patient/Condition) How would you describe a group of patients

similar to yours? What are the most important

characteristics of the patient? This may include the primary problem,

disease, or co-existing conditions Sometimes the sex, age or race of a patient

might be relevant to the diagnosis or treatment of a disease

http://www.umdnj.edu/camlbweb/ebm/picomodel.htm

I: Intervention

(Drug, Procedure, Diagnostic Test, Exposure) Which main intervention, prognostic factor, or

exposure are you considering? What do you want to do for the patient?

Prescribe a drug? Order a test? Order surgery? What factor may influence the prognosis of the

patient? Age? Co-existing problems? What was the patient exposed to? Lead?

Cigarette smoke?http://www.umdnj.edu/camlbweb/ebm/picomodel.htm

C: Comparison

What is the main alternative to compare with the intervention?

Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests?

Your clinical question does not always need a specific comparison


O: Outcome

What can you hope to accomplish, measure, improve or affect?

What are you trying to do for the patient? Relieve or eliminate the symptoms?

Reduce the number of adverse events? Improve function or test scores?


PICO Worksheet

P for population

I for intervention

C for comparison

O for outcome

Before starting a search…

Write down the answers to these PICO questions The key elements in the answers will become search

terms in your on-line search The additional information will help you when

analyzing the studies you find

Then it helps to form a clinical question from these PICO elements

Back to the case…

Presenting the H&P on a 3 month old baby who was admitted overnight with RSV+ bronchiolitis. The night float started the patient on oral steroids but is unsure if they are making a difference. You have noticed that not all patients with bronchiolitis get started on oral steroids…You mention this and your attending asks you to see what you can find in the literature in terms of efficacy of oral steroid therapy…

Your question is:

In otherwise healthy infants aged 0-2 years with RSV+ bronchiolitis, does the addition of oral steroid therapy to conventional supportive care decrease the length of hospitalization?

Go to the Literature

Step 3: ACQUIRE

Go to the Literature

MEDLINE

PubMedCochrane

CAT Banks

AAP.org

Guidelines.gov

TRIP Database

The Type of Question

Certain resources are better for particular questions It will determine which resources you use It will affect how you use it

It will influence the kind of answer you need

It will change the way you analyze the studies you find

Types of Questions

Diagnosis how to select and interpret diagnostic tests

Therapy how to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them

Prognosis how to estimate the patient's likely clinical course over time and anticipate likely complications of disease

Harm/Etiology how to identify causes for disease (including iatrogenic forms)

http://www.hsl.unc.edu/services/tutorials/ebm/Supplements/QuestionSupplement.htm

Which Study Design is the Best?

Type of Question Suggested best type of Study

Therapy RCT>cohort > case control > case series

Diagnosis prospective, blind comparison to a gold standard

Etiology/Harm RCT > cohort > case control > case series

Prognosis cohort study > case control > case series

Prevention RCT>cohort study > case control > case series

Clinical Exam prospective, blind comparison to gold standard

Cost economic analysis


Hierarchy of evidence

http://www.mclibrary.duke.edu/subject/ebm/ebmpyramid.html

Check for validity & applicability

Step 4: APPRAISE

Appraise

What are the results of the study? Are the results valid? Can I apply the results to my patient?

Search Strategy & Application

• Write out your clinical question

• Search Terms

• How else can you limit your search?

• Source of information

• Results/Discussion of findings

• References

• How will you use this information in your clinical practice?

Determine if you can use this newly acquired information in your clinical

practice

Step 5: APPLY

EBM during the Inpatient Rotation Senior residents (PL-3 & PL-2) will generate a

clinical question based on a patient admitted to the pediatric service during weeks 1-2 of the rotation

Senior residents will independently go to the literature to try to answer their clinical question

At the end of the block, senior residents will present their EBM exercise to the inpatient team

In the future, the presentation will be to the entire Pediatric Residency at a morning conference

EBM Worksheet

Summary

Clinicians are life long learners EBM is an important process in clinical

practice The key to an effective search is a

specific question PICO is a useful tool to help start the

process Go to the literature but use it effectively

References

1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2.

2. Guyatt Gordon; Drummond Rennie. Users' guides to the medical literature : a manual for evidence-based clinical practice. Chicago: AMA Press; 2002. 706 p.

3. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier. 4. http://library.downstate.edu/EBM2/intro.htm 5. http://www.openclinical.org/ebm.html 6. www.cche.net 7. http://www.umdnj.edu/camlbweb/ebm/picomodel.htm 8.


9. http://www.mclibrary.duke.edu/subject/ebm/ebmpyramid.html

Documents

EVIDENCE-BASED MEDICINE AT ST. BARNABAS HOSPITAL Hai Jung Helen Rhim, MD, MPHSt. Barnabas Hospital, Bronx, NY Director, Inpatient Pediatrics September