Session I: Evidence Based Medicine and PICO Clinical Question

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Session I: Evidence Based Medicine and PICO Clinical Question. Medical Library & Peyton T. Anderson Learning Resources Center Macon, GA reference.ill@gain.mercer.edu Memorial University Medical Center Health Sciences Library Savannah, GA library@memorialhealth.com. - PowerPoint PPT Presentation

Text of Session I: Evidence Based Medicine and PICO Clinical Question

Session I: Evidence Based Medicine and a PICO Clinical Question:

Medical Library & Peyton T. Anderson Learning Resources CenterMacon, GA

reference.ill@gain.mercer.edu

Memorial University Medical CenterHealth Sciences LibrarySavannah, GA library@memorialhealth.comSession I: Evidence Based Medicine and PICO Clinical QuestionMercer University School of Medicine1Session I Objectives:Participants will:Identify key elements of the EBM process, including: formulating a clinical question locating the best evidence evaluating the evidence for validityDescribe the elements of a PICO clinical questionIdentify and locate online EBM resources

2Session I Objectives (Cont.):Work in groups to evaluate online EBM resources, including:DynamedCochrane Database of Systematic ReviewsNational Guideline ClearinghousePresent their group evaluations of the EBM resources to the classLearn the basic PubMed searches and also utilize advanced features of PubMed

3Your Patient:Shannon, a 19-year-old African American female, visits her local health clinic for her annual STD screening. Shannon is asymptomatic but tests positive for Syphilis. Testing also reveals Shannon is 3-weeks pregnant. She is concerned for the health of her baby. As a physician, what do you do to help Shannon and get her the treatment she needs?

Okay so youre working in a clinic and here is your patient. How would you go about finding the best information to treat your patient?

Shannon = HIV negative. No known allergies (NKA). Syphilis is secondary.4 What is Evidence-based Medicine (EBM)?

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett D, 1996)

Evidence-based medicine is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinicians cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)

The evidence, by itself, does not make the decision, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBM is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, and/or the etiology of disorders.

Evidence-Based Practice requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature. The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning in which caring for one's own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues. Instead of routinely reviewing the contents of dozens of journals for interesting articles, EBM suggests that you target your reading to issues related to specific patient problems. Developing clinical questions and then searching current databases may be a more productive way of keeping current with the literature.5Steps in the EBM Process:Use EBM resources to find evidenceEvaluate evidence for validityApply evidence to your patientFormulate a Clinical QuestionThere are 4 steps in the EBM process:

After assessing your patient, you will need to construct a well-built a clinical question (or a PICO question) based on the case. More on the details of PICO on the next slide.

2) The second step is using EBM resources to find evidence. You will need to select the appropriate resource(s) to review to conduct your search.

3) The third step of the EBM process involves evaluating and appraising the evidence you found for validity (i.e. closeness to the truth) and applicability (usefulness in clinical practice) to the patient.

4) The fourth step of the EBM process is when you apply the evidence to your patient.

6What is PICO?A PICO is a well-built clinical question that seeks a specific answer based on the best evidence available. A well-constructed and thoughtful question makes the search for evidence easier.

After evaluating your patient and have identified concerns or problems, you want to construct a question that is relevant to the case. You want your question to be phrased in such a way as to best facilitate finding an answer. Your question needs to identify the key problem of the patient, what treatment or tests you are considering for the patient, what alternative treatment or tests are being considered (if any), and what is the desired outcome to promote or avoid.

Next well show you the parts of PICO.7PICO =Patient or Population Sex, age, race? Primary complaint? DiseaseHistory?

Intervention What do you want to do for them? Prescribe a drug? Order a test?

Comparison What alternatives do you want to compare the intervention to?

Outcome What do you hope to accomplish, improve or affect? Relieve or reduce symptoms? Improve function or improve test scores?PICO is a mnemonic to help remember the 4 parts of developing your well-focused clinical question.

P = Patient or Population You want to identify the patients problem. Things to think about are: 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 gender, age or race of a patient might be relevant to the diagnosis or treatment of a disease.

I = Intervention - 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? Or what factor may influence the prognosis of the patient - age, co-existing problems, or previous exposure?

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 may not necessarily always have 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?8Our Patients PICO:P (atient) = 19-year-old African American female with secondary syphilis and in 1st trimester of pregnancy I (ntervention) = treatment with PenicillinC (omparison) = alternative treatmentsO (utcome) = a healthy pregnancy and delivery for mom and baby; prevention of congenital syphilis in baby

Shannons PICO: P = 19-year-old African American female with secondary syphilis and in 1st trimester of pregnancy. No history of medication allergy.I = treatment with PenicillinC = alternate treatmentsO = a healthy pregnancy and delivery for mom and baby and prevention of congenital syphilis in baby

This is the PICO we built and that you will use in a few minutes when you break out.9Locating the Best Evidence:Medical literature is immense

Only a small portion is immediately useful in answering clinical questions

Literature reports the whole spectrum of the scientific research process

So how do you determine what is the best evidence? Medical literature is immense. Research is being published daily yet not all of it is necessarily useful to you or applicable to answering your clinical question. An understanding of how various levels of evidence are reported and how this literature is organized will help the searcher retrieve the highest levels of evidence for a particular clinical question. High levels of evidence may not exist for all clinical questions because of the nature of medical problems and research and ethical limitations.10Pyramid of Evidence:

Some research designs provide a stronger level of evidence than others based on their inherent characteristics. This hierarchy is often shown graphically as a pyramid. The pyramid is an ideal shape for this graphic, as it represents the quality of research designs by level, as well as the quantity of each study design in the body of published literature.

Systematic reviews (higher quality), for instance, are the most time-intensive articles to write and are therefore rarer (lower in quantity) than other types of studies. Systematic Reviews provide a summary of the medical literature and use explicit methods to perform a comprehensive literature search and a critical appraisal of individual studies. Systematic reviews provide the strongest type of evidence, as the authors attempt to find all research on a topic, published and unpublished. The authors then combine the research into a single analysis. Keep in mind that systematic reviews are different than review articles. While systematic reviews are conducted to answer a specific clinical foreground question, review articles provide a broad overview on a topic to answer background questions.

Though finding research studies high on the pyramid is preferred, Evidence-Based Medicine may need to draw on research designs lower in the evidence pyramid. Occasionally nothing but case reports or even bench research may exist on a topic. Whe