Session I: Evidence Based Medicine and a PICO Clinical
Question:
Medical Library & Peyton T. Anderson Learning Resources
CenterMacon, GA
[email protected]
Memorial University Medical CenterHealth Sciences
LibrarySavannah, GA [email protected] 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. When
making evidence-based decisions for patient care, it is essential
to select the highest level research design available for the
specific question of interest.
Weve assigned the Medical Librarys resources were talking about
today to the pyramid. As you can see, Cochrane Library and PubMed
Systematic Reviews top the pyramid.
CDC resources, Dynamed, Healthy People 2020, and National
Guideline Clearinghouse sit just under the top of the pyramid. And
towards the bottom youll find other types of research, including
Randomized Controlled Trials, Cohort Studies, Case Series, and
Expert Opinions. There will be far more of this research.11Levels
of Evidence (LOE):Rules of evidence have been established to grade
evidence according to its strength
Several dozen of these hierarchies exist
Some systems comprise three levels and others eight or more
Levels of Evidence is a ranking system used in evidence-based
practices to describe the strength of the results measured in a
clinical trial or research study. The design of the study (such as
a case report for an individual patient or a double-blinded
randomized controlled trial) and the endpoints measured (such as
survival or quality of life) affect the strength of the
evidence.
There are multiple Levels of Evidence hierarchies, many ranging
from Level or Grade I through Level/Grade IV. Grade I levels
include Systematic Reviews and Meta Analyses. The lower the level
number, the higher quality the research is. For example, Level I or
Level II studies would be more reliable than a Level IV study.
You are going to see references of these evidence levels in the
resources you12Group Assignmenthttp://med.mercer.edu/lib/Group 1:
DynamedGroup 2: Cochrane Database of Systematic ReviewsGroup 3:
National Guideline Clearinghouse
10 minutes prep, 5 minutes per group for presentations
Things to consider while searching:Where is the information
coming from? Is the source reliable?How current is the information?
When was it last updated?What level(s) of evidence does this
resource contain?How is the information presented? Would it be
useful as a point-of-care resource?Was it easy to search for/find
the information?What did you particularly like/dislike about the
resource?
Break into 3 groups. Use your assigned resource to try and
answer your PICO. You will need to access these resources by first
logging onto the library site. While searching your resource,
consider: these points [listed on slide]13Your 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?
Heres a reminder of your patient.
HIV negative. No known allergies (NKA). Syphilis is
secondary.14Group Reports
15
What is Dynamed?Dynamed is a clinical reference tool created by
physicians for physicians and other health care professionals for
use at the point-of-care. Includes clinically -organized summaries
for more than 3,200 topics
Site features?16Dynamed:Point-of-care medical information
databaseIncludes content of 3,200+ clinical evidence-based
topicsDraws from 500+ medical journals Eacharticle is evaluated for
clinical relevance and scientific validityConclusions based on
evidence systematically identified, selected and evaluated from the
literatureUpdated dailyPeer reviewedLevels of evidence included in
descending orderSome take away points from Dynamed: [listed on
slide]17
What is Cochrane?Cochrane Library is a collection of several
databases. The core of the collection are the Cochrane Reviews
which are a collection of systematic reviews and meta-analyses
which summarize and interpret the medical research. Systematic
Reviews are the top tier of information (remember our Evidence
Pyramid?) and the gold standard of medical information.
Search = congenital syphilis One result in Cochrane Reviews.
Site features?Updated dailyFull article vs summaryView when last
reviewed18Cochrane Systematic Reviews:Part of the Cochrane Library,
a collection of 6 EBM databasesMethodology considered to be the
gold standard for systematic reviewsReviews address specific
questions about the effects of clinical interventions, including
treatments, prevention, screening and rehabilitation. Meta-analysis
may be performed.Full-text and plain language summaries
availableUpdated dailyAbstracts can also be found in other
resources (i.e. PubMed, DynaMed, etc.)Some take away points from
Cochrane Reviews: [listed on slide]19
What is NGC?NGC is an initiative of theAgency for Healthcare
Research and Quality (AHRQ). The NGC mission is to provide
physicians and other health professionals, health care providers,
health plans, integrated delivery systems, purchasers, and others
an accessible mechanism for obtaining objective, detailed
information on clinical practice guidelines and to further their
dissemination, implementation, and use.
Search congenital syphilis or pregnant syphilis
Site features?guideline syntheses20National Guideline
Clearinghouse:Initiative of the Agency for Healthcare Research and
Quality (AHRQ)Includes evidence-based clinical practice
guidelinesProvides a mechanism for obtaining objective, detailed
information on recommendations for practiceExpert commentaries
includedGuideline Syntheses address similar topic areasFull-text
and summaries availableAbility to compare two or more guidelines
side-by-sideSome take away points from National Guideline
Clearinghouse: [see slide]21PubMed Basics:Searching PubMed at
Mercer
22SYPHILIS ORPREGNANCY=
Syphilis AND PregnancySyphilis OR PregnancyBoolean
TermsSyphilisPregnancySyphilisPregnancy23Searching PubMed at
Mercer
You already know (we hope!) how to find the library at
med.mercer.edu/libraryWhy do you need to access PubMed from our
link? Because the National Library of Medicine has assigned us a
special URL to flag the journals we pay for. Your Mercer pw + our
link = more full text articles!24
Here are 5 important places on the PubMed main page: Advanced,
Single Citation Matcher, Clinical Queries, Topic-Specific Queries,
and MeSH Database.Weve entered Syphilis AND Pregnancy as a search.
Here we go!25
The left channel has some important filters to narrow your
search. Publication dates, Species, and Languages are pretty
standard choices. Then click Display Settings to choose Abstract,
then Apply for more helpful features.26
The Abstract view will give you a summary, and often youll see
icons that lead you to full text. Look for the Get it @ MUSM icon!
Related Citations will do your work for you, fetching other
articles like this one. It works because each article has been
assigned MeSH terms: Medical Subject Headings. The robot fetches
articles similarly indexed.27
Notice, we marked articles #2 and #3 and now we can Choose
Destination to add them to the Clipboard or E-mail them to
ourselves. Remember those helpful filters in the left channel.
28
Remember PubMeds front page? Well talk now about Clinical
Queries and Topic-Specific Queries, where youll find Healthy People
2020.29
Clicking Topic-Specific Queries takes you to this page. Lets
look first at Clinical Queries. This feature lets you find
citations for specific clinical study category, systematic reviews,
meta-analyses, etc.30
Notice, we entered our search and the system found citations in
three areas: Clinical Study Categories, Systematic Reviews, and
Medical Genetics. Its showing us the first 5 in each
category.31
Had we clicked Topic-Specific Queries, then Healthy People
2020.32
Wed find queries already organized. So we picked STDs.33
STD-7 is a pre-done search. Well click the PubMed Search icon
for a list of results. Notice also that the nice folks at PubMed
have given us a link straight to the Healthy People 2020 website.
More about that in Session II!34
35
Got all that?
PubMed is brought to you by.Your tax dollars at work!36
