THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Asking Clinical Questions and Finding an Evidence-Based Answer Daniel Van Durme, MD, MPH Chair, Dept. of Family Med and Rural Health Nancy Clark, MEd Director of Medical Informatics Education 2015-2016 1 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Objectives Distinguish a background question from a foreground clinical question Formulate an evidence-based, PICO formatted, foreground question Find evidence-based answers to your clinical questions
2015-2016 2 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE EBM A Multi-Step Process The patient 1. Start with the patient -- a clinical problem or question arises out of the care of the patient The question 2. Construct a well built clinical question derived from the case The resource 3. Select the appropriate resource(s) and conduct a search The evaluation 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) The patient
5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice Self-evaluation 6. Evaluate your performance with patient & process 2015-2016 3 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE The Question 2. Construct a well built clinical question derived from a case 2015-2016 4 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Background and Foreground Questions What do I know about this condition?
How common is it? Is it usually aggressive and rapidly fatal? How can it be treated surgery, chemotherapy, radiation? What about family history what about his sons risk? Etc. These are called background questions not suitable for PICO format Best source of information for background information? Recent reputable textbook, med app, Google search THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Foreground Questions - apply to that specific patient (or population)
What are my choices to best care for THIS patient? What is the best way to diagnose and treat this patient? What are the patients preferences and special considerations? Use PICO format for Foreground questions THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Constructing A Clinical Question P I C O patient intervention comparison
outcome Who? What? Alternative Intervention? Outcomes How would I describe a group of patients similar to this particular patient? 2015-2016 Which treatment, test or other intervention? What is the Compared to what patient oriented other treatment, test, outcome better
or perhaps compared prognosis? to doing nothing Higher rate of cure? Etc.? 7 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Examples P Kids with acute otitis media -2-4 y/o I Antibiotics Adult with microhematuria IVP Adult patients <70 TIA Healthy adolescents 2015-2016
Routine scoliosis screen C O No treatment except No pain after two acetaminophen days? for pain/fever Diagnostic accuracy (Predictive value or CT scan likelihood ratio) No TIA Rates of CVA within 90 days No screening Pain, disability, evaluate only if need for
problems intervention 8 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Types of Questions Best Answered by EBM Resource Therapy Question Prognosis Question In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis with MRI as predictive of healing as an audible pulse on Doppler examination? Diagnosis Question
In patients with migraine headaches without auras, are antiepileptics more effective than beta blockers for prophylaxis of headaches? In geriatric patients with suspected carotid stenosis, is duplex ultrasound as good as magnetic resonance angiography in detecting significant carotid stenosis? Harm Question 2015-2016 For pregnant patients, does the consumption of large amounts of coffee, (compared to non-coffee drinkers) increase the rate of spontaneous abortion? 9 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Question Worksheet P - Who? I - What? C- Alternatively?
Outcome? Type of Question Therapy Prognosis Diagnosis Harm/Etiology Screening Construct a clinical question from your own clinical experience. 2015-2016 10 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Acquire the Evidence 3. Select the appropriate resource(s) and conduct a search
2015-2016 11 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Major EBM Databases (Foraging Tools) Cochrane ACP Journal Club InfoPOEMS Evidence Based _____ USPSTF National Guidelines Clearinghouse 2015-2016 12 NLM: Drilling down for the Best Evidence
Based Information THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Start at the top and work your way down till you find what you need Cochrane Library Clinical Inquiries Usefulness Specialty-specific POEMs ACP Journal Club Textbooks, Guidelines Journals/ Medline PubMed Impractical and time consuming THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Web and Mobile Major Comprehensive EBM Tools Tools Cochrane
Essential Evidence +* Dynamed Plus Up-To-Date PEPID 2015-2016 ACP Journal Club Guidelines USPSTF LOE
Summaries and Clinical Inquiries * Mobile Formatted Websites 14 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Fastest Method to Answer Start with comprehensive resources:
Dynamed Plus Up-To-Date Essential Evidence Plus Search using terms in PICO question If no answerTrip, Pubmed or Google Scholar 2015-2016 Search the journals for the latest research articles on that question. 15 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE APPENDIX Descriptions of Major EBM Databases 2015-2016 16 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE 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 by Review Groups Conclusions are based on all the evidence from valid randomized trials (treatment and harm questions) Structured abstracts easy to digest Link to abstract 2015-2016 17 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE ACP Journal Club
About 130 internal medicine journals systematically surveyed Highest-validity articles abstracted. Link to article. Structured abstracts to guide critical appraisal Clinical commentary Now published in the Annals of Internal Medicine Alerts available (RSS feed) 2015-2016 18 THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
InfoPOEMS Patient Oriented Evidence that Matters Journal of Family Practice and other specialty journals Systematic surveillance of 100 journals Reviews of recent research articles linked to Pubmed Effect patient concerns morbidity, mortality, quality of life Included in Essential Evidence Plus Daily e-mail updates available Let us know if you would like to receive these Link to a Daily InfoPOEM 2015-2016 19
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Guidelines.gov Stored at National Guidelines Clearinghouse Agency for Healthcare Research and Quality Over 2365 Guidelines may be 2015-2016 Explicit evidence-based Evidence-based Research-based (highly referenced) expert consensus Multiple guidelines on one condition Link to guideline see Recommendations 20
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE US Preventive Services Task Force First convened by the U.S. Public Health Service in 1984 Since 1998 Agency for Healthcare Research and Quality Leading independent panel of private-sector experts in prevention and primary care Conducts rigorous, impartial assessments of the scientific evidence for effectiveness of broad range of clinical preventive services, including screening, counseling, and preventive medications Its recommendations considered "gold standard" for clinical preventive services Link to Online Tool 2015-2016 21
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE Trip Database Allows you to put in your PICO terms and search Pubmed, ClinicalTrials, Guidelines, as well as lower level online resource like eMedicine. Linked to Trip 2015-2016 22
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