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If you teach him how to fish,If you teach him how to fish,
he will eat today …
If you give someone a fish,
he will eat every day…
Evidence –Based Medicine Evidence –Based Medicine Journal Club Journal Club
Prof. EIAD AL-FARISProf. EIAD AL-FARIS
Chairman, Department of Family and Community MedicineChairman, Department of Family and Community Medicine College of Medicine,King Saud UniversityCollege of Medicine,King Saud University
ContentsContents
1.1. Aims and ObjectivesAims and Objectives2.2. IntroductionIntroduction3.3. Definition of EBM.Definition of EBM.4.4. Steps For EBM Practice.Steps For EBM Practice.5.5. Well Built Clinical Questions.Well Built Clinical Questions.6.6. Identifying The EvidenceIdentifying The Evidence7.7. Search Strategy. Search Strategy. 8.8. ConclusionConclusion
Aims and ObjectivesAims and Objectives
What is EBM ?What is EBM ?
Integration of best research evidence with Integration of best research evidence with clinical experience & patient values.clinical experience & patient values.
Which database you are prescribed Which database you are prescribed to?to?
Pubmed Pubmed Cochrane LibraryCochrane Library Clinical EvidenceClinical Evidence Best EvidenceBest Evidence Bandolier Bandolier Therapeutic InitiativeTherapeutic Initiative Trip databaseTrip database GoogleGoogle
WHAT IS EBM ?WHAT IS EBM ?
The conscientious, explicit and The conscientious, explicit and judicious use of current judicious use of current best best evidenceevidence in making decisions about in making decisions about the care of individual patients.the care of individual patients.
DAVID SACKETT
Five steps process ?Five steps process ? Asking the right question.Asking the right question. Searching for information.Searching for information. Evaluating the evidence forEvaluating the evidence for
validity and usefulness. validity and usefulness.
Implement useful findings inImplement useful findings in clinical practiceclinical practice
Evaluate the whole processEvaluate the whole process
Step I.Step I.
Converting the need for Converting the need for information into a answerable information into a answerable question.question.
To answer a clinical question effectively, To answer a clinical question effectively, First, turn your scenarios into First, turn your scenarios into 'well-built' 'well-built' clinical Q.clinical Q.
Four domains:Four domains: PICOPICO
1) the 1) the ppatient (atient (pproblem)roblem)
2) the 2) the iintervention or exposure ntervention or exposure
3) the 3) the ccomparison (intervention)omparison (intervention)
4) the clinical 4) the clinical ooutcomesutcomes
For healthy adults is it For healthy adults is it worthwhile to give aspirin as worthwhile to give aspirin as
prophylaxis to reduce MI prophylaxis to reduce MI and or stroke ?and or stroke ?
Aspirin and Primary PreventionAspirin and Primary Prevention
1. 1. PPatient population.atient population.
2. 2. IIntervention.ntervention.
3. 3. CComparison omparison intervention.intervention.
4. 4. OOutcomes. utcomes.
Asymptomatic adults with no Asymptomatic adults with no risk factors risk factors
Aspirin Aspirin
PlaceboPlacebo
Incidence of CV eventsIncidence of CV events
““In asymptomatic adults no risk factors, would the In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular use of aspirin reduce the incidence of cardiovascular events?events?
Information management Information management PrinciplesPrinciples
Clinical ScenarioClinical Scenario
Ibrahim is a 30 years old teacher, he is known Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented to your case of allergic rhinitis. He presented to your clinic for follow up, he is having a flare up of clinic for follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills rhinitis symptoms, and he wants to get refills of the antihistamine pills that he used to get of the antihistamine pills that he used to get from his physician. from his physician.
You wonder should you prescribe intranasal You wonder should you prescribe intranasal steroids or refill the antihistamines?!steroids or refill the antihistamines?!
Step 1Step 1Formulating an answerable Formulating an answerable
questionquestion
Formulating clinical questionsFormulating clinical questions
PPatient/ Population : Patients with Allergic atient/ Population : Patients with Allergic Rhinitis Rhinitis
IInterventionntervention : Intranasal steroids : Intranasal steroids CComparisonomparison : Antihistamines : Antihistamines OOutcomeutcome : Control of symptoms : Control of symptoms
Formulating clinical questionsFormulating clinical questions
In patients with Allergic Rhinitis, is Intranasal In patients with Allergic Rhinitis, is Intranasal steroids more effective than antihistamines in steroids more effective than antihistamines in the management of Allergic Rhinitis the management of Allergic Rhinitis symptoms?symptoms?
Step II.Step II.
Searching best evidence to answer the Searching best evidence to answer the question.question.
Identifying The EvidenceIdentifying The Evidence
• Primary Sources
• Secondary Sources
MedlineEmbase
Systematic Reviews
Clinical Guidelines
Where to Find the Best Where to Find the Best Evidence ?Evidence ?
Invest in evidence databasesInvest in evidence databases• Using Prefiltered sources
• Using Unfiltered sources
Best Evidence 5.lnk
Search strategySearch strategy
Disease and intervention well understood & Disease and intervention well understood & fully fully evaluated Textbookevaluated Textbook
Common problem Clinical evidence Common problem Clinical evidence ACP ACP Journal ClubJournal Club
New intervention Medline PubMed New intervention Medline PubMed clinical clinical queries.queries.
Broad questions System review Broad questions System review articles e.g articles e.g Cochrane libraryCochrane library
Internet googleInternet google
Q1. For healthy adults is it worthwhile Q1. For healthy adults is it worthwhile to give aspirin as prophylaxis to reduce to give aspirin as prophylaxis to reduce MI and or stroke.MI and or stroke.
Scenario and Questions (Cont’d)Scenario and Questions (Cont’d)
PRIMARY SOURCES PRIMARY SOURCES
Primary Sources of evidencePrimary Sources of evidence
MEDLINEMEDLINE
EMBASEEMBASE
Other Search EnginesOther Search Engines
EMBASEEMBASE CANCERLITCANCERLIT CINAHLCINAHL HealthSTARHealthSTAR
Secondary sources of Secondary sources of EvidenceEvidence
SECONDARY SOURCESSECONDARY SOURCES A Unique Source…A Unique Source…
Its contents are Its contents are driven by driven by questionsquestions rather than rather than by the availability of by the availability of research evidence.research evidence.
It is It is updated every 6 months.updated every 6 months.
Clinical EvidenceClinical Evidence
Produced by the BMJ Publishing GroupProduced by the BMJ Publishing Group Updated every six monthsUpdated every six months www.clinicalevidence.orgwww.clinicalevidence.org
Aspirin and Primary PreventionAspirin and Primary Prevention
1. 1. PPatient population.atient population.
2. 2. IIntervention.ntervention.
3. 3. CComparison omparison
4. 4. OOutcomes. utcomes.
Asymptomatic adults with no Asymptomatic adults with no risk factors risk factors
Aspirin Aspirin
PlaceboPlacebo
Incidence of CV eventsIncidence of CV events
““In asymptomatic adults no risk factors, would the In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular use of aspirin reduce the incidence of cardiovascular events?events?
Aspirin and Primary PreventionAspirin and Primary Prevention
BenefitBenefit
CER=4.8%CER=4.8% EER=4.2%EER=4.2% ARR=4.8-4.2=0.6%ARR=4.8-4.2=0.6% NNT=167NNT=167
HarmsHarms
IC bleeds: IC bleeds: NSNS
EC bleeds:EC bleeds: ARI=0.8-0.5=0.3%ARI=0.8-0.5=0.3% NNH=333NNH=333
The Cochrane LibraryThe Cochrane Library
The Cochrane LibraryThe Cochrane Library
http://www.thecochranelibrary.comhttp://www.thecochranelibrary.com
Clinical ScenarioClinical Scenario
Khalid is a 40 years old smoker, would like to quit Khalid is a 40 years old smoker, would like to quit smoking, he tried to do that, by himself, several times smoking, he tried to do that, by himself, several times over the last two years, but he could not tolerate the over the last two years, but he could not tolerate the withdrawal symptoms. Recently he read an article in withdrawal symptoms. Recently he read an article in the newspaper reporting that anti-depression the newspaper reporting that anti-depression medications can be used to help smoker to quit, he medications can be used to help smoker to quit, he would like your advise about this issue!would like your advise about this issue!
You wonder what is the role of antidepressants in You wonder what is the role of antidepressants in smoking cessation?! smoking cessation?!
Formulating clinical questionsFormulating clinical questions
PPatient/ Population : Smoking Cessationatient/ Population : Smoking Cessation IInterventionntervention : Antidepressants : Antidepressants
therapy therapy CComparisonomparison : Placebo : Placebo OOutcomeutcome : Rate of smoking : Rate of smoking
Cessation Cessation
The Cochrane Database of Systematic The Cochrane Database of Systematic ReviewsReviews
Live Demonstration Live Demonstration
“It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty,
adapted periodically, of all relevant randomised controlled trials.”
Archie CochraneArchie Cochrane
The Cochrane Database of The Cochrane Database of Systematic Reviews (CDSR)Systematic Reviews (CDSR)
Include more than 50 review groups.Include more than 50 review groups.
ContainsContains over 3541over 3541 completed reviews and completed reviews and review protocols.review protocols.
The CDSR abstracts are free The CDSR abstracts are free The CDSR impact factor is 4.654 ranking The CDSR impact factor is 4.654 ranking
number 14number 14 The collection is updated quarterly.The collection is updated quarterly. Reviews are updated every 2 years.Reviews are updated every 2 years.
Review GroupsReview Groups
Acute respiratory infectionsAcute respiratory infections AirwaysAirways AnaesthesiaAnaesthesia BackBack Breast cancerBreast cancer Colorectal cancerColorectal cancer Consumers and communicationConsumers and communication Cystic fibrosis and genetic Cystic fibrosis and genetic
disordersdisorders Dementia & cognitive Dementia & cognitive
improvementimprovement Depression, anxiety & neurosisDepression, anxiety & neurosis
Developmental, psychosocial Developmental, psychosocial and learning problemsand learning problems
Drugs and alcoholDrugs and alcohol Ear, nose and throat disordersEar, nose and throat disorders Effective practice and Effective practice and
organisation of careorganisation of care EpilepsyEpilepsy Eyes and visionEyes and vision Fertility regulationFertility regulation Gynaecological cancerGynaecological cancer HeartHeart Hepato-biliaryHepato-biliary
Database Of Abstracts Of Database Of Abstracts Of Reviews Of Effectiveness Reviews Of Effectiveness
(DARE(DARE)) DARE is a collection of abstracts of DARE is a collection of abstracts of
well-conducted and quality-assessed well-conducted and quality-assessed research reviews about the effectiveness research reviews about the effectiveness of health care interventions.of health care interventions.
http://nhscrd.york.ac.uk/darehp.htmhttp://nhscrd.york.ac.uk/darehp.htm
ACP Journal ClubACP Journal Club
Selects articles from the Selects articles from the literature that are original literature that are original commented on by clinical commented on by clinical experts.experts.
More than 2000 reviews More than 2000 reviews currently available.currently available.
http://www.acpjc.org/http://www.acpjc.org/
ACP Journal Club ACP Journal Club
Selects articles from the literature that are Selects articles from the literature that are original commented on by clinical experts.original commented on by clinical experts.
More than 2000 reviews currently available.More than 2000 reviews currently available. http://www.acpjc.org/http://www.acpjc.org/
Q2. One of my healthy patients Q2. One of my healthy patients
asked whether to take folicasked whether to take folic
acid or not ?acid or not ?
Scenario and Questions (cont’d)Scenario and Questions (cont’d)
BandolierBandolier Search for systematic reviews and abstract Search for systematic reviews and abstract
themthem Include NNT tables Include NNT tables http://www.jr2.ox.ac.uk/Bandolier/http://www.jr2.ox.ac.uk/Bandolier/
Bandolier is an Oxford based Bandolier is an Oxford based appraisal site with lots of good appraisal site with lots of good material. material. http://www.jr2.ox.ac.uk/bandolier/bformHJ.hthttp://www.jr2.ox.ac.uk/bandolier/bformHJ.htmlml
SECONDARY SOURCESSECONDARY SOURCES
Q3. One of your residents asked Q3. One of your residents asked you you should we stop prescribing traditional should we stop prescribing traditional NSAID, and shift to the selective C0X2NSAID, and shift to the selective C0X2
inhibitors? inhibitors?
Scenario and Questions (cont’d)Scenario and Questions (cont’d)
SECONDARY SOURCESSECONDARY SOURCES
Evidence Based Therapeutics Initiative Evidence Based Therapeutics Initiative from UBC, Canadafrom UBC, Canada http://www.ti.ubc.ca/index.html
Q4.Q4.A.A. For type I diabetic patient with For type I diabetic patient with
microalbuminurea, which is the best ACEI or microalbuminurea, which is the best ACEI or ARB that will protect the kidney?ARB that will protect the kidney?
B.B. In diabetic and HTN patients, which is more In diabetic and HTN patients, which is more effective in preventing stroke, captopril or effective in preventing stroke, captopril or enalapril?enalapril?
Scenario and Questions (Cont’d)Scenario and Questions (Cont’d)
TRIP DatabaseTRIP Database
The TRIP Database searches 70 sites of high-The TRIP Database searches 70 sites of high-quality medical information.quality medical information.
The site is updated monthly.The site is updated monthly. http://www.tripdatabase.com/http://www.tripdatabase.com/
Step (3): Critical Appraisal of the Step (3): Critical Appraisal of the EvidenceEvidence
Is the evidence from this article valid? METHODIs the evidence from this article valid? METHOD If valid, are the RESULTS important?If valid, are the RESULTS important? If valid and important, can you apply the If valid and important, can you apply the
evidence in the caring for the patients in the local evidence in the caring for the patients in the local contexts?contexts?
ConclusionConclusion
Five steps process ?Five steps process ? Asking the right question.Asking the right question. Searching for information.Searching for information. Evaluating the evidence forEvaluating the evidence for
validity and usefulness. validity and usefulness.
Implement useful findings inImplement useful findings in clinical practiceclinical practice
Evaluate the whole processEvaluate the whole process
Conclusion Cont.Conclusion Cont.
The main thing is toThe main thing is to
keep asking questions.keep asking questions.
Thank YouThank [email protected]@ksu.edu.sa
King Saud Khazindar Free Journals King Saud Khazindar Free Journals http://www.alkhazindar.com.sa/onlinejournals/first.asp
Literature Review
Training Medical Students in Evidence-based Training Medical Students in Evidence-based Medicine: A Community Campus Approach.Medicine: A Community Campus Approach. Family Med 1999, 31 (10): 703-8.Family Med 1999, 31 (10): 703-8.
Michigan State University (MSU)Michigan State University (MSU) A nine-session 20 hours curriculum A nine-session 20 hours curriculum Third year medical students Third year medical students It compared this group with the AAMC It compared this group with the AAMC graduates and the 1994 class who were not graduates and the 1994 class who were not taught this course taught this course
AAMC Comparison of AAMC Comparison of Literature Analysis SkillsLiterature Analysis Skills
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1994 1995 1996 1997
AAMC
MSU
AAMC Comparison of AAMC Comparison of Research Research Technique SkillsTechnique Skills
0%
10%
20%
30%
40%
50%
60%
70%
1994 1995 1996 1997
AAMC
MSU
CONCLUSIONCONCLUSION
If you teach him how to fishIf you teach him how to fish,,
he will eat today …
If you give someone a fish,
he will eat every day…
Be open to Be open to questions; questions; never avoid never avoid or ignore a or ignore a question.question.
Show Show interest in interest in the patient’s the patient’s story; never story; never act bored.act bored.
Do not give Do not give the patient the patient falsefalse
reassurance.reassurance.
1900 1990 2000
10,000
100,000
?250,000INFORMATION EXPLOSION
MEDICAL JOURNALS
DOE POEMDOE POEM Disease Oriented Evidence Disease Oriented Evidence
(DOE)(DOE) Patient Oriented Evidence that Patient Oriented Evidence that
Matters (POEM)Matters (POEM) the outcomes that matter the outcomes that matter most to our patients.most to our patients.
POEMs POEMs Decreased symptoms, Decreased symptoms,
mortality, morbidity, cost mortality, morbidity, cost Increased QOL.Increased QOL.
Doe Doe
pathophysiological pathophysiological point of viewpoint of view
RELEVANCE RELEVANCE XX VALIDITY VALIDITY
WORK WORK
Shaughnessy et. al. JFP 1994.Shaughnessy et. al. JFP 1994.
USEFULNESS OF USEFULNESS OF
INFORMATIONINFORMATION ==
Relevance Relevance Applicability to practice.Applicability to practice.
DOE DOE VSVS POEMs POEMs
Frequency of the Frequency of the ProblemProblem
DOE makes sense DOE makes sense Can we apply it to our Can we apply it to our
patients before POEM?patients before POEM?
EBM encourages a healthy EBM encourages a healthy skepticism skepticism
Example from the history Example from the history Antiarrhytharic ??Antiarrhytharic ?? ββ -blockers -blockers
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
Clofibrate Increases Clofibrate Increases overall mortalityoverall mortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers decrease blockers decrease mortality in heart mortality in heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
Five steps process ?Five steps process ? Asking the right question.Asking the right question. Searching for information.Searching for information. Evaluating the evidence forEvaluating the evidence for
validity and usefulness. validity and usefulness.
Implement useful findings inImplement useful findings in clinical practiceclinical practice
Evaluate the whole processEvaluate the whole process
Step 1Step 1Formulating an Formulating an
answerable answerable questionquestion
To answer a clinical question effectively, To answer a clinical question effectively, First, turn your scenarios into First, turn your scenarios into 'well-built' 'well-built' clinical Q.clinical Q.
Four domains:Four domains: PICOPICO
1) the 1) the ppatient (atient (pproblem)roblem)
2) the 2) the iintervention or exposure ntervention or exposure
3) the 3) the ccomparison (intervention)omparison (intervention)
4) the clinical 4) the clinical ooutcomesutcomes
Clinical ScenarioClinical Scenario Ibrahim is a 30 years old teacher, he is known case Ibrahim is a 30 years old teacher, he is known case
of allergic rhinitis. of allergic rhinitis. He presented to your clinic for He presented to your clinic for follow up, he is having a flare up of rhinitis follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills of the symptoms, and he wants to get refills of the antihistamine pills that he used to get from his antihistamine pills that he used to get from his physician. physician.
You wonder should you prescribe You wonder should you prescribe intranasal steroids or refill the intranasal steroids or refill the antihistamines?!antihistamines?!
PPatient atient : Patients with : Patients with Allergic Rhinitis Allergic Rhinitis
IInterventionntervention : Intranasal : Intranasal steroids steroids
CComparisonomparison : Antihistamines : Antihistamines
OOutcomeutcome : Symptoms Control : Symptoms Control
Step 2Step 2
SEARCHING FOR THE SEARCHING FOR THE Best EVIDENCEBest EVIDENCE
Identifying The EvidenceIdentifying The Evidence
• Primary Sources
• Secondary Sources
MedlineEmbase
Systematic Reviews
Clinical Guidelines
Medline search
Secondary Secondary sources of sources of EvidenceEvidence
Where to Find the Best Evidence ?Where to Find the Best Evidence ?
Invest in evidence Invest in evidence databasesdatabases
• Using Prefiltered sources
They do steps 3 and 4 They do steps 3 and 4 Focus on relevantFocus on relevant
information information Evaluate its validity.Evaluate its validity.
Aspirin and Primary PreventionAspirin and Primary PreventionBenefitBenefit
CER=4.8%CER=4.8% EER=4.2%EER=4.2% ARR=4.8-4.2=0.6%ARR=4.8-4.2=0.6% NNTNNT=167=167
HarmsHarms
IC bleeds: IC bleeds: NSNS
EC bleeds:EC bleeds: ARI=0.8-0.5=0.3%ARI=0.8-0.5=0.3% NNHNNH=333=333
3rd session:
Boolean Operators Boolean Operators
A A ANDAND B B
Boolean OperatorsBoolean Operators
A A OROR B B
SPECIALIST (MEDICINE SPECIALIST (MEDICINE SPECIFIC) SEARCH ENGINESPECIFIC) SEARCH ENGINE
e.g. e.g. i-TRIP Database i-TRIP Database
ii- OMNI ii- OMNI (Organization Medical Network Information)(Organization Medical Network Information)
Agency for Health Care Agency for Health Care Research & Quality (AHRQ)Research & Quality (AHRQ)
Include a comprehensive guidelines for 19 separate Include a comprehensive guidelines for 19 separate conditions.conditions.
http://www.ahrq.gov/clinic/cpgarchv.htm.http://www.ahrq.gov/clinic/cpgarchv.htm. Include recommendations on a wide range of Include recommendations on a wide range of
clinical preventive services.clinical preventive services. Evidence-based Practice Centers (EPC) Reports:Evidence-based Practice Centers (EPC) Reports: http://www.ahrq.gov/clinic/epcindex.htmhttp://www.ahrq.gov/clinic/epcindex.htm
Other sources of systematic Other sources of systematic reviewsreviews
CFP Critical Appraisal Index CFP Critical Appraisal Index The Therapeutics InitiativeThe Therapeutics Initiative
Canadian Practice GuidelinesCanadian Practice GuidelinesInfobaseInfobase
The most up-to-date Canadian based The most up-to-date Canadian based guidelines site.guidelines site.
Most of the guidelines are evidence-based.Most of the guidelines are evidence-based. http://mdm.ca/cpgsnew/cpgs/index.asphttp://mdm.ca/cpgsnew/cpgs/index.asp
National Guideline ClearinghouseNational Guideline Clearinghouse
Include structured abstracts of guidelines with Include structured abstracts of guidelines with links to full-text guidelines.links to full-text guidelines.
Not all guidelines are evidence-based.Not all guidelines are evidence-based. http://www.guidelines.govhttp://www.guidelines.gov
Guideline Advisory CommitteeGuideline Advisory Committee
Gives quick access to recommended Gives quick access to recommended guidelines for common medical conditions.guidelines for common medical conditions.
Include summaries and ratings of the Include summaries and ratings of the guidelines with full text links to guidelines.guidelines with full text links to guidelines.
http://www.gacguidelines.ca/http://www.gacguidelines.ca/
Other sources of Evidence-based Other sources of Evidence-based GuidelinesGuidelines
The Scottish Intercollegiate Guidelines The Scottish Intercollegiate Guidelines Network (SIGN)Network (SIGN)
http://pc47.cee.hw.ac.uk/sign/clinical.htm.http://pc47.cee.hw.ac.uk/sign/clinical.htm. The New Zealand Guidelines Group The New Zealand Guidelines Group http://www.nzgg.org.nz/index.cfm.http://www.nzgg.org.nz/index.cfm. The NHS and department of Health The NHS and department of Health
Technology assessment programme.Technology assessment programme. http://www.hta.nhsweb.nhs.uk/htapubs.htmhttp://www.hta.nhsweb.nhs.uk/htapubs.htm
The Canadian Task Force on The Canadian Task Force on Preventive Health CarePreventive Health Care
A practical guide for a wide variety of A practical guide for a wide variety of preventive health interventions using EBM preventive health interventions using EBM recommendations.recommendations.
Include age and sex specific recommendation Include age and sex specific recommendation tables.tables.
http://www.ctfphc.org/http://www.ctfphc.org/
Canadian Practice GuidelinesCanadian Practice GuidelinesInfobaseInfobase
The most up-to-date Canadian based The most up-to-date Canadian based guidelines site.guidelines site.
Most of the guidelines are evidence-based.Most of the guidelines are evidence-based. http://mdm.ca/cpgsnew/cpgs/index.asphttp://mdm.ca/cpgsnew/cpgs/index.asp
National Guideline ClearinghouseNational Guideline Clearinghouse
Include structured abstracts of guidelines with Include structured abstracts of guidelines with links to full-text guidelines.links to full-text guidelines.
Not all guidelines are evidence-based.Not all guidelines are evidence-based. http://www.guidelines.govhttp://www.guidelines.gov
Be open to Be open to questions; questions; never avoid never avoid or ignore a or ignore a question.question.
Show Show interest in interest in the patient’s the patient’s story; never story; never act bored.act bored.
Do not give Do not give the patient the patient falsefalse
reassurance.reassurance.
Two million articles /yearTwo million articles /year
500 meters high! 500 meters high!
Introduction
JASPA*JASPA*(Journal associated score of personal angst)(Journal associated score of personal angst)
J: J: Are you ambivalent about renewing your Are you ambivalent about renewing your JOURNALJOURNAL subscriptions?subscriptions?
A: A: Do you feel Do you feel ANGERANGER towards prolific authors? towards prolific authors?
S: S: Do you ever use journals to help you Do you ever use journals to help you SLEEPSLEEP??
P: P: Are you surrounded by Are you surrounded by PILESPILES of PERIODICALSof PERIODICALS??
A: A: Do you feel Do you feel ANXIOUSANXIOUS when journals arrive? when journals arrive?
* Modified from: BMJ 1995;311:1666-1668
0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)
Systematic reSystematic revview of iew of bed rest bed rest after medical proceduresafter medical procedures
Allen, Glasziou, Del Mar. Lancet, 1999
10 trials 10 trials of bed restof bed rest after spinal puncture after spinal puncture no no change in headache withchange in headache with bed rest bed rest Increase in back painIncrease in back pain
PProtocols in rotocols in UK UK neurology units neurology units -- 80% still 80% still recommend bed rest after LPrecommend bed rest after LP
Serpell M, BMJ 1998;316:1709–10Serpell M, BMJ 1998;316:1709–10
……evidence of harm available for 17 years evidence of harm available for 17 years preceding...preceding...
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
It Increases overall It Increases overall mortalitymortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
It Increases overall It Increases overall mortalitymortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
Clofibrate Clofibrate decreases decreases
cholesterol cholesterol
Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/
MorbidityMorbidity
It Increases overall It Increases overall mortalitymortality
ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients
ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients
Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs
Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms
Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality
DOE POEM
The cardiac arrhythmia suppression trial. N Engl J Med 1991.
Primary Sources of Evidence Primary Sources of Evidence PubMedPubMed
PubMed is a Web-based retrieval system PubMed is a Web-based retrieval system developed by the National Center for developed by the National Center for Biotechnology Information (NCBI) at the Biotechnology Information (NCBI) at the NLM.NLM.
The database is updated weeklyThe database is updated weekly Approximately 12 million citations Approximately 12 million citations Citations from over 3,900 journalsCitations from over 3,900 journals
PubMedPubMed
85% of citations are in English85% of citations are in English
75% of citations have abstracts75% of citations have abstracts
Data is leased to commercial providers (e.g., Data is leased to commercial providers (e.g., OVID)OVID)
GuidelinesGuidelines Center for Disease ControlCenter for Disease Control
http://www.cdc.gov/ This is an easy to navigate site with a good This is an easy to navigate site with a good
section on Traveler's Health. Travel map section on Traveler's Health. Travel map Internet PageInternet Page
http://www.cdc.gov/travel/travelmap.html National Cancer InstituteNational Cancer Institute
http://cancernet.nci.nih.gov/pdq.htm
Systematic ReviewsSystematic Reviews
Well-formulated questionWell-formulated question Comprehensive data searchComprehensive data search Unbiased selection and abstraction processUnbiased selection and abstraction process Critical appraisal of dataCritical appraisal of data Synthesis of dataSynthesis of data
Evidence-Based Evidence-Based GuidelinesGuidelines
The Canadian Task Force on The Canadian Task Force on Preventive Health CarePreventive Health Care
A practical guide for a wide variety of A practical guide for a wide variety of preventive health interventions using EBM preventive health interventions using EBM recommendations.recommendations.
Include age and sex specific recommendation Include age and sex specific recommendation tables.tables.
http://www.ctfphc.org/http://www.ctfphc.org/
Guideline Advisory CommitteeGuideline Advisory Committee
Gives quick access to recommended Gives quick access to recommended guidelines for common medical conditions.guidelines for common medical conditions.
Include summaries and ratings of the Include summaries and ratings of the guidelines with full text links to guidelines.guidelines with full text links to guidelines.
http://www.gacguidelines.ca/http://www.gacguidelines.ca/