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Presentation given to 4th year MD students taking "Introduction to Health Informatics" at the University of Western Ontario on April 6th, 2010
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Strategies for Answering Clinical QueriesIntroduction to Health InformaticsApril 6, 2010
Robin Featherstone, BA, MLISClinical Medicine LibrarianAllyn & Betty Taylor [email protected]
Presentation available at: http://www.slideshare.net/featherr
Objectives
1. Develop an understanding of search tools within an EBM framework
2. Introduce a variety of products to support clinical decision making
Agenda• Sources of Medical Evidence (EBM) & PICO• Searching Exercises
1. Medical Literature– Cochrane Library– PubMed (Clinical Queries)– TRIP Database– Natural Standard
2. Point-of-Care Tools– ACP Pier– UpToDate– DynaMed
3. Drug Information Resources– E-CPS– MICROMEDEX– Lexi-Interact
SOURCES OF MEDICAL EVIDENCE & PICO
Level of Evidence Pyramid
Qualitative Studies
Trip searches both
Refine Questions using PICO
P = Patient, Problem or PopulationI = Intervention or ExposureC = ComparisonO = Outcomes
PICO Example
A patient travels frequently and report suffering from the effects of jet lag. They ask about prevention methods. Have you heard of using melatonin? They’ve also read that exercise can be used to prevent symptoms. What do you recommend?
Use PICO to develop your query
P: Jet lagI: MelatoninC: ExerciseO: Prevention of symptoms
Which is more effective in preventing jet lag: melatonin or exercise?
Determine your Question Type1,2
1. Aetiology: What is the cause of the disease and its mode of operation?
2. Diagnosis: How accurate is this diagnostic test?3. Prognosis: What is the probable course of the disease?4. Therapy: Is one intervention more effective than
another?5. Prevention: How to reduce the risk of this disease?6. Cost-effectiveness: Is one intervention more cost-
effective than another?7. Quality of life: What will be the patient’s quality of life?
1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
Studies to Answer Each Type1,2
Type of Question Type of Evidence
Aetiology •Randomized controlled trials•Case-control or cohort studies•Case series
Diagnosis •Diagnostic validation studies•Prospective studies / blind comparison to a gold standard
Prognosis •Inception cohort studies•Case control studies•Case series
Therapy •Randomized controlled trials•Systematic reviews / meta-analyses
Prevention •Randomizes controlled trials•Cohort studies, case control studies•Systematic reviews / meta-analyses
Cost-effectiveness •Economic analyses
Quality of life •Qualitative studies1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
Level of Evidence Pyramid
Qualitative Studies
Trip searches both
SEARCHING EXERCISE – MEDICAL LITERATURE
Searching the Medical Literature
• Please search the following sources to answer the question: Are probiotics effective in reducing symptoms of eczema/atopic dermatitis?
1. Cochrane Library2. PubMed (clinical queries) 3. TRIP Database4. Natural Standard
Treatment Question - Results
Source Results
Cochrane Library 2 Cochrane Reviews3 Other Reviews47 Clinical Trials
PubMed 199 Citations total88 Review articles48 citations if searching Clinical Queries – looks for randomized controlled trials
TRIP Database 81 Citations
Natural Standard 1 disease summary 1 drug summary
SEARCHING EXERCISE – POINT OF CARE TOOLS
Searching Point-of-Care Tools
• Search the following sources to answer the question: What is an appropriate second-line topical treatment for atopic dermatitis?
1. ACP Pier2. UpToDate3. DynaMed
– Locate temporary link from: http://taylormedinfo.blogspot.com/
2nd Line Treatment Question - Results
Source Contains
ACP Pier •Evidence rating •Evidence summary•Recommendations
•Link to drug monograph from AHFS DI Essentials (US)
UpToDate •Some evidence ratings•Evidence summary•Recommendations
•Link to detailed drug monograph from Lexi-Comp (US)
DynaMed •Evidence rating•Evidence summary•Links to guidelines
•Link to detailed drug monograph from AHFS DI Essentials (US)
• Search the following tools to answer the question: Should a 53 year old, postmenopausal woman who smokes one pack of cigarettes a day and reports low calcium intake be screened for osteoporosis?
1. ACP Pier2. UpToDate3. DynaMed
– Locate temporary link from: http://taylormedinfo.blogspot.com/
Searching Point-of-Care Tools:2. Screening question
Screening Question - ResultsSource Contains
ACP Pier •Evidence rating •Evidence summary•Links to assessment tools
UpToDate •Detailed screening topic•Screening recommendations•List of risk factors
DynaMed •Prevention and Screening Information together•Evidence rating•Evidence summary
SEARCHING EXERCISE – DRUG INFORMATION
Searching for Drug Information
You consider prescribing Tacrolimus to a patient who is taking Fluconazole, Gabapentin and Aspirin. Search the following tools to identify any potential interactions:
1. Lexi-Interact (UpToDate)2. MICROMEDEX3. E-CPS
Drug Interactions - Results
Source Results
Lexi-Interact •Interaction analysis tool•Risk ratings•Patient Management recommendations
MICROMEDEX •Interaction analysis tool•Risk ratings•Includes other interactions (ex. Drug-Food)•Canadian
E-CPS •Detailed drug monographs•Drug Interactions
Summary
• Use PICO to develop clinical queries• Select the level of evidence to best answer
your query type• Consider using a variety of filtered
information tools based on the information needed
QUESTIONS