EBM for the busy Clinician
Gil C. Grimes, MDEBM Working Group, Department
Family MedicineScott & White
Objectives Levels of Evidence DOE vs. POEMs Sources for Evidence Incorporating EBM into Precepting Modeling behavior (dealing with Pharma)
First a few Questions I am familiar with Evidence Based
Medicine? Yes or No
I am familiar with or have used the following databases.
What is EBM? Simply put it is the integration of
research evidence with clinical expertise and patient values.
EBM will allow us to do more good than harm
Patients want to know the following “Will it make me live better” “Will it make me live longer”
Levels of Evidence This is a method for grading journal
articles, guidelines etc. This is not “universal” AAFP uses Level A, B, C Centre for EBM Oxford uses 1,2,3
Focuses on the type of article and quality Therapy/Prevention/Etiology/Harm, Diagnosis,
Prognosis Either way is just fine We will begin with the alphabet first…
Level A Randomized controlled trial/meta-analysis
High-quality randomized controlled trial (RCT) that considers all important outcomes.
High-quality meta-analysis (quantitative systematic review) using comprehensive search strategies.
Level B Other study types and some guidelines
Well-designed, nonrandomized clinical trial. Nonquantitative systematic review with appropriate
search strategies and well-substantiated conclusions. Lower quality RCTs Clinical cohort studies and case-controlled studies with
nonbiased selection of study participants and consistent findings.
Other evidence, such as high-quality, historical, uncontrolled studies, or well-designed epidemiological studies with compelling findings, is also included.
Level C
Consensus/expert opinion Consensus viewpoint or expert opinion. May represent the only evidence that is out there Use with caution
Level 1 Therapy/Prevention/Etiology/Harm:
1a: Systematic reviews (with homogeneity ) of randomized controlled trials
1b:Individual randomized controlled trials (with narrow confidence interval)
1c:All or none randomized controlled trials Prognosis:
1a: Systematic review (with homogeneity) of inception cohort studies; or a clinical rule validated on a test set.
1b: Individual inception cohort study with > 80% follow-up
1c:All or none case-series
Level 2 Therapy/Prevention/Etiology/Harm:
2a: Systematic reviews (with homogeneity) of cohort studies 2b: Individual cohort study or low quality randomized
controlled trials <80% follow-up 2c: 'Outcomes' Research
Prognosis 2a:Systematic review (with homogeneity) of Level >2
diagnostic studies 2b: Independent blind or objective comparison; study
performed in a set of non-consecutive patients, or confined to a narrow spectrum of study individuals (or both) all of whom have undergone both the diagnostic test and the reference standard; a diagnostic clinical rule not validated in a test set.
Level 3, 4, & 5 Therapy/Prevention/Etiology/Harm:
3a: Systematic review (with homogeneity) of case-control studies
3b: Individual case-control study 4: Case-series (and poor quality cohort and case-
control studies) 5: Expert opinion without explicit critical
appraisal, or based on physiology, bench research or 'first principles'
Where’s the beef? Levels of evidence
are good….
What I want to know is how this will work for me.
Friends the path requires moving from DOE to POE…
Disease Oriented Evidence Most common type of
evidence found in research journals
Important to our understanding of disease
Responsible for many therapeutic advances
Intended for a research audience
Pathophysiology Pharmacology Etiology
Patient Oriented Evidence Uncommon in
most journals Outcomes patients
care about Mortality Morbidity Quality of Life Cost Harm
POEMs Patient-Oriented
Evidence that Matters
Addresses a clinical problem encountered by primary care physicians
Uses patient-oriented outcomes
Potential to change our practice if valid and applicable
DOES vs. POEMs
The Numbers…. 6 month survey of 90 journals 8,047 articles 213 POEMs
97% DOEs and other material
2.6% POEMs
A few examples A 72 year old male with COPD and CAD
presents with angina. In treating him a Beta blocker is contraindicated.
True False
False Salpeter SS, Ormiston T, Salpeter E, Poole P, Cates C. Cardioselective
beta-blockers for chronic obstructive pulmonary disease (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software click here
Examples A 23 year old female presents to the ER
with RLQ pain and an acute abdomen. The surgeon is 30 minutes away. Pain medication is contraindicated until the surgeon examines the patient.
True False
False Thomas SH, Silen W. Effect on diagnostic efficiency of
analgesia for undifferentiated abdominal pain. Br J Surg 2003; 90:5-9.click here
Examples When treating mild to moderate alcohol
withdrawal (not DT),benzodiazipines are the most effective therapy in helping with detox.
True False
False Malcolm R, Myrick H, Roberts J, Wang W, Anton RF,
Ballenger JC. The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial. J Gen Intern Med 2002; 17:349-55.click here
Examples Tight glycemic control of gestational
diabetics improves outcomes for mother and child.
True False
False Garner P, Okun N, Keely E, et al. A randomized
controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: a pilot study. Am J Obstet Gynecol 1997;177:190-5.click here
So where do I find this? You could search the literature
Yeah like you have that much time!
You could ask you colleagues Expert opinion Level C
You could familiarize yourself with one or two good sources That sounds pretty good…
Usefulness equation Usefulness= relevance x validity
work
Go for sources that have done the work for you
Drilling for the Best Information
Cochrane Library
POEMs, InfoRetriever,ACP J ournal Club
TRIPS, DynaMed,Bandolier, DARE
Clinical EvidenceClinical Inquiries
Up-to-Date, 5-Minute Clinical Consult,Textbooks
Usefu
lness
J ournals/ Medline
Systematic Reviews
Summarized Evidence-Referenced Resources
Research Articles
Other Sources
Cochrane It is an international organization
that aims to help people make well informed decisions about health care by preparing, maintaining and ensuring the accessibility of systematic reviews of the effects of health care interventions.
Cochrane The Collaboration is built on ten
principles: collaboration building on the enthusiasm of individuals avoiding duplication minimizing bias keeping up to date striving for relevance promoting access ensuring quality continuity enabling wide participation
Cochrane Focus is on therapy Excellent resource Solid source Degree of scrutiny limits some
applicability Let’s look
Clinical Evidence Published by BMJ Collects evidence on a wide variety
of topics You are eligible for their book, and
free access to their web site Let’s look
InfoRetriever Founded by three Family
Physicians, a PharmD and a Psychologist
Goal to improve the health and lives of people by providing patient-oriented evidence that matters in a rapid and accessible form
I use this database daily Let’s Look
TRIP Database TRIP was created in 1997 to bring
together all the 'evidence-based' healthcare resources available on the Internet.
Excellent resource Allows focused PubMed search if all
else fails Tracks your usage for educational
purposes Let’s Look
PubMed Clinical Queries PubMed is a Huge database Typical searches are tough Clinical Queries makes that
easier Let’s Look
Journal Sources Journal of Family Practice Journal Watch from NEJM InfoPOEMs ACP-Journal Club Relevance before Validity
Relevance Slice the bedside stack
Is this something that is common to my practice?
Is it an outcome my patients would care about?
If the outcome is true would I have to change my practice?
If relevant then examine for validity
Mentoring Every Question
is a teachable moment
If you look up two questions with the student they will learn
It should not slow you down
My Experience New MSIII on his second rotation Lot’s of questions InfoRetriever answered 90% We discussed outcomes No one had discussed outcomes with him
to that point It added 15 minutes to my morning and
afternoon He reports that he continues to utilize the
EBM tools demonstrated
Pharma Interactions Modeling behavior for students Demonstrating the sales methods
being utilized Real life scenarios
Handhelds This is the key to just in time
information InfoRetriever can run off Palm or
Microsoft handheld (click here) Very functional Gives you decision tools in your
hand when you need them
Handouts List of useful websites Password for InfoRetriever for
TAMU Worksheets for reviewing articles Worksheet for pharm reps My contact information
Questions?