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7/31/2019 EBM WARDWORK

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MADELEINE GRACE M. SOSA, MDChair, Dept. of Clinical Epidemiology

EBM WARDWORK

Orientation


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ELGAs Objectives OR Expected LearningOutcomes

Content ActivitiesTeacher Student

Resources Evaluation

HEALTH

CAREPROVIDER( Competent,compassionate and SafePhysician)

RESEARCHER(Life Longlearner)

Psychomotor:To generatesound clinical

question relevantto themanagement ofthe patientTo criticallyappraise articlethat will answerthe clinicalquestion for

effectivemanagement ofpatientTo applyknowledge/techniques gained fromcritical appraisal,health economics,health policies and

health socialscience in thedecisionspertaining topatients, theirfamily andcommunityMaking decisionsand taking action

informed byresearch finding

EBMworkshop

PreceptorialEBMwardworkIndividualstudy periodLibrary Period

ComputerVideo

Journals

LibraryPatients

Criticalappraisal ofarticles in

diagnosis andtreatmentWritten exam


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Year level 3 ELGAELGAs Objectives OR

Expected LearningOutcomes

Content Activities

TeacherStudent


HEALTHCAREPROVIDER( Competent

,compassionate andSafePhysician)RESEARCHE

R(Life Longlearner)

Affective/Attitudinal:

To conductcriticalappraisal in

an honest,correct andethicalmanner

Tocompetentlyaddressquestions andproblemspertaining tohealth tosubjects andtheir family

EBMWardwork

Patients Preceptorialgrade/evaluationEBMwardwork

grade


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Year level 3 ELGAELGAs Objectives OR

ExpectedLearningOutcomes

Content Activities

TeacherStudent


TEACHER/ACADEMICIAN

(Effectivecommunicator

Cognitive:

To understandthe

significanceand use of theresultobtained fromcriticalappraisal

To understandthe

significance,applicationand variousmethods usedin healtheconomics,health policiesand socialscience

EBMwardworkPreceptorialLecturesndividual

study period

Hand outsVideosComputers

Criticalappraisal ofarticles indiagnosis andtreatmentWritten examEBM wardwork grade


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Content ActivitiesTeacherStudent


TEACHER/

ACADEMICIAN(Effectivecommunicator

Psychomotor:

To demonstrateacceptable levelof competence inthe conduct offocus groupdiscussions andinterviews amongpatients, theirfamily andcommunity whenappropriate

To applyacceptable levelof competence insearching forliteratures andknowledge toaddress medicalquestions andassignmentsTo publishresults in plainlanguage andacceptableformats

Focus groupdiscussionIndividualstudy periodLibrary period SimulatedGroupactivities

VideosComputers

Preceptorialgrade/evaluationCriticalappraisal ofarticles indiagnosis andtreatmentWritten exam


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Year Level 3 ELGAELGAs Objectives OR Expected Learning

Outcomes



TEACHER/ACADEMICIAN

(Effectivecommunicator

Affective/Attitudinal:

To influence

subsequentrounds ofresearchbased on theimpact ofknowledge

use

Preceptorialevaluation/grade


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Year Level 3 ELGA




SOCIALMOBILIZER

Ethicallyandsociallyresponsive

Cognitive:1. To understand

the principlesof ethicalconduct in theconduct ofevidencebasedmedicine

2. To understandthe principlesof good clinicalpractice in thedesign,conduct,record andreport ofclinical trials inhumansubjects

LectureEBMwardwork

WrittenexamsEBM wardwork grade

Psychomotor:1. To apply the

principles ofethical conductin performing

EBM wardwork

Ward workgradePreceptorialevaluation


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What is evidence-basedmedicine?

Evidence-based medicine is the integrationof best research evidencewith clinicalexpertise andpatient values

- Dave Sackett 2001

Patient

Concern

s Clinical

Expertis

e

Bestresearc

h

evidenc

e

EBM


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RESEARCH

EVIDENCE

CLINICALCIRCUM-STANCE

PATIENT

PREFERENCES

CLINICAL

EXPERTISE

EBM : Evidence Based Medicine


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Its practice requires:

Asking

Acquiring

Appraising

Applying

Assessing


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The 4 steps of pull EBM

1. Formulate an answerable question

2. Track down the best evidence

3. Critically appraise the evidence

4. Individualise, based clinical expertise and patientconcerns


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Clinical Scenario


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Formulating a FocusedClinical Question

Population Intervention/Exposure

Comparison Outcome


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P - Who is the patient or whatproblem is being addressed?

I - What is the intervention orexposure?C What is the comparisongroup?

O - What is the outcome orendpoint?

Architecture of a focused

question:a 4-part review question

+ studydesignRichardson et al. The well-built clinical question: a key to evidence-based decisions. ACP Journal Club

1995;A-12Counsell C. Formulating questions and locating primary studies for inclusion in systematic reviews. AnnIntern Med 1997;127:380-7.


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Formulation of an etiologyquestion

Is snoring a risk factor fordiabetes?

Exposure

Outcome


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Formulation of an etiologyquestion

Is snoring a risk factor fordiabetes?

Are people who snore regularly at a greater risk ofdeveloping type II diabetes mellitus as compared tothose who do not snore?

Exposure

Outcome

Exposure

Patient

Outcome

Comparison

+ cohort & case-control

studies


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Finding the Evidence


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Finding the Evidencs

It is important when searching forevidence that search terms arereferred back to your original PICO

question. The process of findingevidence therefore follow three keysteps:

Identify terms to fit your PICO question

Look for secondary sources

Search for primary sources


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1. Identify terms to fit your PICOquestion

Population

Intervention

Comparator

Outcome


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2. Look for secondary sources

Guidelines: UKNational Library for Health, NICE, SIGN;US National Guidelines Clearinghouse;Canadian Medical Association;New Zealand Guidelines Group.

CATs: CAT CrawlerEvidence-Based Summaries:

Bandolier, Clinical Evidence

Structured Abstracts: EBM Online,ACP Journal Club
http://www.library.nhs.uk/http://www.nice.org.uk/http://www.sign.ac.uk/http://www.guideline.gov/http://mdm.ca/cpgsnew/cpgs/index.asphttp://www.nzgg.org.nz/http://www.bii.a-star.edu.sg/research/mig/cat_search.asphttp://www.jr2.ox.ac.uk/bandolier/http://www.clinicalevidence.com/http://ebm.bmjjournals.com/http://www.acpjc.org/shared/menu_about.htmlhttp://www.acpjc.org/shared/menu_about.htmlhttp://ebm.bmjjournals.com/http://www.clinicalevidence.com/http://www.jr2.ox.ac.uk/bandolier/http://www.bii.a-star.edu.sg/research/mig/cat_search.asphttp://www.nzgg.org.nz/http://mdm.ca/cpgsnew/cpgs/index.asphttp://www.guideline.gov/http://www.sign.ac.uk/http://www.nice.org.uk/http://www.library.nhs.uk/


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3. Search for Primary Sources

Use methodological filters to target

the right type of study. For instance,PubMED filters for:

Therapy

DiagnosisPrognosis

Aetiology

Systematic review
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmedhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed


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2. Searching: finding goodanswers?


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Search Strategy

Step 1: Create a search strategy

Scenario: A 64 year old obese male

who has tried many ways to loseweight presents with a newspaperarticle about fat-blazer (chitosan).He asks for your advice.

Your question in PICO format mightbe:

Population/problem : obese patients

Intervention/indicator : chitosan


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Search Strategy

Step 2: Now convert this PICOquestion to a search strategy

To do this, you should do three things:

1.Underline the key terms those mostspecific to your question

2. Number the PICO elements in order

of importance from 1-4

3. Think of alternate spellings,synonyms and truncations

You might end up with:


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Search Strategy

NOTE: * is a truncation symbol that means further letters canbe added to the wordOR finds studies containing either of the specifiedwords/phrases, and broadens your searchAND finds studies containing both specified words/phrases,

and narrows your search

1. Open your browser (eg Explorer) and go towww.pubmed.gov

2. Type into the search box the term we chose as (1) :chitosan. Write down the number of results you found.

3. Select Clinical Queries (left hand menu)

4. Select the Therapy category (which is the default) andsearch on chitosan again. Write down the number of resultsyou now found.

Why has this decreased? It is because of the filter thatPubMed uses to focus on clinical trials (to see the actual filter


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Search Strategy

5. Try adding AND another stage, ietype in chitosan AND (obes* ORoverweight) note that you need

brackets around your OR search. Thisshould reduce the number of articleseven further and certainly down to a

manageable number.If we had used all terms the search

may looked like this:

Search #1:chitosan


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Clinical Question

Among patients with chronic cough andfever in a TB endemic country, how

accurate is a same day 2 smear sputum

exam in the diagnosis of pulmonarytuberculosis?


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Search Strategies


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Step 3: Appraise theevidence

Did you find goodquality studies?

Two steps PICO RAMMbo


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3. Rapid Critical Appraisal

Its peer-reviewed, therefore it must beOK?


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CRiTICAL APPRAISAL

CLAIMS OF EFFECTIVENESS

CLAIMS OF ACCURACY

CLAIMS ON CAUSATION

CLAIMS ON PROGNOSIS

Claims for Accuracy Articles


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Claims for Accuracy Articleson Diagnosis

A i i di ti t t 3 t


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Appraising diagnostic tests: 3 easy steps

1. Are the results valid?

2. What are the results?

3. Will they help melook after my patients?

A i i di ti t t 3 t


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Appropriate spectrum of patients?

Does everyone get the gold standard?Is there an independent, blind or

objective comparison with the goldstandard?

A i i di ti t t 3 t


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Sensitivity, specificity

Likelihood ratios

Predictive values

A i i di ti t t 3 t


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Can I do the test in my setting?Do results apply to the mix of patientsI see?Will the result change mymanagement?

Costs to patient/health service?


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l i f ff i


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Claims of Effectiveness


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THERAPY STUDY:Are the results of the trial valid? (Internal Validity)What question did the study ask?


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Patients

Intervention -

Comparison -

Outcome(s) -


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Claims of prognosis


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St 4 A l i t th


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Step 4: Applying to theindividual

What do theresults mean on

average?What do they

mean for thisindividual?


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Presentations will cover:1. searchstrat egy;2. searchresults;3. thevalidityof this evidence;4. theimportanceof this validevidence;5. canthis valid, important evidencebeappliedtoyour patient;

6. your evaluationof this process.

3-part Clinical

Patients Name Learner:

Target Disorder:

Dateandplacetobefilled:

Intervention(+/ - comparison):

Outcome:

Im sorry doctor


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I m sorry doctor,but again I have to

disagree.


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CLINICALQUESTION

ASSESSMENT OFVALIDITY

ASSESSMENT OFAPPLICABILITY

CLINICALCIRCUMSTANCE

AND PATIENT

VALUESEBM AS A

CYCLE

DECISION

SYSTEMATIC

SEARCH FORBEST EVIDENCE


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Life long learning

The hardest conviction to get into the mind of abeginner is that the education upon which he isengaged is not a medical course, but a life

course, for which the work of a few years underteachers is but a preparation.

Sir William Osler (1849-1919), from: The Studentof Medicine


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THANK YOU FORLISTENING

ANDGOOD LUCK!!


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Wardwork Report

Clinical Scenario

Focused question

Search StrategyCritical Appraisal

Discuss applicability

Conclusion

ebm wardwork

Documents