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Donna Windish, MD, MPH

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Donna Windish, MD, MPH

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  2. <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllAnswers />

  3. Importance of Answering Clinical Questions • Provision of evidence-based care • Teaching (patients/colleagues) • Lifelong self-directed learning

  4. Yale trainees Knowledge Performance Outcomes Time since training → Choudhry NK, Ann Intern Med. 2005;142(4):260-273

  5. Evidence-based practice Acquire (Appraise) Ask Apply Clinical expertise Clinical state and circumstances Haynes RB, ACPJC. 2002 Mar-Apr;136:A11

  6. Epidemiology of clinical questions • 2 questions for every 3 patients seen in office1,2,3 • Most involve therapy and diagnosis • Majority of questions clinically important • 30% pursued, often using non-evidence-based sources • Factors predicting pursuit • patient expectation (OR = 2.3, p = 0.004) • perceived malpractice liability (OR = 2.1, p = 0.05) 1Covell DG, Ann Intern Med. 1985;103(4):596-599 (practicing MDs) 2Gorman PN, Med Decis Making. 1995;15(2):113-119 (practicing MDs) 3Green ML, Am J Med. 2000;109(3):218-23 (internal medicine residents)

  7. Clinical Scenario You are caring for a 64-year-old man who has just developed non-valvular atrial fibrillation. PMH includes hypertension, type 2 diabetes mellitus, and a remote history of an upper GI bleed. He has no history of stroke or TIA. An echocardiogram shows an EF of 50% and mildly dilated left atrium. Initial attempts at cardioversion were unsuccessful. You opt for a rate control strategy and consider the options for primary prevention of stroke (aspirin versus warfarin).

  8. Step 1: Ask Identify information needs and translate them into answerable clinical questions

  9. Background vs. Foreground Questions • What causes non-valvular afib? • What left atrial size puts a patient at risk for afib? • What are the recommendations for cardioversion in afib? Background question Addresses general knowledge that would help clinicians better understand a particular disorder, health state, diagnostic test, treatment, or other aspect of health care

  10. Background vs. Foreground Questions Foreground question Addresses specific knowledge to inform clinical decisions or actions.

  11. Question clinical exam prognosis harm diagnosis therapy prevention “Intervention/ Exposure” physical finding risk factor exposure diagnostic test treatment maneuver Question Classification

  12. Foreground Question (PICO) Therapy/Prevention Question

  13. Foreground Question (PICO) Therapy/Prevention Question

  14. Foreground Question (PICO) Therapy/Prevention Question

  15. Foreground Question (PICO) Therapy/Prevention Question

  16. Foreground Question (PICO) Therapy/Prevention Question

  17. Why Ask Clinical Questions So Specifically? • Use time wisely • Search efficiently (sources and search terms) • Know “when to stop” • Integrate evidence with clinical context and patient preferences in decision-making • Communication clearly with other clinicians

  18. Efficiently acquire the best evidence Step 2: Acquire

  19. EBM 1992 Clinical question MEDLINE search for original clinical research studies Critically appraise each article for it is validity and usefulness Summarize results Customize for your patient Make a decision

  20. EBM 2013 Appraisal mode (“Doer”) Summary mode (“User”) Ask Acquire Appraise Apply Ask Apply Acquire Appraise Guyatt GH, BMJ. 2000;320(7240):954-5 Haynes RB, ACPJC 2001;134(2):A11-A13 McColl A, BMJ 1998;316:361-5 Straus, Evidence-based Medicine, 2005 Akl EA, Med Teach. 2006;28(2):192-194

  21. Hierarchy of EBM Resources Full integration (CDSS) EMR and POE push technology patient specific info systems Clinical Evidence PIER UpToDate EBM guidelines All questions for condition summaries DARE health-evidence.ca ACPJC, EBM journal synopses of syntheses Systematic reviews Cochrane library SRs in journals SRs in guidelines Single focused question syntheses ACPJC on line EBM Journal synopses of studies Medline or PubMed (clinical queries) BMJ Updates ACPJC plus studies DiCenso A, Bayley L, Haynes RB. Editorial: Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. Ann Intern Med. 2009;151(6):JC3-2-

  22. “Specialized” EBM Summaries • Specialized • JAMA Rational Clinical Exam (clinical findings) • USPSTF Guide (screening, counseling, immunizations, chemoprophylaxis)

  23. Summaries • Explicit and preferably exhaustive search strategy • Explicit criteria for inclusion of articles • Explicit and preferably accepted appraisal criteria • Inferences and recommendation based on highest level of evidence (and include citations) • Revised and updated regularly

  24. Yes, There’s an App for ThatiPhone

  25. Practice “In a 64 year-old man with non-valvular a-fib, hypertension, diabetes and a past GI bleed, is the use of aspirin as effective as wafarin in the primary prevention of stroke?” Studies PubMed www.pubmed.gov Syntheses Cochrane www.thecochranelibrary.com SummariesClinical Evidence www.clinicalevidence.com National Guidelines Clearninghouse www.guidelines.gov UpToDate www.uptodate.com Guideline Central App

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