Asking Clinical Questions and Finding an Evidence-Based Answer

1. Asking Clinical Questions andFinding an Evidence-Based Answer Daniel Van Durme, MD, MPHChair, Dept. of Family Med and Rural Health Nancy Clark, MEd Director of Medical Informatics Education

2. Objectives • Distinguish a background question from a foreground clinical question • Formulate an evidence-based, PICO formatted, foreground question • Find evidence-based answers to your clinical questions

3. EBM – A Multi-Step Process

4. The Question 2. Construct a well built clinical question derived from a case 

5. Background and Foreground Questions • What do I know about this condition? • How common is it? • Is it usually aggressive and rapidly fatal? • How can it be treated – surgery, chemotherapy, radiation? • What about family history – what about his son’s risk? • Etc. • These are called “background” questions not suitable for PICO format • Best source of information for “background” information? • Recent reputable textbook, med app, Google search

6. Foreground Questions - apply to that specific patient (or population) • What are my choices to best care for THIS patient? • What is the best way to diagnose and treat this patient? • What are the patient’s preferences and special considerations? • Use PICO format for Foreground questions

7. Constructing A Clinical Question

8. Examples

9. Types of Questions Best Answered by EBM Resource • Therapy Question • In patients with migraine headaches without auras, are antiepileptics more effective than beta blockers for prophylaxis of headaches? • Prognosis Question • In diabetic patients with foot ulcers, is the diagnosis of osteomyelitis with MRI as predictive of healing as an audible pulse on Doppler examination? • Diagnosis Question • In geriatric patients with suspected carotid stenosis, is duplex ultrasound as good as magnetic resonance angiography in detecting significant carotid stenosis? • Harm Question • For pregnant patients, does the consumption of large amounts of coffee, (compared to non-coffee drinkers) increase the rate of spontaneous abortion?

10. P - Who? I - What? C- Alternatively? Outcome? Type of Question Therapy Prognosis Diagnosis Harm/Etiology Screening Question Worksheet Construct a clinical question from your own clinical experience.

11. Acquire the Evidence 3. Select the appropriate resource(s) and conduct a search

12. Major EBM Databases (Foraging Tools) • Cochrane • ACP Journal Club • InfoPOEMS • Evidence Based _____ • USPSTF • National Guidelines Clearinghouse

13. Cochrane Library Clinical Inquiries Specialty-specific POEMs ACP Journal Club Textbooks, Guidelines Usefulness Journals/ Medline PubMed NLM: Drilling down for the Best Evidence Based Information Start at the top and work your way down till you find what you need Impractical and time consuming

14. Major Comprehensive EBM Tools Web and Mobile Summaries and Clinical Inquiries * Mobile Formatted Websites

15. Fastest Method to Answer • Start with comprehensive resources: • Dynamed Plus • Up-To-Date • Essential Evidence Plus • Search using terms in PICO question • If no answer…Trip, Pubmed or Google Scholar • Search the journals for the latest research articles on that question.

16. APPENDIX Descriptions of Major EBM Databases

17. Cochrane Library • The current resource with the highest methodological rigor • For each clinical question, all of the English literature meticulously searched for randomized trials • Large systematic reviews with valid methods + collaborative effort by Review Groups • Conclusions are based on all the evidence from valid randomized trials (treatment and harm questions) • Structured abstracts easy to digest Link to abstract

18. ACP Journal Club • About 130 internal medicine journals systematically surveyed • Highest-validity articles abstracted. Link to article. • Structured abstracts to guide critical appraisal • Clinical commentary • Now published in the Annals of Internal Medicine • Alerts available (RSS feed)

19. InfoPOEMS • Patient Oriented Evidence that Matters • Journal of Family Practice and other specialty journals • Systematic surveillance of 100 journals • Reviews of recent research articles linked to Pubmed • Effect patient concerns – morbidity, mortality, quality of life • Included in Essential Evidence Plus • Daily e-mail updates available – Let us know if you would like to receive these • Link to a Daily InfoPOEM

20. Guidelines.gov • Stored at National Guidelines Clearinghouse • Agency for Healthcare Research and Quality • Over 2365 Guidelines may be • Explicit evidence-based • Evidence-based • Research-based (highly referenced) • “expert consensus” • Multiple guidelines on one condition • Link to guideline – see Recommendations

21. US Preventive Services Task Force • First convened by the U.S. Public Health Service in 1984 • Since 1998 Agency for Healthcare Research and Quality • Leading independent panel of private-sector experts in prevention and primary care • Conducts rigorous, impartial assessments of the scientific evidence for effectiveness of broad range of clinical preventive services, including screening, counseling, and preventive medications • Its recommendations considered "gold standard" for clinical preventive services • Link to Online Tool

22. Trip Database Linked to Trip Allows you to put in your PICO terms and search Pubmed, ClinicalTrials, Guidelines, as well as lower level online resource like eMedicine.