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Effective Clinical Question Search

Learn how to efficiently search for evidence-based answers to clinical questions and improve patient care. This session will provide strategies for acquiring, appraising, and applying the best evidence based on clinical expertise and circumstances.

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Effective Clinical Question Search

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  1. <?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 /> Evidence-Based Medicine: How to Effectively and Efficiently Search for the Answer to your Clinical Questions Donna Windish, MD, MPH Associate Professor of Medicine

  2. What is the Importance of Answering Clinical Questions? • Provide evidence-based care • Teach patients and colleagues • Lifelong self-directed learning

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

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

  5. Epidemiology of clinical questions Studies of outpatient physicians • For every 3 patients seen in the office, 2 clinical questions were generated1,2,3 • Most questions involved therapy and diagnosis • Majority of questions deemed clinically important • 30% pursued, often using non-evidence-based sources • Factors predicting pursuit of an answer • 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)

  6. 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).

  7. Step 1: Ask Identify information and translate this into answerable clinical questions

  8. 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

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

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

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

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

  13. Foreground Question (PICO) Therapy/Prevention Question In Action

  14. Foreground Question (PICO) Therapy/Prevention Question In Action

  15. Foreground Question (PICO) Therapy/Prevention Question In Action

  16. Foreground Question (PICO) Therapy/Prevention Question In Action

  17. Foreground Question (PICO) Therapy/Prevention Question In Action

  18. Why Ask Clinical Questions So Specifically?

  19. 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 • Communicate clearly with other clinicians

  20. Efficiently acquire the best evidence Step 2: Acquire

  21. 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

  22. EBM 2015 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

  23. Hierarchy of EBM Resources Full integration (CDSS) EMR and POE push technology patient specific info systems Clinical Evidence ACP Smart Medicine 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-

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

  25. 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

  26. Yes, There’s an App for ThatiPhone

  27. Yes, There’s an App for ThatiPhone

  28. Yes, There’s an App for ThatiPhone

  29. Yes, There’s an App for ThatiPhone

  30. 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 PubMed4Hh App ACP Smart Medicine Guideline Central App

  31. <?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 />

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