Session I: Evidence Based Medicine and PICO Clinical Question

1. Session I: Evidence Based Medicine and PICO Clinical Question Medical Library & Peyton T. Anderson Learning Resources Center Macon, GA reference.ill@gain.mercer.edu Memorial University Medical Center Health Sciences Library Savannah, GA library@memorialhealth.com • Mercer University School of Medicine

2. Session I Objectives: Participants will: • Identify key elements of the EBM process, including: • formulating a clinical question • locating the best evidence • evaluating the evidence for validity • Describe the elements of a PICO clinical question • Identify and locate online EBM resources

3. Session I Objectives (Cont.): • Work in groups  to evaluate online EBM resources, including: • Dynamed • Cochrane Database of Systematic Reviews • National Guideline Clearinghouse • Present their group evaluations of the EBM resources to the class • Learn the basic PubMed searches and also utilize advanced features of PubMed

4. Your Patient: • Shannon, a 19-year-old African American female, visits her local health clinic for her annual STD screening. Shannon is asymptomatic but tests positive for Syphilis. Testing also reveals Shannon is 3-weeks pregnant. She is concerned for the health of her baby. As a physician, what do you do to help Shannon and get her the treatment she needs?

5. What is Evidence-based Medicine (EBM)?

6. Steps in the EBM Process: Formulate a Clinical Question Use EBM resources to find evidence Evaluateevidence for validity Apply evidence to your patient

7. What is PICO? • A PICO is a well-built clinical question that seeks a specific answer based on the best evidence available. A well-constructed and thoughtful question makes the search for evidence easier.

8. PICO = Patient or Population – Sex, age, race? Primary complaint? Disease History? Intervention – What do you want to do for them? Prescribe a drug? Order a test? Comparison – What alternatives do you want to compare the intervention to? Outcome – What do you hope to accomplish, improve or affect? Relieve or reduce symptoms? Improve function or improve test scores?

9. Our Patient’s PICO: • P (atient) = 19-year-old African American female with secondary syphilis and in 1st trimester of pregnancy • I (ntervention) = treatment with Penicillin • C (omparison) = alternative treatments • O (utcome) = a healthy pregnancy and delivery for mom and baby; prevention of congenital syphilis in baby

10. Locating the Best Evidence: Medical literature is immense Only a small portion is immediately useful in answering clinical questions Literature reports the whole spectrum of the scientific research process

11. Pyramid of Evidence:

12. Levels of Evidence (LOE): Rules of evidence have been established to grade evidence according to its strength Several dozen of these hierarchies exist Some systems comprise three levels and others eight or more

13. Group Assignmenthttp://med.mercer.edu/lib/ • Group 1: Dynamed • Group 2: Cochrane Database of Systematic Reviews • Group 3: National Guideline Clearinghouse • 10 minutes prep, 5 minutes per group for presentations • Things to consider while searching: • Where is the information coming from? Is the source reliable? • How current is the information? When was it last updated? • What level(s) of evidence does this resource contain? • How is the information presented? Would it be useful as a point-of-care resource? • Was it easy to search for/find the information? • What did you particularly like/dislike about the resource?

14. Your Patient: • Shannon, a 19-year-old African American female, visits her local health clinic for her annual STD screening. Shannon is asymptomatic but tests positive for Syphilis. Testing also reveals Shannon is 3-weeks pregnant. She is concerned for the health of her baby. As a physician, what do you do to help Shannon and get her the treatment she needs?

15. Group Reports

17. Dynamed: • Point-of-care medical information database • Includes content of 3,200+ clinical evidence-based topics • Draws from 500+ medical journals • Each article is evaluated for clinical relevance and scientific validity • Conclusions based on evidence systematically identified, selected and evaluated from the literature • Updated daily • Peer reviewed • Levels of evidence included in descending order

19. Cochrane Systematic Reviews: • Part of the Cochrane Library, a collection of 6 EBM databases • Methodology considered to be the “gold standard” for systematic reviews • Reviews address specific questions about the effects of clinical interventions, including treatments, prevention, screening and rehabilitation. Meta-analysis may be performed. • Full-text and plain language summaries available • Updated daily • Abstracts can also be found in other resources (i.e. PubMed, DynaMed, etc.)

21. National Guideline Clearinghouse: • Initiative of the Agency for Healthcare Research and Quality (AHRQ) • Includes evidence-based clinical practice guidelines • Provides a mechanism for obtaining objective, detailed information on recommendations for practice • Expert commentaries included • Guideline Syntheses address similar topic areas • Full-text and summaries available • Ability to compare two or more guidelines side-by-side

22. PubMed Basics:Searching PubMed at Mercer

23. Boolean Terms = Syphilis AND Pregnancy Syphilis Pregnancy SYPHILIS OR PREGNANCY Syphilis OR Pregnancy Syphilis Pregnancy

24. Searching PubMed at Mercer

36. Got all that? PubMed is brought to you by…. Your tax dollars at work!