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Using evidence for patient care

Using evidence for patient care. Keeping up on the medical literature: evidence to improve patient care Angelo Tomedi, MD Rania Khan, MD Department of Family and Community Medicine. Using evidence for patient care.

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Using evidence for patient care

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  1. Using evidence for patient care Keeping up on the medical literature: evidence to improve patient care Angelo Tomedi, MD Rania Khan, MD Department of Family and Community Medicine

  2. Using evidence for patient care • “Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half. So the most important thing to learn is how to learn on your own.” • --- David Sacket (widely regarded as the father of evidenced-based medicine)

  3. Using evidence for patient care • About 40 percent of what we consider state-of-the-art health care is likely to turn out to be unhelpful or actually harmful. • Vinayak K. Prasad and Adam S. Cifu. Ending Medical Reversal: Improving Outcomes and Saving Lives. September 2015

  4. Using evidence for patient care OBJECTIVE:identify medical practices that offer no net benefits We reviewed all original articles published in 10 years (2001-2010) in one high-impact journal. Of the 363 articles testing standard of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it. --- Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013;88:790–8

  5. EvidenceAlerts “EvidenceAlerts” is a collaboration of DynaMed Plus and McMaster University's Health Information Research Unit. Articles are chosen from “over 110 premier clinical journals,” are pre-rated for quality then rated for clinical relevance and interest. It’s FREE! Web site: https://plus.mcmaster.ca/EvidenceAlerts/

  6. ACP Journal Club The journal Ann.Intern.Med includes 9-10 reviewed articles in each monthly issue. The journal is available full text from UNM HS Library web page. Under “Worldcat” tab, click on “E-journal” and enter “ACP Journal Club” in the “Title” search box, click on “search.”

  7. ACP Journal Club Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians “Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.”

  8. POEMs POEMs (“Patient-Oriented Evidence that Matters”) Research Summaries are synopses of new evidence filtered for relevance to patient care and evaluated for validity. Reviews and appraises 3000+ studies published monthly in more than 100 journals. Database of EssentialEvidence Plus Web site: https://www.essentialevidenceplus.com/product/features_ir.cfm?show=infopoems/

  9. Evidence-Based Medicine The journal Evidence-based Medicine is available full text from UNM HS Library web page. Under “Worldcat” tab, click on “E-journal” and enter “evidence based medicine” in the “Title” search box, click on “search,” click on “evidence based medicine.”

  10. Example #1 N.B. is a 39 y.o. female with chronic back pain. She is in clinic for a follow-up visit after being started on gabapentin 2 months ago. She reports only minimal improvement since starting gabapentin. Since she is only taking 300 mg bid, the resident considers increasing the dose of gabapentin.

  11. Example #1 If the resident had been reading EvidenceAlerts, she might have seen the following article that appeared 2 weeks before seeing this patient: Enke O, New HA, New CH, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. CMAJ. 2018 Jul 3;190(26):E786-E793

  12. Example #1 “Nine trials compared topiramate, gabapentin or pregabalin to placebo in 859 unique participants…” There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.

  13. Example #2 S.F. is a 61 y.o. male with diabetes and HTN who is seeing you for a routine scheduled follow-up visit. He is a current smoker with a 50 pack-year smoking history. After the DM and HTN issues are addressed, you ask about smoking cessation and he states that he is not yet ready to quit.

  14. Example #2 In the past you would have stopped the discussion at this point except to offer help if or when he decides to attempt to quit. But you recently saw the following article in EvidenceAlerts: Ali A, Kaplan CM, Derefinko KJ, et al. Smoking Cessation for Smokers Not Ready to Quit: Meta-analysis and Cost-effectiveness Analysis. Am J Prev Med. 2018 Jun 11. pii: S0749-3797(18)31704-5

  15. Example #2 Twenty-two studies on pharmacological, behavioral, and combination smoking-cessation interventions targeting smokers not ready to quit were analyzed. Smoking interventions targeting smokers not ready to quit can be as effective as similar interventions for smokers ready to quit… The most cost-effective interventions identified for this group were those using varenicline and those using behavioral interventions.

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