EBP in practice…

1. EBP in practice…

2. 43-year-old woman with 1-3 migraine headaches per week. • Otherwise healthy. • Stress is a significant trigger for her headaches, • Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost. • She prefers “alternative” approaches • Has heard that acupuncture can help migraines.

3. The patient asks: • Should she pursue treatment with us or try an “alternative” approach such as acupuncture? • What do we think would be the most effective treatment for her?

4. The 5-stepprocess: • Convert information needs into a clear question. • Search for the best evidence in the literature. • Critically appraise the evidence. • Integrate with a patient’s needs, preferences, circumstances, and values. • Evaluate the outcome.

6. Background Questions • What are the most effective treatments for chronic migraine headache? • Pharmacological • Non-pharmacological • Is acupuncture an effective treatment for migraine headache? • Are there any significant risks associated with acupuncture?

7. Foreground Questions P = I = C = O = In middle aged women with migraine headaches is there any evidence that acupuncture compared to sham treatment, biofeedback, relaxation training, and cognitive-behavioral therapy reduces the frequency, intensity, and/or duration of migraines?

8. Background vs. Foreground Questions: Where to look Background questions  EB e-textbooks [UpToDate, Clinical Evidence] EB guidelines, systematic reviews, ESTs Foreground questions  if not found at a higher level, search MEDLINE / PsycINFO search

10. UptoDate and Clinical Evidence for background information • Two evidence-based guidelines • AAN (pharmacological and non) • Headache Consortium (behavioral and physical treatments)

12. Acupuncture for idiopathic headache

13. Conclusion from Cochrane Systematic Review: • Existing evidence supports the value of acupuncture for the treatment of idiopathic headaches… • There is insufficient evidence to assess … whether it is as effective as other headache treatments.” • No significant risks.

14. SUMMARIES What did we find? SYNTHESES Clinical Evidence and UptoDate, e-textbooks: • Evidence-based up to date background information on migraine Recent evidence-based guidelines on HA management: • American Academy of Neurology • Headache Consortium (behavioral and physical treatments) Systematic reviews: • From the Cochrane Library: • “Acupuncture for idiopathic headache” • Two reviews on “Is acupuncture safe?” Specific EBP search tools in Medline and PsycINFO (MeSH terms/ filters/ clinical queries in PubMED) Individual articles

15. What did we know thus far? • Acupuncture > sham or no tx • ? Compared to other txs • Relatively safe • Relaxation, CBT, and BFT ….have all been shown to reduce migraine headaches between 40-60%.

16. Foreground questions: • In middle aged women with migraine, is CBT more effective than biofeedback in reducing frequency, duration or intensity of migraine headaches? • Or…In middle aged women with migraine, is acupuncture more effective than CBT in reducing frequency, duration or intensity of migraine headaches?

17. Medline and PsycINFO

18. PsycINFO and PubMed: Important search concepts • Why not just type in keywords? • Truncation • Alerts

19. Why not just type keywords? Keywords look for that exact word in the article. Acupuncture……………Acupressure Behavior……………….. Behaviour Tension headache……… Muscle contraction headache Depression………………Major depressive disorder dysthymia

20. Controlled Vocabulary Librarians “tag” each article with labels based on the concepts in the article. These labels are standardized. This allows the user to retrieve information that uses different terminology for the same concept. Medline: MeSH terms

21. Truncation Keywords look for that exact word in the article. Acupuncture……………Acupressure (acup$) Behavior……………….. Behaviour (behav*) Tension headache……… Muscle contraction headache Depression………………Major depressive disorder dysthymia

22. How to do a Medline/ PsycINFO EBP search: • Select terms from the controlled vocabulary list • Search each term individually • Use AND / OR to combine the sets. • Limit to Humans and English • Limit to EBM reviews.

23. …and we set up Alerts

24. Alerts • Individual journals and databases • Medline and PsycINFO: • save your search • automatic email • Partner with your medical librarian • Ask people in your own field…

25. EBP begins and ends with the patient

26. Relaxation, BFT, • CBT: A • Behavioral therapy + • Med : B • Acupuncture: some evidence but inconclusive • More evidence for acupuncture than other “alternative” treatments • Acupuncture is low risk Best research evidence CD Patient Characteristics, Values, and Context Clinical Expertise

27. Best research evidence Prefers “alternative” treatments Concerned about cost No co-morbid conditions Similar to pts in studies Behavioral treatments feasible Insight into the link between stress and headaches Cost of acupuncture unknown at time of assessment Not needle-phobic CD Patient Characteristics, Values, and Context Clinical Expertise

28. Best research evidence CD • Assess the patient accurately • Communicate with the patient • Integrate the research and clinical evidence • Ability to deliver the txs of choice? Patient Characteristics, Values, and Context Clinical Expertise

29. Step 4: Applying the evidence • Clinical intervention that involves the patient • Clinical decision is made jointly

30. The Clinical Decision: Begin treatment with BFT and relaxation training “Alternative” treatment Affordable, feasible Incorporate CBT Monitor outcome Reconsider acupuncture therapy

31. Questions and Discussion….