Evidence-Based Medicine Introduction

1. Evidence-Based MedicineIntroduction Department of Medicine - Residency Training Program Tuesdays, 9:30 a.m. - 12:00 p.m. - UW Health Sciences Library

2. Faculty Director: Matt Hollon MD MPH, Assistant Professor, UWMC General Internal Medicine, e-mail: mfhollon@u.washington.edu Instructors: Erin Fouch MD, Outpatient Chief Resident, July-December, e-mail: emsfouch@u.washington.edu Travis Baggett MD, Outpatient Chief Resident, January-June, e-mail: baggettt@u.washington.edu Librarians: Sherry Dodson MLS, Clinical Medical Librarian, UW Health Sciences Library, e-mail: sdodson@u.washington.edu

3. Course Web Sitehttp://courses.washington.edu/ebmed/EBM/index.shtml You can link to this site from the Medicine Residency web page, the Roosevelt GIMC Residents’ web page, or HSL Evidence Based Practice web page.

4. Evidence-based medicine is the integration of the best available research evidence with clinical expertise and patient values.

5. Why Teach and Practice EBM? • It is required to be taught by ABIM. • Outcomes research has documented that patients who do receive evidence-based therapies have better outcomes than those who don’t. • It may be a more efficient means of remaining current than traditional methods (e.g. journal subscriptions). • A host of developments make EBM more possible than ever.

6. Developments • Efficient strategies for tracking and appraising evidence. • Availability of evidence-based journals. • Creation of systematic reviews and concise summaries. • Information systems allowing access to resources in seconds.

7. Objectives • Hands-on, real-time learning of skills necessary to incorporate EBM into your daily practice of medicine. • Provide the opportunity to apply these skills to actual clinical encounters. • Have fun learning and teaching others. • Minimize work outside of day to day clinical responsibilities.

8. Responsibilities • Attend all the sessions. • Each week during your clinical encounters generate at least one question about patient care you would like to try and answer in EBM. We will tackle these questions thematically (therapy, prognosis, diagnosis). • Apply and teach what you learn.

9. Steps in Practicing EBM • Convert the need for information into an answerable question. • Track down the best evidence with which to answer that question. • Critically appraise the evidence for its validity, impact, and applicability. • Integrate the evidence with our clinical expertise and our patient’s characteristics and values.

10. Limitations* • Time. • Shortage of coherent and consistent scientific evidence (therapeutic nihilism). • Challenges of applying evidence to care of individual patients. • General barriers to the practice of quality medicine (e.g. costs, patient expectations, etc.).

11. Putting Skills into Practice • Find evidence supporting one clinical decision made on each of your inpatients. • Find evidence supporting one clinical decision made on one patient per clinic day. • Encourage the students and colleagues you work with to follow your lead. • Work as a team to find evidence-based answers.

12. Course Structure - 8 week cycle • Week 1 • Introduction • Asking a clinical question • Critical appraisal of therapy articles • Therapy questions • Searching • Week 2 • Critically appraise therapy articles • Write CAT • New question and real-time practice session • Week 4 • Critically appraise prognosis articles • Write CAT • New question and real-time practice session • Week 3 • Review asking a clinical question • Critical appraisal of prognosis articles • Prognosis questions • Searching • Week 6 • Critically appraise diagnosis articles • Write CAT • New question and real-time practice session • Week 5 • Introduction • Asking a clinical question • Critical appraisal of diagnosis articles • Diagnosis questions • Searching • Week 7 • Review asking a clinical question • Critical appraisal of articles about harm • Searching • Week 8 • Critically appraise harm articles • Write CAT • New question and real-time practice session Think of Therapy ?’s Think of Prognosis ?’s Think of Diagnosis ?’s Think of Harm ?’s

13. The Answerable Question

14. Steps in Practicing EBM • Convert the need for information into an answerable question. • Track down the best evidence with which to answer that question. • Critically appraise the evidence for its validity, impact, and applicability. • Integrate the evidence with our clinical expertise and our patient’s characteristics and values.

15. Good questions are the backbone of practicing EBM. It takes practice to ask the well-formulated question.

16. SPECIFIC KNOWLEDGE TYPE OF QUESTION GENERAL KNOWLEDGE CLINICAL EXPERIENCE The nature of the question asked is critically experience dependent.

17. “Background” question composed of question modifier and condition. Cover the full range of biologic, psychologic, or sociologic aspect of human illness Can be answered by reference works.* Can be used as a trampoline for generating specific questions to be answered by EBM. “Foreground” question composed of patient and/or problem, intervention (therapy, diagnostic test, etc.), comparison and outcome. Often requires more comprehensive and intensive search strategies (not necessarily more time consuming). Suitable to answering using the techniques of EBM. Differences in Type of ?’s General Specific

18. Well-Built Clinical ?’s • Directly relevant to the care of the patient and our knowledge deficit. • Contains the following elements: • the patient or problem being addressed • the intervention or exposure being considered • the comparison intervention or exposure, when relevant • the clinical outcomes of interest.

19. Well Formulated ?’s • Focus scarce learning time on evidence directly relevant to patient’s needs and our particular knowledge needs. • Suggest high-yield search strategies. • Suggest forms that useful answers might take. • Help us to model life-long learning techniques for our colleagues and students. • Are answerable and, thus, reinforce the satisfaction of finding evidence that makes us better, faster clinicians.

20. Q: How do you find current best evidence? A: Ask your librarian!Sherry Dodson - Clinical Medical Librarian

21. Q: What is best evidence? OR Q: What kind of evidence is least likely to be wrong?

22. Steps in Practicing EBM • Convert the need for information into an answerable question. • Track down the best evidence with which to answer that question. • Critically appraise the evidence for its validity, impact, and applicability. • Integrate the evidence with our clinical expertise and our patient’s characteristics and values.

23. The Evidence Pyramid Time Spent in Critical Appraisal Validity/Strength of Inference

24. Levels of Evidence

25. Resources META-SEARCH ENGINES PrimeAnswers TRIP+ SUMSearch SYSTEMATIC REVIEWS/META-ANALYSES Cochrane Library PubMed Clinical Queries using Research Methodology Filters EVIDENCE GUIDELINES/SUMMARIES AHRQ Evidence Reports Clinical Evidence AHRQ Preventive Services CLINICAL RESEARCH CRITIQUES ACP Journal Club 1996- Bandolier 1994- BestBETs CASE REPORTS/SERIES, PRACTICE GUIDELINES, ETC National Guideline Clearinghouse PubMed

26. Steps in Practicing EBM • Convert the need for information into an answerable question. • Track down the best evidence with which to answer that question. • Critically appraise the evidence for its validity, impact, and applicability. • Integrate the evidence with our clinical expertise and our patient’s characteristics and values.