EBM WORKSHOP

2012.1.17
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EBM

components EBM contest

EBM COMPONENTS

Information Mastery (IM) Critical Appraisal (CA) Knowledge Translation (KT)

LEVELS OF EDUCATION IN EBM

Level 3: Residency (graduate medical education)

Plan and implement simple research studies Develop EBM teaching skills Use EBM and epidemiological evidence in daily patient care Create new practice patterns based on critical reading Use the Journal Club as a vehicle for development of critical appraisal Demonstrate the use of EBM at the point of care under VS Supervise medical student EBM projects EBM Forte for those whose had undergraduate EBM training Create clinically useful forms of new evidence Perform advanced EBM projects such as systematic reviews Use EBM in quality improvement projects

A FRAMEWORK FOR TEACHING EVIDENCE BASED MEDICINE (EBM), A KNOWLEDGE TRANSLATION TOOL, ACROSS THE MEDICAL CURRICULUM 4 Interest Group of the Society of Academic Emergency Medicine

EBM COMPONENT

(5A)
- Ask - Acquire - Appraisal - Apply - Audit

 ASK

 - ASK
EBM

EBM

Foyacute

pancreatitis bronchiolitis PICO

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 - PICOS

PICO(S)?

Population (patient):

How would I describe a group of patients similar to mine? Which main /new intervention am I considering? What is the alternative to compare with the intervention? (placebo,standard of care, etc.) What can I hope to accomplish, measure, improve, or affect? What study design would provide the best level of evidence for this question?

Intervention (therapy):

Comparison:

Outcome:

Study design

 - PICOS

PICOS

CTASAH

Solution?

 - PICOS

PICO(S) in diagnostic study

Population

What are the characteristics of the patients? What is the condition that may be present? Which diagnostic test am I considering? What is the diagnostic gold standard? How likely is the test to predict/rule out this condition?
What study design would provide the best level of evidence for this question?

Intervention (diagnostic test)

Comparison

Outcome

Study design

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 - PICOS

PICO(S) in prognostic study

Population

How would I describe a cohort of patients similar to mine? Which main prognostic factor am I considering? What is the diagnostic gold standard? How likely is the test to predict/rule out this condition?
What study design would provide the best level of evidence for this question?

Intervention (prognostic factor)

Comparison

Outcome

Study design

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 - ASK

EBM? PubMed

PICO! http://PubMedhh.nlm.nih.gov/ nlmd/pico/piconew.php

hao0903.pixnet.net/ blog/category/558005/3

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 ACQUIRE

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 - ACQUIRE
EBM?

PubMed OVID MEDLINE

DynaMed ACP Journal club CDSR Cochrane Database of Systematic Review CCTR Cochrane Central Register of Controlled Trials DARE Database of Abstracts of Reviews of Effectiveness
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 - ACQUIRE

EBM BestBETs:
http://www.bestbets.org/ Free

DynaMed:
http://www.ebscohost.com/dynamed/ Need subscription

Journal Watch
http://www.jwatch.org/ Need subscription
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 - ACQUIRE
PubMed PICO,PubMed (or Medline)?

http://www.ncbi.nlm.nih.gov/PubMed/clinical http://www.ncbi.nlm.nih.gov/PubMed/

MeSH term?

Medical Subject Headings

Boolean logic
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DIFFERENCE BTW PUBMED VS. OVID MEDLINE

Use PubMed

If you want to learn a MEDLINE interface that will be always available to you, even if you leave CGMH. If you are off-campus and having connection issues. When you want quick results with strategies automatically created for you. When you are looking for extremely recent citations. When you also want to search for genetics and molecular biology information. To be guided through selections for a precise search based on Medical Subject Headings, subheadings, and limits. To build a search strategy in steps and by trying multiple combinations.
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Use Ovid MEDLINE

DIFFERENCE BTW PUBMED VS. OVID MEDLINE

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MESH HEADING - ACQUIRE

Strength of MeSH
Secondary topic pre-linked to a MeSH term by an indexer Standardization

Aortic rupture vs. Ruptured aorta vs. Rupture of the thoracic aorta

Focus/major topic Subheadings Explode

Find MeSH below in the tree Difference between PubMed vs. Ovid MEDLINE

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MESH HEADING - ACQUIRE

Limitation
Not

for all (e.g. Aortic dissection) Not for recent citations Not every word in abstract New MeSH not retroactive

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TEXT WORD SEARCHING - ACQUIRE

Helpful if no MeSH term, and to supplement MeSH Strength

Instant index Up-to-date terminology Every word in abstract searchable

Challenge
Easy to miss information Different words for same topic

Cant

use Explode, Focus, or Subheadings

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TEXT WORD SEARCHING - ACQUIRE

Searching for variations

Truncation character (*): Sep* Synonyms: Sepsis, bacteremia British spellings: Baecteremia Break up phrases

Septic shock sep* AND shock ($ = *

? OR #)

Search MeSH as major topic (focus)

then scan results to see variation in titles PubMed: Entry Terms Ovid MEDLINE: [i] in mapping or tree display; look for used for list
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Display MeSH scope note

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SEARCH PROCESS (1/4) - ACQUIRE

Analyze the question

Identify critical topics, keeping only essential ones (fewest possible) Most important topic first Why? Different thought processes: MeSH
Use mapping; check Tree display to decide whether to explode Make major topic (focus) decision Check Subheadings for exact match to search topic.

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Search each topic separately

Create separate result sets for MeSH and for text words

SEARCH PROCESS (2/4) - ACQUIRE

Create separate result sets for MeSH and for text words (cont)

Text words

Type synonyms, Use truncation character, Different spellings, spacings, etc. Combine word variations using OR

(RU486 or RU 486 or RU-486).

Be sure topics in text word search match topics in MeSH search. If MeSH is major topic, search text words in title only (major point).
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SEARCH PROCESS (3/4)

Combine set numbers

Use

OR to combine words or set numbers expressing SAME TOPIC.

Computer

merges results and eliminates duplicates.

Use

AND to combine words or set numbers expressing DIFFERENT topics

Computer

finds citations with both topics (or all, if >2)

Use

parentheses to avoid logic errors PubMed: (#6 OR #9) AND (#12 OR #15) and (5 OR 8)

Ovid: 1

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SEARCH PROCESS (4/4) - ACQUIRE

Too many irrelevant citations?

Make one or more topics a major point (focus). Review articles Core Clinical Journals NEJM, JAMA, and other frequentlyused journals Valid clinical evidence limits: Publication Type, Subject Subset Search all MeSH and text word variations match topics. If see another good MeSH, add it to your search.
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LIMIT to target large search results better:

Look at MeSH Headings assigned to the best results.

 APPRAISAL

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 - APPRAISAL

EBM

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Lancet 2002; 359: 57-61

 CRITICAL APPRAISAL

VIP principle
Validity, Validity
(closeness

Impact & Practice applicability

to the truth): chance (p value, power, confident interval), bias (selection, measurement, recall bias)?
Impact
(size

of the effect): NNT, NNH (ARR, RRR...)

Practice

applicability
in our clinical practice)
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(usefulness

ILLUSTRATION OF PRECISION VS. ACCURACY

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VALIDITY - RAM-BO

1. Representative?
selection)//) ,? ( (random allocation)/)
(random

2. Ascertainment/follow-up?
//>80%

3. Measurement
(blinded) (objective)
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 - CRITICAL APPRAISAL

vs. t-PA

RR for bad outcome

(+) EER/CER 0.56/0.66 = 0.83 NNT? NNT=9

ARR

for poor/no recovery

2/18 = 1/9 NNH? NNH=18

AHI

for bleeding

1/18

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 - CRITICAL APPRAISAL
crude outcomeRR

Not

so good

(8/18) tPA1/6RRR=0.16
tPAoutcome

NNTNNH
Better
9tPA 18tAP
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 APPLY

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 - APPLY
threshold model Likelihood ratio

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THRESHOLD MODEL
Go Home 0% More Testing Gold Standard Treat! 100%

Probability Of Disease

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LRTHRESHOLD MODEL

Pretest probability = 5%, odds5/95 = 1/19 CT (+), CTLR(+)=19 post-test odds = 1/19 x 19 = 1 Post-test probability = 1/(1+1) = 0.50 = 50%
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LIKELIHOOD RATIO - APPLY

!

LR (+) = (TPR/FPR) = sen/(1-spe)

! positivepositive

LR (-) = (FNR/TNR) = (1-sen/spe)

! negativenegative

LR(+)>10LR(-)<0.1
! pre-test

probability

! PEHistory

!
! http://araw.mede.uic.edu/cgi-bin/testcalc.pl
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 - APPLY

()disposition

Disposition Likelihood ratio (LR)

Tintinalli

performance ()
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TABLE FROM TINTINALLI

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 - MEDCALC

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Practical Teaching in Emergency Medicine Robert L. Rogers , Amal Mattu , Michael Winters , Joseph Martinez

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Users' Guides to the Medical Literature: Essentials of EvidenceBased Clinical Practice, Second Edition (Jama & Archives Journals) Gordon Guyatt , Drummond Rennie , Maureen Meade , Deborah Cook

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Evidence-Based Medicine: How to Practice and Teach EBM David L. Sackett , Sharon E. Straus, W. Scott Richardson, William Rosenberg, R. Brian Haynes

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Evidence-based Medicine Toolkit (Evidence-Based Medicine) Carl Heneghan Douglas Badenoch

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PubMed: http://www.ncbi.nlm.nih.gov/PubMed/ ACP Journal Club: http://www.acpjc.org/ CDSR (Cochrane Database of Systematic Reviews) ~ http://www3.interscience.wiley.com/cgi-bin/mrwhome/ 106568753/HOME?CRETRY=1&SRETRY=0 Cochrane ~ CCTR (Cochrane Central Register of Controlled Trials) : http://onlinelibrary.wiley.com/o/ cochrane/cochrane_clcentral_articles_fs.html Cochrane ~ DARE (Database of Abstracts of Reviews of Effects): Centre for Evidence-Based Medicine: http:// www.cebm.net
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McMaster UniversityHIRU(Health Information Research Unit) Cochrane Collaboration: http://hiru.mcmaster.ca/ American College of Physician(ACP): http://www.acponline.org NGC (National Guideline Clearinghouse): http://www.guideline.gov/ Bandolier: http://www.ebandolier.com : http://www.jr2.ox.ac.uk/ bandolier/AHRQ website: http://www.ahrq.gov InfoPOEMs: http://www.infopoems.com Micromedex (CCIS) , http://www.uptodate.com/ http://www.mdconsult.com/ CINAHL (Cumulative Index to Nursing and Allied Health Literature) Joanna Briggs Institute (JBI)

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TAKE HOME POINTS

EBM components
- Ask - Acquire - Appraisal - Apply - Audit

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Questions?
kfchen@cgmh.org.tw

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