EVIDENCE EVIDENCE- -BASED HEALTH CARE BASED HEALTH CARE BASED - PowerPoint PPT Presentation

EVIDENCE EVIDENCE- -BASED HEALTH CARE BASED HEALTH CARE BASED HEALTH CARE EVIDENCE EVIDENCE BASED HEALTH CARE … AND OTHER MYTHS OF A MODERN AGE … AND OTHER MYTHS OF A MODERN AGE AND OTHER MYTHS OF A MODERN AGE AND OTHER MYTHS OF A MODERN AGE Peggy Mancuso, PhD, CNM, RN Peggy Mancuso, PhD, CNM, RN . . 1

An Overview of EBM An Overview of EBM 2

Evidence- -Based Health Care Based Health Care Evidence Definition Definition � Conscientious, explicit, judicious use Conscientious, explicit, judicious use � � Current best evidence Current best evidence � � To make decisions about health care To make decisions about health care � � Application of working knowledge to treatment: Application of working knowledge to treatment: � � Medical informatics Medical informatics � � Clinical epidemiology Clinical epidemiology � � Integration of: Integration of: � � Clinical expertise Clinical expertise � � Best external evidence Best external evidence � � Patient and society values Patient and society values � � Patient expectations Patient expectations � 3

Ways to Classify the Evidence Ways to Classify the Evidence Type of Review – – or Individual Study or Individual Study Type of Review Systems Systems 1. 1. Synopses Synopses 2. 2. Syntheses Syntheses 3. 3. Studies Studies 4. 4. 4

Hierarchy of Evidence Hierarchy of Evidence Classification of Intervention Studies Classification of Intervention Studies Evidence Therapy/prevention/etiology/harm Evidence Therapy/prevention/etiology/harm Level Level 1a Systematic review with homogeneity of RCTs Systematic review with homogeneity of RCTs 1a Individual RCT with narrow confidence interval 1b Individual RCT with narrow confidence interval 1b 1c All or none All or none 1c 2a Individual cohort study or ↓ ↓ quality RCT quality RCT 2a Individual cohort study or 3a Systematic review with homogeneity of case- Systematic review with homogeneity of case -control control 3a Individual case- -control control 3b Individual case 3b 4 Case series (poor cohort or case- -control) control) Case series (poor cohort or case 4 5 Expert opinion without explicit critical appraisal or 5 Expert opinion without explicit critical appraisal or based on physiology or bench research based on physiology or bench research 5

The Most Basic of Statistics The Most Basic of Statistics � Validity Validity � � Accuracy of measure Accuracy of measure � � Measure what we intends? Measure what we intends? � � Reliability Reliability � � Repeatability of measure Repeatability of measure � � P P- -value (probability) value (probability) � � Not as good as we think Not as good as we think � � Number needed to treat Number needed to treat � � Number needed to harm Number needed to harm � Source: Stroudwater Associates - MacKinney 6

Two Different Approaches to Two Different Approaches to Evidence- -Based Practice Based Practice Evidence � Clinical practice guidelines Clinical practice guidelines � � “Top “Top- -down” approach down” approach � � Tell clinicians how to practice Tell clinicians how to practice � � Favored by health care systems Favored by health care systems � � Evidence Evidence- -based medicine based medicine � � “Bottom “Bottom- -up” approach up” approach � � Teach clinicians how to find answers Teach clinicians how to find answers � � Favored by medical educators Favored by medical educators � 7

Basic 5- -Step Process of Evidence Step Process of Evidence- - Basic 5 Based Practice Based Practice Formulate the question Formulate the question 1. 1. Search for answers Search for answers 2. 2. Appraise the evidence Appraise the evidence 3. 3. Apply the results Apply the results 4. 4. Assess the outcome Assess the outcome 5. 5. 8

Methods of Evidence- -Based Practice Based Practice Methods of Evidence � Formulate the question Formulate the question � � Patients or problem of interest Patients or problem of interest � � Intervention Intervention � � Control or alternative treatment Control or alternative treatment � � Outcome of interest Outcome of interest � � Search for answers Search for answers � � Appraise the evidence Appraise the evidence � � Apply the results Apply the results � � Assess the outcome Assess the outcome � Mark A. Goedecker, MD Mark A. Goedecker, MD 9

Example of 4- -Part Question (PICO) Part Question (PICO) Example of 4 � Patients or problem of interest Patients or problem of interest � � In patients who have become pregnant through ART In patients who have become pregnant through ART � � Intervention Intervention � � Does the addition of progesterone during first trimester Does the addition of progesterone during first trimester � � Control or alternative treatment Control or alternative treatment � � When compared to usual care alone When compared to usual care alone � � Outcome of interest Outcome of interest � � Increase percentage of pregnancies that progress to term Increase percentage of pregnancies that progress to term � birth of healthy newborns? birth of healthy newborns? Mark A. Goedecker, MD Mark A. Goedecker, MD 10

Methods of Evidence- -Based Practice Based Practice Methods of Evidence � Formulate the question Formulate the question � � Search for answers Search for answers � � What type of study best answers the question? What type of study best answers the question? � � Where can I quickly find the evidence? Where can I quickly find the evidence? � � Appraise the evidence Appraise the evidence � � Apply the results Apply the results � � Assess the outcome Assess the outcome � Mark A. Goedecker, MD Mark A. Goedecker, MD 11

Examples Examples Computerized Computerized Syste ms decision support decision support Evidence-based Evidence-based Synopses journal abstracts journal abstracts Cochrane reviews Cochrane reviews Synthese s Original journal Original journal Studies articles articles Page 34 Page 34 12

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Searching for Answers → → Examples Examples Searching for Answers The “4S” Approach The “4S” Approach � Systems Systems (comprehensive resources) (comprehensive resources) � � Good Clinical Decision Support for Electronic Good Clinical Decision Support for Electronic � Medical Records Medical Records � Clinical Evidence ( Clinical Evidence (www.clinicalevidence.com www.clinicalevidence.com) ) � � British Medical Group British Medical Group � � UptoDate ( UptoDate (www.uptodate.com www.uptodate.com) (updated quarterly) ) (updated quarterly) � � E E- -textbook textbook � � Collection of evidence Collection of evidence- -based guidelines based guidelines � � Some incorporated within electronic medical record Some incorporated within electronic medical record � 14

Searching for Answers: Searching for Answers: The “4S” Approach The “4S” Approach � Syntheses Syntheses (systematic reviews) (systematic reviews) � � Cochrane Database (OVID) Cochrane Database (OVID) � (www.cochranelibrary.com www.cochranelibrary.com) ) ( � DARE ( DARE (http://agatha.york.ac.uk/darehp.htm http://agatha.york.ac.uk/darehp.htm) ) � 15

Searching for Answers: Searching for Answers: The “4S” Approach The “4S” Approach � Studies Studies (original research) (original research) � � OVID OVID � � PubMed PubMed � � http://www4.ncbi.nlm.nih.gov/entrez/query.fcgi http://www4.ncbi.nlm.nih.gov/entrez/query.fcgi � � Clinical queries screen has built Clinical queries screen has built- -in filters in filters � � Type of question Type of question � � Sensitivity versus specificity Sensitivity versus specificity � 16

Alternatives to the “4S” Search Approach Alternatives to the “4S” Search Approach – or help to find the studies or help to find the studies – � TRIP database ( TRIP database (www.tripdatabase.com www.tripdatabase.com) ) � � Searches Cochrane, DARE, collections of systematic reviews Searches Cochrane, DARE, collections of systematic reviews � and guidelines, and some on- and guidelines, and some on -line journals line journals � Links to PubMed clinical queries Links to PubMed clinical queries � � SUMSearch ( SUMSearch (http://sumsearch.uthsca.edu http://sumsearch.uthsca.edu) ) � � Searches MEDLINE, DARE, National Guidelines Searches MEDLINE, DARE, National Guidelines � Clearinghouse Clearinghouse � Takes longer than TRIP Takes longer than TRIP � 17

Methods of Evidence- -Based Based Methods of Evidence Practice Practice � Formulate the question Formulate the question � � Search for answers Search for answers � � Appraise the evidence Appraise the evidence � � Critical appraisal worksheets Critical appraisal worksheets � � Apply the results Apply the results � � Assess the outcome Assess the outcome � 18