Overview Asking focused answerable questions Evidence Based - PDF document

APNA 27th Annual Conference Session 1031: October 9, 2013 Overview • Asking focused answerable questions Evidence Based Practice: • Conducting efficient searches Skills Boot Camp • Analyzing study methods • Determining how to implement evidence Joanne DeSanto Iennaco PhD, PMHNP ‐ BC Evidence Based Practice: Evidence Based Practice is : • “The conscientious, explicit and judicious use ‘The integration of best research of current best evidence in making decisions evidence with clinical expertise and about the care of individual patients . ” patient values .” (Sackett, DL, Rosenberg, WMC, Gray, JAM, Haynes, RB, Richardson, WS. Evidence based medicine: what it is and Sackett, DL, Straus, SE, Richardson, WS, Rosenberg, W., Haynes, RB. (2000). Evidence ‐ based medicine:How to practice and teach EBM. (p.1). Sackett DL Straus SE Richardson WS Rosenberg W Haynes RB (2000) Evidence based medicine:How to practice and teach EBM (p 1) what it isn’t. BMJ (1996) 312:71 ‐ 2.) h i i ’ BMJ (1996) 312 71 2 ) • What is the ‘best research evidence’? • What is ‘clinical expertise’? • What do we mean by ‘patient values’? Asking a Focused Question… Steps in Evidence Based Practice 1. Identify a question (PICO) PICO • P = The Patient or Population 2. Find the best evidence to answer question “Who will be the focus?” 3. Critically appraise the evidence for validity, EX: In (patient, problem, risk factor) does… • I = Intervention or Clinical Action impact and applicability impact and applicability “What is the Exposure or the Treatment of interest?” 4. Integrate evidence with clinical expertise EX: does Treatment A compared to … • C = Comparison and patient values/wishes EX: Compared to Treatment B Reduce… 5. Evaluate process (prior steps) to improve • O = Outcome next time EX: Reduce Outcome of interest Iennaco 1

APNA 27th Annual Conference Session 1031: October 9, 2013 Refining the Question Prioritizing: Deciding on a Question • Disease/Condition: – Patient: Severity, Duration, Cost • State of the science may dictate – Societal: Prevalence, Severity, Costs • Too few studies… go up! • Intervention: – Potential for meeting unmet needs, Lowering cost • Too many studies… • Practice Change: …move down! move down! – How would it benefit practice? Preferences? Timing? – Motivation to change • Specificity important • Feasibility: – What age group? – Information/data availability – What dose? – Cost • Other: – What setting? (inpt, outpt, cty) – Interest – What about outcome? – Innovation – Social or Ethical implications Does SGA treatment increase risk of Asking a Focused Question… metabolic s/e? PICO • P: In youth • Does age of patient • P = The Patient or Population matter? ‐ All patients   Is this all ages? “Who will be the focus?”  Does setting matter? EX: In (patient, problem, risk • Does diagnosis of pt factor) does…  Does diagnosis matter? matter? I = Intervention or Clinical Action • • I: Does SGA treatment “What is the Exposure or the • Does setting matter? Treatment of interest?”  Any SGA or all?  Any SGA or all? EX: does Treatment A • All SGA’s or just some? • C: (vs. …….. compared to … • C = Comparison  First generation? • Compare to FGA’s? EX: Compared to Treatment B  Mood stabilizers? What about mood Reduce… • O = Outcome  Placebo? stabilizers? Placebo? EX: Reduce Outcome of interest • O: Increase risk of • All metabolic s/e? BMI? metabolic s/e and weight Wt gain? Lipids? gain? Why will asking these In adolescents, does aripiprazole vs questions help us? Now try it with your question… risperidone treatment lower risk of wt gain and increased BMI? Searching the Literature Searching the Literature • Defining a Search Strategy – Database Choices What is the usefulness of an evidence based review if – References/Bibliographies we don’t find all the evidence out there? – Hand searching Hand searching – Contacting authors/researchers Will we ever find ‘ALL’ the evidence? – Conferences/Associations – Abstracts What if the evidence overwhelms us? • Dates to search • Savvy searching… What is the usefulness of an evidence based review if we don’t find all the evidence out there? Iennaco 2

APNA 27th Annual Conference Session 1031: October 9, 2013 Searching the Literature Search strategy terms… • Defining a Search Strategy • Dates to search  Database Choices  When does date matter? Topic1 And Topic2 And Topic3 And Topic4 And Topic5 • Medline, PubMed, CINAHL, or or or or or • Savvy searching… PsychInfo, Social sci, web of sci Synonym Synonym Synonym Synonym Synonym • Vs. TRIP? Cochrane? Save or print what you did! • Vs. Google scholar? Synonym y y Synonym y y Synonym y y Synonym y y Synonym y y  References/Bibliographies Synonym Synonym Synonym Synonym Synonym  Hand searching  Contacting What is the usefulness of an Synonym Synonym Synonym Synonym Synonym authors/researchers evidence based review if Synonym Synonym Synonym Synonym Synonym  Conferences/Associations we don’t find all the  Abstracts evidence out there? Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Thoughts about Searching… Search Results… • ‘Google it’… key terms… # ▲ Searches Results Search Type Actions exp Depression/ dt, th [Drug 1 16881 Advanced • Combining terms… Therapy, Therapy] 2 ketamine.mp. or exp Ketamine/ 11664 Advanced  Be careful of early ‘AND’ use 3 1 and 2 32 Advanced Display Blocking NMDA receptor at rest: a possible alleviation of depression.  Like terms – ‘OR’ Lu W. Zhongguo Yao Li Xue Bao/ Acta Pharmacologica S inica. 32(9):1087-8, 2011 S ep. [Journal Article] UI: 21804573 [Journal Article] UI: 21804573  Focus with ‘AND’ Involvement of AMPA receptor in both the rapid and sustained antidepressant ­ like effects of ketamine in animal models of depression. • Step by step… Koike H. Iijima M. Chaki S. Behavioural Brain Research. 224(1):107‐11, 2011 Oct 10. [Journal Article] UI: 21669235 For future… NMDA receptor blockade at rest triggers rapid behavioural antidepressant responses. Autry AE. Adachi M. Nosyreva E. Na ES. Los MF. Cheng PF. Kavalali ET. Monteggia LM. Nature. 475(7354):91‐5, 2011 Jul 7. [Journal Article. Research Support, N.I.H., Extramural. Research Support, Non‐U.S. Gov't] UI: 21677641 • How would you study the question… Be prudent of ketamine in treating resistant depression in patients with cancer. Yang C. Zhou ZQ. Yang JJ. Journal of Palliative Medicine. 14(5):537, 2011 May.  Why that design vs. others… [Letter] UI: 21592028 Ketamine plus imipramine treatment induces antidepressant ­ like behavior and increases CREB and BDNF protein levels and PKA and PKC phosphorylation in rat brain. Reus GZ. Stringari RB. Ribeiro KF. Ferraro AK. Vitto MF. Cesconetto P. Souza CT. Quevedo J. Behavioural Brain Research. 221(1):166‐71, 2011 Aug 1. [Journal Article. Research Support, Non‐U.S. Gov't] UI: 21397634 Kinds of Evidence? Comparing Searches… • Empirical research (hierarchy) • Medline • PubMed #3 Search #1 AND #2 740 • Professional literature 41 exp Depression/ dt, t h [Drug Therapy, Therapy] 16931 #2 Search ketamine 12254 42 ketamine.mp. or exp Ketamine/ 11695 • Effectiveness data 43 41 and 42 32 #1 Search depression 267907 Blocking NMDA receptor at rest: a possible g p p 1. New drug targets in depression: inflammatory, cell‐mediated • Clinical intervention & Observation • Clinical intervention & Observation immune, oxidative and nitrosative stress, mitochondrial, antioxidant alleviation of depression. and neuroprogressive pathways. And new drug candidates‐Nrf2 Lu W. activators and GSK‐3 inhibitors. Maes M, Inflammopharmacology. 2012 • Patient response to intervention Zhongguo Yao Li Xue Bao/Acta Pharmacologica Jan 24. [Epub ahead of print] PMID: 22271002 Sinica. 32(9):1087 ­ 8, 2011 Sep. 2. Neuromodulators for pain management in rheumatoid arthritis. [Journal Article] Richards BL, Cochrane Database Syst Rev. 2012 Jan 18;1:CD008921. • Clinical expertise PMID: 22258992 UI: 21804573 3. Minimum infusion rate and hemodynamic effects of propofol, NMDA receptor blockade at rest triggers rapid propofol‐lidocaine and propofol‐lidocaine‐ketamine in dogs. – Judgement behavioural antidepressant responses. Mannarino R, Vet Anaesth Analg. 2012 Jan 17. doi: 10.1111/j.1467‐ 2995.2011.00679.x. [Epub ahead of print] PMID: 22248386 Autry AE. Adachi M. Nosyreva E. Na ES. Los MF. – Adaptation to needs 4. The effect of sub‐anesthetic and anesthetic ketamine on water Cheng PF. Kavalali ET. Monteggia LM. maze memory acquisition, consolidation and retrieval. Nature. 475(7354):91 ­ 5, 2011 Jul 7. Moosavi M, Eur J Pharmacol. 2011 Dec 23. [Epub ahead of print] [Journal Article. Research Support, N.I.H., Extramural. PMID: 22209880 Research Support, Non ­ U.S. Gov't] 5.Ketamine as a novel antidepressant: from synapse to behavior. Murrough JW. Clin Pharmacol Ther. 2012 Feb;91(2):303‐9. doi: UI: 21677641 10.1038/clpt.2011.244. Epub 2011 Dec 28. PMID: 22205190 Iennaco 3