Comp2 Unit5b Lecture Slides

The Culture of Healthcare
Evidence-Based Practice
Lecture b
This material (Comp2_Unit5b) was developed by Oregon Health and Science University, funded by the Department of Health
and Human Services, Office of the National Coordinator for Health Information Technology under Award Number
IU24OC000015.
Objectives
Define the key tenets of evidence-based medicine (EBM) and its
role in the culture of health care (Lectures a, b)
Construct answerable clinical questions and critically appraise
evidence answering them (Lecture b)
Apply EBM for intervention studies, including the phrasing of
answerable questions, finding evidence to answer them, and
applying them to given clinical situations (Lecture c)
Understand EBM applied to the other key clinical questions of
diagnosis, harm, and prognosis (Lectures d, e)
Discuss the benefits and limitations to summarizing evidence
(Lecture f)
Describe how to implement EBM in clinical settings through clinical
practice guidelines and decision analysis (Lecture g)

2
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Lecture b
Making Evidence-Based Clinical
Decisions (Mulrow, 1997)
5.1 Figure: Adapted from (Mulrow, Cook, &
Davidoff ,1997)
3
Lecture b
Best Resources For EBM
Three major books:
Straus et al., Evidence-Based Medicine: How to
Practice and Teach EBM, Third Edition, 2005
Formerly known as the Sackett book
Guyatt et al., Users Guides to the Medical Literature,
2008 (two books one a handbook, the other more
complete)
Web sites
http://www.cebm.net
http://www.cche.net/
http://ktclearinghouse.ca/cebm/
http://www.nettingtheevidence.org.uk/
4
Lecture b
The Changing Nature Of EBM
(Hersh, 1999)
Initial approach (aka, first generation) was for
clinician to find and critically appraise evidence
Takes too much time, clinicians lack expertise
More recent approach (aka, next generation) is
synthesis and synopsis of evidence for clinician
Access to on-line, up-to-date information makes
easier
Slawson & Shaughnessy (2005) argue there
should be more emphasis on teaching
information management (seeking) than the
techniques of EBM
5
Lecture b
Another Viewpoint Concerning
Evidence (Haynes, 1999)
Can it work?
Efficacy studies take place under ideal circumstances
This unit looks mainly at such studies
Does it work?
Effectiveness studies ascertain whether something works in the
real world
Sometimes called outcomes research (Clancy & Eisenberg,
1998)
Is it worth it?
Cost-benefit or cost-effectiveness studies determine whether
benefits worthwhile in relation to cost or other resources
6
Lecture b
Hierarchy of Evidence The 4S Model
(Haynes, 2001)
Subsequently updated to
5S
(Haynes, 2005) and 6S
models (DiCenso, 2009),
but this one is preferred

5.2 Figure: adapted from Haynes 4S model of the Hierarchy of Evidence (2001)
Lecture b
7
Where The Evidence Comes From
5.3 Figure: Adapted from Haynes S4 model of the Hierarchy of Evidence (2001) with types and sources of evidence
8
Lecture b
Studies
Accessed (usually) in literature databases such
as MEDLINE
Most common and freely available system for
accessing medical literature is Pubmed,
available at http://pubmed.gov/
Retrieved from journals
Many available electronically now
Application of critical appraisal and formulae
e.g., relative risk, number needed to treat,
sensitivity, odds ratio, etc.
9
Lecture b
Syntheses
Systematic reviews
Exhaustive review of data on a topic done in a
systematic manner
Not a simple literature review or overview of papers
one knows about
Application, where appropriate, of meta-analysis,
the combination of results from multiple studies in
a single analysis
Studies must be appropriately similar, and there are
methodological means to assess that
Available in Pubmed or in specialized Pubmed
Health
http://www.ncbi.nlm.nih.gov/pubmedhealth/
10
Lecture b
Synopses And Systems
Synopses highly summarized information
appropriate for clinical setting, e.g.,
Critically appraised topics (CATs)
Clinical Evidence, InfoPOEMS, PIER
Clinical practice guidelines
Systems decision support within electronic
health records
Best way to provide evidence to clinicians at point of
decision-making
11
Lecture b
Overview Of The Application
Of EBM
Steps include
Phrasing a clinical question that is pertinent
and answerable
Identifying evidence to address the question
Critically appraising the evidence to determine
if it applies to the patient
12
Lecture b
Phrasing The Clinical Question
Background vs. foreground questions
Background questions ask for general
knowledge about a disorder
Usually answered with textbooks and
classical review articles
Foreground questions ask for
knowledge about managing patients
with a disorder
Usually answered using EBM techniques
13
Lecture b
Background Questions
General information not specific to a given
patient
Examples
What causes pneumonia?
When do complications of diabetes usually
occur?
Distinction from foreground questions can
be blurry
New etiologies of disease
Level of training, e.g., specialist vs. student
14
Lecture b
Foreground Questions
Have three or four essential components
(PICO)
Patient and/or problem
Intervention
Comparison intervention (if appropriate)
Outcomes
Example
In an elderly patient with congestive heart
failure, are beta blockers helpful in reducing
morbidity and mortality without excess side
effects?
15
Lecture b
Four categories of foreground
questions
Intervention (or Therapy) benefit of
treatment or prevention
Diagnosis test diagnosing disease
Harm etiology or cause of disease
Prognosis outcome of disease course
16
Lecture b
Questions To Ask About The
Results From Any Study
Are the results valid?
Are the results important?
Can the results be applied to patient care?

Specific sub-questions depend on type of
question and study
17
Lecture b
Summary Lecture b

18
There are many easily accessible resources for EBM
Approach has changed over the years
Can be best viewed from the 4S model demonstrating
the hierarchy of evidence, based on a foundation of
studies, brought together where possible by syntheses,
summarized in synopses, and implemented in systems
that make it actionable
When seeking evidence, it is critical to appropriately
phrase the clinical question

Lecture b
References Lecture b
19
Lecture b
References
Centre for Evidence Based Medicine - Homepage. (n.d.). Retrieved December 14, 2011, from Centre for Evidence
Based Medicine website: http://www.cebm.net/
Centre for Evidence-Based Medicine, Toronto - Homepage. (n.d.). Retrieved December 14, 2011, from KT
Clearninghouse website: http://ktclearinghouse.ca/cebm/
Centre for Health Evidence - Homepage. (n.d.). Retrieved December 14, 2011, from Centre for Health Evidence
website: http://www.cche.net/
Clancy, C., & Eisenberg, J. (1998). Outcomes research: measuring the end results of health care. Science, 282, 245-
246.
DiCenso, A., Bayley, L., & Haynes, R. (2009). ACP Journal Club. Editorial: Accessing preappraised evidence: fine-
tuning the 5S model into a 6S model. Annals of Internal Medicine, 151(6), JC3-2, JC3-3.
Evidence Based Medicine. (2009, November 11). Retrieved December 14, 2011, from Netting the Evidence - Blog
website: http://www.nettingtheevidence.org.uk/
Guyatt, G., Rennie, D., Meade, M., & Cook, D. (2008a). Users' Guides to the Medical Literature: A Manual for
Evidence-Based Clinical Practice. New York, NY: McGraw-Hill.
Guyatt, G., Rennie, D., Meade, M., & Cook, D. (2008b). Users' Guides to the Medical Literature: Essentials of
Evidence-Based Clinical Practice. New York, NY: McGraw-Hill.
Haynes, R. (1999). Can it work? Does it work? Is it worth it? British Medical Journal, 319, 652-653.
Haynes, R. (2001). Of studies, syntheses, synopses, and systems: the "4S" evolution of services for finding current
best evidence. ACP Journal Club, 134, A11-A13.
Haynes, R. (2006). Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information
services for evidence-based healthcare decisions. Evidence-Based Medicine, 11, 162-164.
References Lecture b (continued)
20
Lecture b
Charts, Tables, Figures
5.1 Figure: Adapted from Mulrow, 1997) Mulrow, C., Cook, D., & Davidoff, F. (1997). Systematic reviews: critical links
in the great chain of evidence. Annals of Internal Medicine, 126, 389-391.
5.2 Figure: Adapted from Haynes 4S model of the Hierarchy of Evidence: Haynes, R. (2001). Of studies, syntheses,
synopses, and systems: the "4S" evolution of services for finding current best evidence. ACP Journal Club, 134,
A11-A13.
5.3 Figure: Adapted from Haynes 4S model of the Hierarchy of Evidence with types and sources of evidence:
Haynes, R. (2001) Of studies, syntheses, synopses, and systems: the "4S" evolution of services for finding current
best evidence. ACP Journal Club, 134, A11-A13.

Reference (continued)
Hersh, W. (1999). "A world of knowledge at your fingertips": the promise, reality, and future directions of on-line
information retrieval. Academic Medicine, 74, 240-243.
Mulrow, C., Cook, D., & Davidoff, F. (1997). Systematic reviews: critical links in the great chain of evidence. Annals of
Internal Medicine, 126, 389-391.
PubMed Health Homepage. (n.d.). Retrieved December 14, 2011, from US National Library of Medicine website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/
PubMed Homepage. (n.d.). Retrieved December 14, 2011, from National Institutes of Health - US National Library of
Medicine website: http://www.ncbi.nlm.nih.gov/pubmed/
Slawson, D., & Shaughnessy, A. (2005). Teaching evidence-based medicine: should we be teaching information
management instead? Academic Medicine, 80, 685-689.
Straus, S., Richardson, W., Glasziou, P., & Haynes, R. (2005). Evidence Based Medicine: How to Practice and Teach
EBM, Third Edition. New York, NY: Churchill Livingstone.

Comp2 Unit5b Lecture Slides

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