Introduction - Evidence-Based Medicine for Haematology
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First workshop in the "EBM for Haematology Residents" course. Presented on July 25, 2012 at the Jewish General Hospital in Montreal.
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Introduction - Evidence-Based Medicine for Haematology
- 1. Jewish General Hospital LIFE SCIENCES LIBRARY Library Introduction: Evidence-Based Medicine for Haematology Chantal Cassis, MD Robin Featherstone, MLIS Francesca Frati, MLIS Summer 2012 Roland Grad, MDCM MSc FCFP
- 2. Why EBM?
- 3. Workshop 1 - Objectives By the end of the workshop, you will be able to: 1. Describe the five stages of the EBM process 2. Differentiate background from foreground questions 3. Develop a well-formed PICO question 4. Categorize PICO questions and identify the best studies to answer each question type 5. Select an appropriate source to search for evidence to best answer your PICO questions
- 4. EBM for Haematology Pilot program designed for specialist residents Focused on real-life clinical questions Aims to integrate EBM into your everyday practice
- 6. Curriculum Overview Year-long EBM curriculum for PGY-4 & PGY-5 Five workshops (small-group, case-based) Weekly homework Assessment: Fresno & course evaluation Integrated EBM journal clubs Image: http://goodmancenter.stanford.edu/education/postgraduate.html
- 7. Workshops July 25 - Introduction to EBM for Haematology Aug 8 - Hands-on Searching Workshops Aug 22 - Critical Appraisal Sept 5 - Resident Presentations Sept 19 - Review
- 8. EBM Process Formulating Workshop Evaluating the clinical the Process Workshop 5 question 1 Your patient for whom you are uncertain about therapy, diagnosis, or Searching Incorporating prognosis the Evidence evidence into Workshop decision-making 2 Workshop Workshop 3 4 Appraising the Evidence
- 9. Can a 70 year old pancytopenic patient with suspected meningitis receive platelets before undergoing a lumbar puncture? What is pancytopenia? What is the diagnostic test for meningitis? [1.] Guyatt G, Rennie D, Cook D. Users' Guides to the Medical Literature : A Manual for Evidence-Based Clinical Practice (2nd Edition). New York, NY, USA: McGraw-Hill Professional Publishing; 2008.
- 10. Background Questions Sources for Background Questions • Textbooks • Handbooks • Manuals • etc [1.]
- 11. Patient Scenario You are following a 35 year-old pregnant female for low platelets thought to be due to immune thrombocytopenia as she had thrombocytopenia prior to her pregnancy. During the pregnancy, her platelets fluctuated quite a bit, ranging from her pre-pregnant baseline of 120 to as low as 60. When she presented to hospital in labour, her platelets count was 75 preventing her from getting an epidural, but ensuring a safe delivery. She undergoes a spontaneous vaginal delivery without complications. She and the baby are medically ready to leave the hospital 48 hours later. Her platelet count has risen to 110. She asked if she should be concerned for her newborn, knowing that her antibodies, the same that are causing her immune thrombocytopenia, are passed along to baby. Should a blood test be done to check the baby’s platelet count. If so, when?
- 12. Formulating a Clinical Question Patient, population, or problem Intervention, prognostic factor, or exposure Comparison or intervention Outcomes to measure or be achieved
- 13. What’s the PICO? You are following a 35 year-old pregnant female for low platelets thought to be due to immune thrombocytopenia as she had thrombocytopenia prior to her pregnancy. During the pregnancy, her platelets fluctuated quite a bit, ranging from her pre-pregnant baseline of 120 to as low as 60. When she presented to hospital in labour, her platelets count was 75 preventing her from getting an epidural, but ensuring a safe delivery. She undergoes a spontaneous vaginal delivery without complications. She and the baby are medically ready to leave the hospital 48 hours later. Her platelet count has risen to 110. She asked if she should be concerned for her newborn, knowing that her antibodies, the same that are causing her immune thrombocytopenia, are passed along to baby. Should a blood test be done to check the baby’s platelet count. If so, when?
- 14. PICO P: Newborns born to mothers with immune thrombocytopenia I: Blood test to check platelet count C: No blood test O: Diagnosis of immune thrombocytopenia
- 15. Clinical Question In newborn patients with suspected immune thrombocytopenia, is a blood test to determine platelet count recommended to diagnose immune thrombocytopenia?
- 16. What is the “evidence”? Systematic Reviews Case-control studies Randomized control trials Cohort studies Case reports Editorials Animal research All types of articles found in PubMed
- 17. Question Best Evidence Cost •Cost-effectiveness study Diagnosis •Diagnostic validation studies •Prospective studies / blind comparison to a gold standard Etiology/Harm •Cohort study •Case control study Prognosis •Cohort study •Case control study Quality of life •Qualitative studies Therapy •Systematic review of Randomized Controlled Trials (RCTs) •Single RCT 1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006. 2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
- 18. Levels of Evidence for Therapy Question Level of Evidence Type of Study 1a Systematic reviews of randomized controlled trials (RCTs) 1b Individual RCTs with narrow confidence interval 2a Systematic reviews of cohort studies 2b Individual cohort studies and low-quality RCTs 3a Systematic reviews of case-control studies 3b Case-control studies 4 Case series and poor quality cohort and case-control studies 5 Expert opinion Levels of evidence (2001). Centre for Evidence Based Medicine. Retrieved 26 Aug 2008 from http://www.cebm.net/index.aspx?o=1025 18
- 19. Information Sources for Diagnosis Question Synopsis of synthesis Summaries Filtered 1b 1a 1b 1a 2b 2a 2b 2a Unfiltered 3b 3b 4 5 4 5
- 20. Criteria for Selecting an Information Source 1. Soundness of evidence-based approach 2. Comprehensiveness and specificity 3. Ease of use 4. Availability See also: http://www.jgh.ca/en/hslinteractivepyramid
- 21. Information Sources some examples } includes: • Cochrane Database of Systematic Reviews • DARE (Database Filtered of Abstracts of Reviews of Effects)
- 22. Information Sources some examples Filtered
- 23. Information Sources some examples Filtered Unfiltered
- 24. Information Sources some examples Unfiltered Expert Opinion
- 25. Information Sources some examples Filtered Unfiltered
- 26. Filtered Unfiltered Expert Opinion
- 27. What’s the PICO? A 25 year-old female has been recently diagnosed with classical Hodgkin’s lymphoma (nodular sclerosing subtype). Staging reveals that she is a stage IIA (early favorable HL) with a 4.5 cm nodal mass in her neck and mediastinal nodes. You recommend combined modality therapy (chemotherapy /- radiation therapy). The patient has done some reading about therapy and is worried about the long term effects of radiation especially the risk of breast cancer. She asked you if combined modality therapy is truly superior to chemotherapy alone? What if she was a stage IIB (early unfavorable)? She agrees to begin ABVD chemotherapy and asked if she will be getting G-CSF (neupogen) injection to ensure that her white blood cells recover prior to the subsequent chemotherapy cycle. You inquire with your colleagues and realize that some give all their patients neupogen while others never do. Is there a benefit to giving neupogen while getting ABVD?
- 28. Possible PICO 1 P: 25 year old female with stage IIA Hodgkin’s Lymphoma I: Combined modality therapy C: Chemotherapy alone O: Risk of breast cancer
- 29. Possible PICO 2 P: 25 year old female with stage IIB Hodgkin’s Lymphoma I: Combined modality therapy C: Chemotherapy alone O: Risk of breast cancer
- 30. Possible PICO 3 P: Patient undergoing ABVD chemotherapy I: G-CSF (neupogen) injection C: No neupogen O: Recovery of white blood cells prior to chemotheraphy
- 31. Possible PICO 4 P: 25 year old female with stage IIA Hodgkin’s Lymphoma I: Combined modality therapy C: Chemotherapy alone O: Most effective treatment
- 32. Summary Quiz 1. UpToDate is a _______ resource. And EMBASE is a ________ resource. 2. The 5 stages in the EBM process are _______. 3. The best evidence to answer a diagnosis question is _______. 4. To find systematic reviews of RCTs use _______. 5. PICO stands for ________.
- 33. Homework For next workshop (9 am to noon, Aug 8th, JGH A-805) record two PICO formulated clinical questions encountered during practice Send one PICO to instructor – robin.featherstone@mcgill.ca – by 5 pm on Aug 1. If you don’t have a PICO, let us know by Aug 1 Bring these PICO questions to the next workshop Slides available:
Notes de l'éditeur
- Ask the residents what they know about Evidence Based Medicine and why they should practice it. Key points:Mandated by the Royal College of Physicians and Surgeons of CanadaMandated by the Accreditation Council for Graduate Medical EducationAllows you to identify flawed research (residency program directors really like this)Allows you to apply research findings to patient care (residency program directors really like this too)Helps you comprehend research methodology (probably a good idea if you’re going to be conducting research… not to mention using research to inform clinical decision-making!)
- Process can also be described as: Ask, Acquire, Appraise, Apply and Assess
- To format foreground questions, use PICO. Note: not all PICO elements are mandatory, but (in my experience) the P and the I are pretty much always included. Why is it important? (1) helps to keep the question clear and avoid side-tracking (2)helps avoid changing to question to suit the evidence (3) helps avoid looking for what you think you will find (4)helps to identify when more than one search is needed to answer the full question in cases where there are multiple PICOs
- Note: In the case of babies born to mother's with immune thrombocytopenia, they merely passively acquire their mom's antibodies via the placenta and so they do not have immune thrombocytopeniaAnother possible PICO question includes the timing of the test.
- From here, you have many choices to conduct your search. You want the best, most reliable evidence possible.
- From here, you have many choices to conduct your search. You want the best, most reliable evidence possible.
- Mention how EBM works really well for therapy questions. That the levels of evidence doesn’t necessarily apply for all kinds of question types. Take your question and the search the literatureLooking for the best evidence possible for your question. For questions of therapy = Systematic ReviewsBut there aren’t always systematic reviews for your questionSo you have to move down the list to the best type of evidence available for your questionOne reason it is important to understand the different types of study designs that you are learning about in this course. –if you understand the study design, you will understand the studies and the best evidence. --understand why a cohort study is better than a case-control studyYou will also hear about something called “Levels of Evidence” and this is just short hand for these types of studies. (click to reveal levels)So if you see somewhere that a question has level 1a evidence, you know that there is a systematic review of RCTs to support the answer to that question. It is just a shorthand instead of having to say sys rev of RCT all of the time. the best evidence available may not be the highest level of evidence attainable for a specific clinical question. Findings from such research would receive a lower grade of recommendation that for a clinical question answered by a higher level of evidence.study
- Click to start animation1a – Systematic reviews of randomized controlled trials1b – Individual RCTs with narrow confidence interval2a – Systematic reviews of cohort studies2b - Individual cohort studies and low-quality RCTs3a – Systematic reviews of case-control studies3b – Case-Control Studies4 – Case series and poor quality cohort and case-control studies5 – Expert opinion
- Questions to ask:Bias? Conflict of interest? Evidence grading or ranking applied? Links? Discipline coverage? Consistent and quick to search? Cost? Available in my location?
- Some controversy over where UpToDate belongs. Could be used to answer background or foreground questions. Could be considered “evidence-based” tool, or expert opinion. For the purposes of these courses, I would recommend UpToDate as being a higher level of evidence than expert opinion, but it should not be considered on the same level as a Cochrane Systematic Review. And UpToDate should definitely be considered a filtered information source. It will take you far less time to search than individual studies.