Ebm rounds jgh_29_nov2012
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EBM JGH 2012 Psychiatry Rounds Presentation with clinical scenarios
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Ebm rounds jgh_29_nov2012
- 1. "There is nothing like looking, if you want to find something" - asking questions and searching for answers - the evidence based approach Jill Boruff, Assistant Librarian, McGill University Teodora Constantinescu, Librarian, JGH Ashley Wazana, MD, JGH JGH Psychiatry Rounds 29 Nov 2012 Contacts: jill.boruff@mcgill.ca tconstantinescu@jgh.mcgill.ca
- 2. DISCLAIMER • Haroon M, Phillips R. "There is nothing like looking, if you want to find something" - Arch Dis Child Educ Pract Ed. 2010 Apr;95(2):34-9. PubMed PMID: 20351149. • “There is nothing like looking, if you want to find something. You certainly usually find something, if you look, but it is not always quite the something you were after.” J.R.R. Tolkien, The Hobbit
- 3. OBJECTIVES • To structure the clinical question for finding relevant answers • To select the appropriate information sources • To know the tools for supporting the practice of EBM in clinical settings
- 4. OUTLINE • Introduction • Background • Structuring the Clinical Question & EBM Information Sources • Information on Mobile Devices • Discussion
- 5. WHY TODAY’S PRESENTATION (1) CanMeds Objectives: Medical Expert 2. Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice; 2.4. Contribute to the enhancement of quality care and patient safety in their practice, integrating the best available evidence and best practices
- 6. WHY TODAY’S PRESENTATION (2) JGH : • 2010: EBM 1-Awareness and survey in Child Psych • 2011: EBM 2-Reflections after one year Journal Club in Child Psych McGill - Centralized teaching: • Sep 2011: Intro to EBM R1 • Sep 2012: Intro to EBM R1 (6 hours) • Jan 2013 : EBM R2 (6 hours) Psychiatry Residency Curriculum Committee: • Need to sustain EBM in clinical settings • McGill teaching hospitals (knowledge, skills, support)
- 7. WHY TODAY’S PRESENTATION (3) To develop a more reflective, research based practice: • EBM Educational activities at JGH Psychiatry: • Child Psychiatry Research based presentations • Psychiatry Nursing EBM skills building workshops • Skills building workshops for OTs • Residents’ Journal Club
- 8. WHY TODAY’S PRESENTATION (4) • A successful start in EBP depends on the ability to formulate a clear clinical question
- 9. BRIEF BACKGROUND Evidence Based Practice
- 10. PRINCIPLES OF EVIDENCE BASED PRACTICE 1. Practice should be based on best evidence* 2. There is a hierarchy of evidence 3. Evidence alone is not enough • Clinical expertise • Patient preferences Archie Cochrane, CBE FRCP FFCM, (1909 - 1988) *“Effectiveness and Efficiency: Random Reflections on Health Services” (1972) Source: Cardiff University Library, Cochrane Archive, University Hospital Llandough.
- 11. LIMITS OF EBM • Research related – Sampling, bias, ethics, etc. – Evidence (from non-biomedical sciences) – Many clinical questions have not been researched • Translating efficacy studies into clinical effectiveness • Tool related – Evidence based summaries relatively few – Access – Technological changes • Implementation - Knowledge, Skills, Training - Organizational support and mandate - Time
- 13. 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/
- 14. EVIDENCE BASED PRACTICE (EBP) – 5 Steps PATIENT CENTERED
- 15. OUTLINE • Introduction • Background • Structuring the Clinical Question & EBM Information Sources • Information on Mobile Devices • Discussion
- 16. THE QUESTION & EBM INFORMATION SOURCES Clinical Scenarios
- 17. WHAT IS THE QUESTION ? Are cognitive- behavioural parenting interventions effective in reducing early- onset child conduct What are the atypical disorder? antipsychotic drugs? (Problem solving) 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.
- 18. BACKGROUND QUESTIONS – INFORMATION SOURCES
- 19. Patient Scenario #1 “Ms X is a 34 year old woman brought by her friend for increasing binging and purging behaviors. Patient is diagnosed with bulimia nervosa. She is reluctant to take medication and does not believe in psychotherapy. She is has mixed feelings regarding her eating behaviors and any form of treatment and is afraid to relinquish control. There is no imminent risk. You consider recommending self-help programs as an initial treatment.
- 20. Background questions What is standard treatment for bulimia nervosa? Others? Residents and other students might have more (or simple) background questions than you
- 21. Patient Scenario #1 “Ms X is a 34 year old woman brought by her friend for increasing binging and purging behaviors. Patient is diagnosed with bulimia nervosa. She is reluctant to take medication and does not believe in psychotherapy. She is has mixed feelings regarding her eating behaviors and any form of treatment and is afraid to relinquish control. There is no imminent risk. You consider recommending self-help programs as an initial treatment.
- 22. Figuring out your question with PICO Patient, population, or problem Intervention, prognostic factor, or exposure Comparison or intervention Outcomes to measure or be achieved
- 23. Figuring out your foreground question with PICO P: Female with bulimia nervosa I: Self-help program C: Psychotherapy O: Improvement of binging and purging behaviours
- 24. Figuring out your foreground question with PICO P: Female with bulimia nervosa I: Self-help program C: Medication O: Improvement of binging and purging behaviours
- 25. Figuring out your foreground question with PICO P: Female with bulimia nervosa I: Self-help program C: Medication with psychotherapy O: Improvement of binging and purging behaviours
- 26. Writing a clinical question In patients with bulimia nervosa, is self-help treatment as effective as psychotherapy in reduction of symptoms?
- 27. Searching the evidence Systematic Systematic Reviews Reviews Contained in databases like Randomized Randomized Controlled Controlled PubMed Trials Trials PsycInfo EMBASE Case-Control Case-Control studies studies Cohort Studies Cohort Studies Case Reports
- 28. 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/
- 29. Information Sources: some examples } includes: • Cochrane Database of Systematic Reviews Filtered Filtered • DARE (Database of Abstracts of Reviews of Effects)
- 30. Information Sources: some examples Filtered Filtered
- 31. Information Sources: some examples Filtered Filtered Unfiltered Unfiltered
- 32. Information Sources: some examples Unfiltered Unfiltered Expert Opinion
- 33. Information Sources: some examples Filtered Filtered Unfiltered Unfiltered
- 34. Filtered Filtered Unfiltered Unfiltered Expert Opinion
- 35. Patient Scenario #2 • Mr M, 22 yr old, presents with 3 weeks history of ↓ concentration, ↓sleep and poor appetite, agitation, severely depressed mood, feeling hopeless and with thoughts of suicide. He also feels people might be laughing at him on the street. He has a 3 yrs history of marijuana and cocaine use. Inquiry about family history reveals that maternal aunt “was not well” and was known to have “ups and downs” and had been apparently treated with lithium or ECT (?). • Clinically, what are the risk factors that predict bipolar disorder when a patient presents with first episode of depression?
- 36. Background Questions What is the prognosis of major depression? What are the risk factors for bipolar I and II ? Differential diagnosis: manic, mixed, hypomanic episodes?
- 37. Figuring out your question with PICO Patient, population, or problem Intervention, prognostic / risk factor, or exposure Comparison or intervention Outcomes to measure or be achieved Type of Question / Ideal Type of Study
- 38. PICO P : major depression, 22 yr , co-morbid substance abuse I : predictors C : none O : bipolar disorder (conversion) T : Risk factors studies: Cohort Studies > Case Control > Case Series/Case Report
- 39. Writing a clinical question •In a 22 year old male presenting with first episode (major) depression with co-morbid substance abuse (P) does …..[psychotic episode] [aunt with BD]….. (I) predict conversion to bipolar disorder (O) ?
- 40. Information Sources: some examples CLINICAL EVIDENCE (BMJ) : •Evidence based summaries (by disorder) •Background •Evidence for effectiveness of Filtered Filtered interventions (GRADE)* •Guidelines •Patient information (UK)
- 41. Information Sources: some examples Filtered Filtered Unfiltered Unfiltered
- 42. Filtered Filtered Unfiltered Unfiltered Expert Opinion
- 43. Scenario #2 : Search in PubMed Clinical Queries or TRIP Search : depression conversion bipolar risk factors Gilm S , Dupuy J , P an E M erlis R . R H isks for the transition from m ajor depressive disorder to bipolar disorder in the National Epidem iologic Survey on Alcohol and R elated Conditions. JClin P sychiatry. 2012 Jun;73(6):829-36. Epub 2012 F 21. P eb ubM P ID: 22394428. ed M
- 44. Question #3 • Is insight a mediator of change in dynamic psychotherapy?
- 45. PICO P: patient in psychodynam therapy ic I : insight (m ediator) C : none O : im provem (m ent easurem on a scale) ent T : effectiveness studies, (longitudinal, follow-up studies, com parative outcom e studies)
- 46. Information Sources: Individual studies PubMed, PsycINFO Filtered Filtered Unfiltered Unfiltered
- 47. Information Sources: some examples Individual studies PsycINFO: - B ehavioral sciences literature - Over 3 m illion records/citations - Own vocabulary - E Insight (P .g. sychotherapeutic Process) = index term PubMed: - B edical literature iom - Over 22 million records/citations - B edical Vocabulary (M iom edical subject headings M H eS ) - E Insight = not an index term (non-M H > search as keyword .g. eS ) - e.g. Search: insight psychodynam therapy ic
- 48. Scenario #3 : PubMed Search : insight psychodynam psychotherapy ic J ohansson P H , øglend P Ulberg R Am S M , , lo , arble A, B øgwald K , S P ørbye O, Sjaastad M H C, eyerdahl O. The mediating role of insight for long- term im provements in psychodynam therapy. JConsult Clin P ic sychol. 2010 J un;78(3):438-48. PubM P ID: 20515219 ed M .
- 49. Searching for Individual Studies (“Nuts and Bolts”) • Identify concepts • Identify information resources to search in • Choose appropriate search term s –S ubject headings (standardized index terms) and/or –K eywords • Search databases and apply : –B oolean operators – Truncation, adjacency – L its: research m im ethodology, population, language, type of publication etc.
- 50. Question #4 • Do antipsychotics work on the core sym ptom of delirium s , or do they just work as sedatives (for agitation) and to treat psychosis in delirium?
- 51. PICO P patients with delirium : I : antipsychotics C : none O : core sym ptom of delirium (disorientation, fluctuating s levels of consciousness, sleep wake cycle disturbance) T : outcom studies e
- 52. Information Sources: Individual studies EMBASE E base is an international m biom edical and pharm acological database, especially strong in its Filtered Filtered coverage of drug and pharm aceutical research from 1947 to present day. Over 27 m illion records: covers all M DL E INE citation and 5 m illion non- M edline. Unfiltered Unfiltered
- 53. EMBASE
- 54. SUMMARY: Searching Determined by: • Purpose of your search – Clinical decision making vs. – Literature review • Importance of your question – Does patient’s well being depend on this answer? – Does question appear often in practice or not? • Background knowledge of the searcher • Time you have
- 55. SUMMARY : Asking structured unambiguous questions • To clarify need : – what you know, what you do not know – what you REALLY need to know • To locate evidence : – Choice of information source – Identify search terms • To keep search on track
- 56. In CONCLUSION • You own the question and the answer ! • If you have spent 15 minutes and haven’t found the answer, ask a librarian!
- 57. OUTLINE • Introduction • Background • The Question & EBM Information Sources • Mobile Devices • Discussion
- 58. MOBILE DEVICES
- 59. Some technical information Mobile-optimized sites versus regular web pages. Downloadable applications versus web pages Setting up VPN—not always necessary
- 60. Tour of the mobile subject guide m.library.mcgill.ca/healthsciguide/
- 61. CONCLUSION: Support for EBM in Practice Frameworks: • EBP Process (5 steps) • PICO framework (question) • Evidence Pyramid EBM Resources (website) : • Dr Henry Kravitz Psychiatry Website http://www.jgh.ca/en/icfplibrary • Clinical Decision Making (Evidence Based Practice) http://www.jgh.ca/en/icfpebmresources • Using Mobile Devices to Access McGill Resources http://www.jgh.ca/en/icfp-use-mobile-devices Handouts (JGH): FindingGoodAnswers_Psychiatry.doc EBM resources summary Psychiatry 2012.doc
- 62. DISCUSSION: How do we support EBM at JGH? Some suggestions: • Start with a clear clinical question • Search for an evidence based answer • Engage the whole team in the EBM problem solving – Nurses, OTs, psychologists, students, librarian • Use the EBM tools: – ICFP Website: http://www.jgh.ca/en/icfplibrary
Notes de l'éditeur
- “ Archie Cochrane is best known for his influential book, Effectiveness and Efficiency: Random Reflections on Health Services published in 1972 [1] . The principles he set out in it so clearly were straightforward: he suggested that, because resources would always be limited, they should be used to provide equitably those forms of health care which had been shown in properly designed evaluations to be effective. In particular, he stressed the importance of using evidence from randomised controlled trials ( RCT 's) because these were likely to provide much more reliable information than other sources of evidence. In 1979 he wrote, "It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials." [2] His challenge led to the establishment during the 1980s of an international collaboration to develop the Oxford Database of Perinatal Trials .” (Cochrane collaboration website)
- Translating efficacious practices to routine practice settings to produce effective results is one of the more challenging issues of evidence-based practice.
- Looking for best evidence—may not always be available! Sometimes systematic review not available for any of these questions. Define: Diagnostic validation study: demonstrating whether a diagnostic test is valid (can we trust it?) and reliable (would we get the same result every time?). Preferred study type is when both the new test and the gold standard are performed. Case control study: A study that compares two groups of people: those with the disease or condition under study (cases) and a very similar group of people who do not have the disease or condition (controls). Researchers study the medical and lifestyle histories of the people in each group to learn what factors may be associated with the disease or condition. For example, one group may have been exposed to a particular substance that the other was not. Also called retrospective study. Cohort study; A longitudinal research study that compares a particular outcome (such as lung cancer) in groups of individuals who are alike in many ways but differ by a certain characteristic (for example, female nurses who smoke compared with those who do not smoke). Can be either retrospective or prospective. M ention: also possible to have prevention questions. Best answered by RCTs, SRs & meta-analyses, Cohort studies, Case control studies
- EBP : problem based approach to clinical decision making for better patient care
- You need to understand the background thoroughly before addressing foreground questions Seasoned clinician needs background info for new syndromes: e.g. SARS or a new diagnostic test
- What, when, how, how much …
- What questions could we have here? Background? Foreground?
- One question can have many outcomes One patient can have many questions!
- One question can have many outcomes One patient can have many questions!
- One question can have many outcomes One patient can have many questions!
- One question can have many outcomes One patient can have many questions!
- How many of you use PubMed? Ovid Medline?
- Looking for best evidence—may not always be available! Sometimes systematic review not available for any of these questions. Define: Diagnostic validation study: demonstrating whether a diagnostic test is valid (can we trust it?) and reliable (would we get the same result every time?). Preferred study type is when both the new test and the gold standard are performed. Case control study: A study that compares two groups of people: those with the disease or condition under study (cases) and a very similar group of people who do not have the disease or condition (controls). Researchers study the medical and lifestyle histories of the people in each group to learn what factors may be associated with the disease or condition. For example, one group may have been exposed to a particular substance that the other was not. Also called retrospective study. Cohort study; A longitudinal research study that compares a particular outcome (such as lung cancer) in groups of individuals who are alike in many ways but differ by a certain characteristic (for example, female nurses who smoke compared with those who do not smoke). Can be either retrospective or prospective. M ention: also possible to have prevention questions. Best answered by RCTs, SRs & meta-analyses, Cohort studies, Case control studies
- Bulimia self-help Two interesting reviews Show them “other reviews”! 3 things in there
- Self help bulimia – 3 rd entry Cochrane review not cited 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.
- 21 sys reviews, not just 5 like in cochrane—don’t know the quality Also see original research
- For this question, we have found something quickly. For some complex questions, you might need to tackle unfiltered sources. Clinical queries does this for you, but less control in your search This is where the librarian can help you! If you have spent 15 minutes and haven’t found anything, ask for help! Something to teach your students, too.
- Show different options (Canada guidelines not necessarily useful here)
- What other questions come to mind when you read this case? What background questions could you search for first?
- Background questions may differ with learner : specialty, novice vs proficient DSM IV: diagnostic criteria MDD single episode p 375 See p 385 : 10-15% adolescents with recurrent MDD develop BD I Presence of Manic or Mixed episodes predictors of BD (p 373) ? Course of BDII p 395 , Hypomanic episodes often precede or follow MD episodes
- PICO format works well for therapy questions (efficacy studies) comparing one intervention versus another But what about Aetiology, diagnosis, prognosis? Often Comparison not included Outcomes important! NOTE: “PICO is not meant to be a framework that must be used, it is merely a device to help frame questions and as such can be adapted (Haroon, 2010)”
- Prediction of conversion from unipolar depression to bipolar disorder What kind of studies best answer this question? (risk factors/prognosis question)
- DSM IV p 373 “It is difficult to predict whether the first episode of a MDDin a young person will ultimately evolve into a BDD some data suggest that the acute onset of severe depression especially with psychotic features and psychomotor retardation in a young person without prepubertal psychopathology is more likely to predict a bipolar course. A family history of BD may also be suggestive of subsequent development of BD.”
- Cochrane: SR that answers a precise question, mainly therapy Clinical Evidence (BMJ) gives a thorough evidence summary by disorder : e.g. Depression, Bipolar disorder Show Clinical Evidence: Can not answer current question but can check aetiology/risk (in Background) of a disease Show Interventions : Beneficial/unknown Show GRADE Table of evaluation of interventions for bipolar disorder (studies graded by strength of evidence) ANALOGY : Searching in EBM resources (filtered) systems, syntheses, summaries, synopses, is like going to IKEA and getting a ready made (still to be assembled) table Searching for Individual studies with selection of research methodology is like building your own table by learning carpentry first (buts and bolts of searching) – not the purpose of today’s presentation – but we show Residents in 3hrs with hands-on practice)
- Show search in PubMed Clinical Queries (a “pre-designed” search strategy, a “filter” where best methodologies were selected by type of question) Search: major depression conversion bipolar disorder select Prognosis Broad (can mention that if we change one search term, different results e.g. major depression predictors bipolar disorder) Check article : J Clin Psychiatry. 2012 Jun;73(6):829-36. Epub 2012 Feb 21. Risks for the transition from major depressive disorder to bipolar disorder in the National Epidemiologic Survey on Alcohol and Related Conditions. Gilman SE, Dupuy JM, Perlis RH. PMID: 22394428 MeSH Bipolar Disorder /epidemiology* Depressive Disorder , Major/diagnosis Depressive Disorder , Major/epidemiology* Risk Factors Follow-Up Studies Disease Progression*
- TRIP Search : depression conversion bipolar risk factors Found Gilman article in top relevant results Show PICO search : P = depression (or major depression) I = risk factors O = bipolar disorder (TRIP searches in title only)
- Background question: what is insight? how do we measure insight ? For which patients ? What therapeutic factors influence it? ? But can tackle as a background question, a lit search / lit review in PsycINFO – books See chapter: “Evaluating insight” in Miller, Nancy E [Ed]; Luborsky, Lester [Ed]; Barber, Jacques P [Ed]; Docherty, John P [Ed]. (1993). Psychodynamic treatment research: A handbook for clinical practice. (pp. 407-422). xxvi, 577 pp. New York, NY, US: Basic Books; US. PsycINFO insight AND psychodynamic therapy: Castonguay, Louis G [Ed]; Hill, Clara [Ed]. (2007). Insight in psychotherapy. (pp. 9-29). xvi, 481 pp. Washington, DC, US: American Psychological Association; US. On line @Mcgill
- Therapy > Insight > Change comparative outcomes studies
- PubMed : Search: insight psychodynamic therapy J Consult Clin Psychol. 2010 Jun;78(3):438-48. The mediating role of insight for long-term improvements in psychodynamic therapy. Johansson P, Høglend P, Ulberg R, Amlo S, Marble A, Bøgwald KP, Sørbye O, Sjaastad MC, Heyerdahl O.
- We need to learn carpentry to build the table
- Background: What are core symptoms of delirium What are outcome measures Find out a study that looks at treatment of delirium of medication, scales How significant are changes before and after treatment? Very technical, not an obvious PICO
- Background: What are core symptoms of delirium What are outcome measures Find out a study that looks at treatment of delirium of medication, scales How significant are changes before and after treatment? Very technical not a PICO
- EMBASE Embase is a biomedical and pharmacological database containing bibliographic records with citations, abstracts and indexing derived from biomedical articles in peer reviewed journals, and is especially strong in its coverage of drug and pharmaceutical research.
- Each resource accessed differently depending on the device—have to provide instructions McGill VPN versus free included some important free sites Not all resources are mobile-optimized sites but included them because they are important point of care or ebm tools. Benefits of a resource that provides an application Icons – ID resource more easily—used to info in this format Show site; point out: --Clinical evidence for detailed instructions; application download --Mdconsult for sign-up = no VPN necessary.