WEEK 1 EBP – Flashcards

Patient, population or problem Interventions Comparisons Outcomes

Once your question is developed its helpful to understand the category type of your question. Clinical questions generally fall into one of the following areas - diagnosis, therapy, harm or etiology, and prognosis. The type of question will influence the search strategies you will pursue, and the types of resources you will consult

Questions concerning the ability of a test to predict the likelihood of a disease. "In patients with suspected depression what is the accuracy of a two-question case-finding instrument for depression compared with six-previously validated instruments?"

Questions concerning the effectiveness of a treatment or preventative measure. "In children with colds, are zinc lozenges safe and effective for relief of cold symptoms?"

Questions concerning the likelihood of a therapeutic intervention to cause harm. "Is there an increased risk of breast cancer for a healthy post-menopausal patient on HRT?"

Questions concerning outcome of a patient with a particular condition. "What are the risk factors for developing diabetes mellitus type II in adolescent males?"

Three: Evidence based paralysis=looking for the perfect evidence which doesn't exist instead look for the best evidence which might just be a professional opinion, Changing your entire belief system because of one Latest and Greatest Experiment always be skeptical of everything we read, EBM Ass-hole=don't alienate the people we are trying to teach by the way we are presenting research who you are where you work and who you treat may be different than who you are talking with thus the evidence may mean something different to them.

Clinical Experience, Patient Preferences, Best Evidence=intersection between all three is Evidence Based Medicine or (The Optimal Decision)

1. Two Types of Questions: • Background:BROAD provides general concepts and options for interventions Example: What are some techniques used to prevent pressure ulcers during hospitalization? • Foreground: Once the Background Question is asked you ask the Foreground Question (could be made into a PICO question)-FOCUSED asked something specific in order to make an informed clinical decision or action Example: How does continuous lateral rotation compare to mattress overlays in preventing the occurrence of pressure ulcers?

1. Absolutely NOT only Foreground questions can be formatted into PICO questions.

1. P (Problem, Patient, Population, Program), I (Intervention, prognostic factor or exposure) aka what I am wanting to do to help the patient, C (Comparison) aka what you are doing now to help patient, O (Outcome) what can you hope to accomplish, measure, improve, or affect Also the health practitioner needs to know about the study 1. T (Type of Question) and T (type of study)? What type of Question goes with which study or research design to answer particular question? Therapy (RCT, Systematic review, meta-analysis), Diagnosis (Prospective, Blind comparison to gold standard), Etiology/Harm (cohort study, Case-control study, case series), Prognosis (Cohort Study), Quality Improvement (RCT and qualitative studies), Cost (Economic evaluation)

Most common question (RCT, Systematic review, meta-analysis)

(Prospective, Blind comparison to gold standard) RCT is not the best study design for diagnostic studies (more covered in week 5) Prospective cohort study design that can be formatted into a 2x2 table

(cohort study, Case-control study, case series) (more in week 5)

(Cohort Study) (More in week 4)

(RCT and qualitative studies)

(Economic evaluation)

1. 1. Problem/ construct question 2. Formulate your search strategy 3. Choose the appropriate database or resource for your topic 4. Perform the search 5. Evaluate the results 6. Good results=Use the data Bad results=start over

Title and Abstract, Methods, and Results should be the most objective sections of the paper. Intro, Discussion, and conclusion are subjective

the bottom of the pyramid usually cannot prove causality Studies further up the pyramid get stronger and stronger at inferring causality

• Do you have good reason to believe that your patient is sufficiently similar to the patients in the studies you have examined? • does the treatment have a clinically relevant benefit that outweighs the harms? • Is another treatment better? • Are the patient's values and circumstances compatible with the treatment?

• Case series and case reports-collections of reports on the treatment of individual patients or a report on a single patient. No control groups to compare outcomes • Case control studies-patients WHO ALREADY HAVE A SPECIFIC CONDITION are compared with people who do not have the condition • Cohort studies-identify a group of patients who are ALREADY TAKING A PARTICULAR TREATMENT OR HAVE AN EXPOSURE, follow them forward over time, and then compare their outcomes with a similar group that has not been affected by the treatment or exposure being studied. • Randomized controlled clinical trials- are carefull planned experiments that introduce a treatment or exposure to study its effect on real patients. Use randomization and blinding and use comparison between intervention group and control group (control=no intervention) • Systematic review-focus on a clinical topic and answer a specific question • Meta-analysis-thoroughly examine a number of valid studies on a topic and mathematically combine the results using accepted statistical methodology to report the results as if it were one large study • Cross-sectional studies-describe the relationship between diseases and other factors at one point in time in a defined population. This is a controlled trial that looks at patients with varying degrees of an illness and administers both diagnostic tests-the test under investigation and the "GOLD STANDARD" test=to all of the patients in the study group. The sensitivity and specificity of the new test are compared to that of the gold standard to determine potential usefulness • Qualitative research- answers a wide variety of questions related to human responses to actual or potential health problems. The purpose of qualitative research is to describe, explore and explain the health-related phenomena being studied. • Retrospective cohort (or historical cohort)-follow the same direction of inquiry as a cohort study. Subjects begin with the presence or absence of an exposure or risk factor and are followed until the outcome of interest is observed. However, this study design uses information that has ben collected in the past and kept in files or databases.

1. Are the results of the study valid? What are the results? will the results help in caring for my patient?

• Randomization: were patients randomized? • Concealed allocation: Was group allocation concealed? • Baseline characteristics: Were patients in the study similar with respect to known prognostic (aka intervention) variables? • Blinding: To what extent was the study blinded? • Follow-up: Was follow-up complete? • Intention to treat: Were patients analyzed in the groups to which they were first allocated? Equal treatment: Aside from the experimental intervention, were the groups treated equally?

Experimental Event Rate (EER) = 15 / 20 = 75% outcome present / total in experimental group Control Event Rate (CER) = 2 / 20 = 10% outcome present / total in control group Absolute Benefit Increase (ABI) = 75% - 10% = 65% is the arithmetic difference between the rates of events in the experimental and control group. An Absolute Benefit Increase (ABI) refers to the increase of a good event as a result of the intervention. An Absolute Risk Reduction (ARR) refers to the decrease of a bed event as the result of the intervention. [ARR = EER-CER] Relative Risk (RR) = .75 / .10 = 7.5 is the ratio of the risk in the experimental group compared to the risk in the control group.proportional reduction in risk between the rates of events in the control group and the experimental group. [RR = EER/CER] Relative Benefit Increase (RBI) = 65% / 10% = 650% is the proportional increase in benefit between the rates of events in the control group and the experimental group. [RBI = EER - CER / CER] Numbers Needed to Treat (NNT) = 1 / .65 = 2 is the number of patients who need to be treated to prevent one bad outcome or produce one good outcome. In other words, it is the number of patients that a clinician would have to treat with the experimental treatment compared to the control treatment to achieve one additional patient with a favorable outcome. [NNT = 1/ARR]

Large studies can be significant without being clinically important and small studies may be important without being significant.

• Were the study patients similar to my population of interest? • Does your patient match the study inclusion criteria? If not, are there compelling reasons why the results should not apply to your patient? • Were all clinically important outcomes considered? • Are the likely treatment benefits worth the potential harm and costs?

ASK the question Choose the BEST clinical question: What is the best treatment for diarrhea? In patients taking antibiotics, are probiotics helpful in preventing diarrhea? BEST CLINICAL QUESTION Do probiotics prevent diarrhea in the elderly hospitalized patient? Choose the best PubMed search strategy to address the clinical question. Search: diarrhea AND best treatment Limited to Free Full Text. Search: diarrhea AND probiotics AND elderly AND female AND adult Limited to English. Search: antibiotics AND diarrhea AND probiotics Limited to randomized controlled trial. BEST PUBMED SEARCH STRATEGY

ASK the question Choose the BEST clinical question: Do magnets help control pain in elderly patients? Do magnetic bracelets help control pain in patients with osteoarthritis? Do magnetics help control pain in patients with osteoarthritis of the hip? (BEST CLINICAL QUESTION) Choose the best PubMed search strategy to address the clinical question. Search: magnets AND pain AND elderly Limited to English. Search: magnetics AND osteoarthritis AND hip Limited to randomized controlled trial. (BEST PUBMED SEARCH STRATEGY) Search: magnetics AND pain Limited to randomized controlled trial.

ASK the question Choose the BEST clinical question: Is dry or moist heat more effective at reducing pain and anxiety? Does heat help improve the time to insertion of an IV catheter? Is dry or moist heat helpful in reducing pain and time of IV catheter insertion in patients undergoing chemotherapy? (BEST CLINICAL QUESTION) Choose the best PubMed search strategy to address the clinical question. Search: heat AND chemotherapy Limited to randomized controlled trial. Search: hyperthermia AND catheterization Limited to randomized controlled trial. (BEST PUBMED SEARCH STRATEGY) Search: heat AND IV catheter Limited to Human and English and last 5 years.

(AND, OR, NOT)

Medical Subject Headings database

The Cumulative Index to Nursing and Allied Health Literature