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Evidence-Based Medicine and the Medical Librarian

Evidence-Based Medicine and the Medical Librarian. Frank Domino, MD Associate Professor, Community & Family Medicine Len Levin, MS LIS, MA, AHIP Manager, Educational Programming Jim Comes, MSLS, Ed.D Associate Director REIS.

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Evidence-Based Medicine and the Medical Librarian

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  1. Evidence-Based Medicine and the Medical Librarian

  2. Frank Domino, MD Associate Professor, Community & Family Medicine Len Levin, MS LIS, MA, AHIP Manager, Educational Programming Jim Comes, MSLS, Ed.D Associate Director REIS

  3. A skeptical Family Physician approaches you to “do a Medline search to see if Cranberry Juice to Prevent UTIs.” Where do you look to determine if Cranberry Juice Prevent A UTI?We will look at this in greater detail later

  4. Think about… • Clinical questions that you have received from a patron recently or that you are curious about. • We will be collecting some of YOUR examples in a little while to use for hands-on searching later this afternoon

  5. Objectives • Become familiar with the history and growth of Evidence-Based medicine. • Understand Evidence-Based terminology. • Be able to select appropriate Evidence-Based resources. • Have an opportunity to learn and apply basic statistical techniques used in evaluating the Evidence-Based literature.

  6. What is: Evidence Based Medicine?

  7. Evidence Based Medicine Sackett: Integrating individual expertise with the best available clinical evidence from systematic research. Domino: Basing the care of patients on clinical research whose outcomes are our main priority.

  8. History of EBM • Traditional Deductive Reasoning (the old way) • If you understood the Pathophysiology and • had a treatment that addressed this, then • using that treatment would improve the disease. • Evidence Based Reasoning • If there is a preponderance of data, when viewed in aggregate (published and unpublished) that supports a treatment for a disease, then can it be safely used.

  9. Old Paradigm: If you know problem And You have a solution to the problem Then Using the solution will solve the problem. Analogy: The trash (the problem) will be taken out to the curb if you ask your teenager (solution)

  10. First “Clinical Trial” • Scurvy trials in 1747 • Sea Water • Vinegar • Lemons & Limes • Elixir Vitriol (Copper Sulfate) • Garlic & Mustard • Cider

  11. First “Meta-Analysis” BMJ, 1904

  12. Dr. Joseph Bell & Sherlock Holms PSHAW! Evidence-Based Medicine, my dear Watson?

  13. Flexner Report 1910

  14. Very first RCT Published by the British Medical Journal in 1948

  15. Archie Cochrane

  16. Archie Cochrane’s seminal book on EBM

  17. “Cochrane estimated that fewer than 10% of medical interventions were supported by objective evidence…” Dickerson K, Manheimer E The Cochrane Collaboration: evaluation of health care and services using systematic reviews of the results of randomized controlled trials. Clinical Obstetrics and Gynecology, 41(2):316 – add date

  18. Iain Chalmers • Mid to late 1980’s • Developed Oxford Database of Perinatal Trials • (1989)Published Effective Care in Pregnancy & Childbirth. 1st Systematic Review

  19. Founded in 1993 in the United Kingdom

  20. EBM not without critics 1995 Lancet editorial states that “EBM…revolutionaries…demand to have [EBM] hallowed as the new orthodoxy…” and that they “…deplore attempts to foist [EBM] of the profession as a discipline…”

  21. This article is Friday’s headlines

  22. Why is EBM new?

  23. Ottawa Rules: Study of Patient Outcomes Ankle Injury Standard of Care X-ray all Ankle Sprains Cost: $$$$$ Result: Ottawa Rules

  24. 2. What EBM is NOT A MEDLine abstract that supports a treatment based upon One researcher’s conclusions Remember: Statistically Significant does NOT equal Clinically Significant

  25. Wall Street Journal, N Y Times, Washington Post “Breastfeeding Increases I.Q.” Lead Article May 8, 2002 JAMA 2 IQ Tests: WAIS & BPP <1 month 99.4 2-3 months 101.7 4-6 months 102.3 7-9 months 106.0 >9 months 104.0 P=0.003 all F tests

  26. EBM focuses on Patient Focused Outcomes Which of the following is a PFO? • Using HMG CoA RI (statins) lowers Apolipoprotein (a) levels. • Screening CXR’s identify Lung Cancer • Smoking Cessation counseling leads to increased quit rates

  27. EBM focuses on Patient Focused Outcomes Which of the following is a PFO? • Using HMG CoA RI (statins) lowers Apolipoprotein (a) levels. • Screening CXR’s identify Lung Cancer • Smoking Cessation counseling leads to increased quit rates PFO: Actual Benefits, rather than theoretical or intermediate benefits

  28. Traditional Reasoning Lead to False Conclusions EBM Reasoning looks at Patient Outcomes: Mortality, Morbidity, Risk

  29. Which is the best agent to get rid of Ear Wax??? • A. Cerumenex • B. Hydrogen Peroxide • C. Baking Soda • D. Oil (Mineral, Olive, WD 40) • E. Colace Burton, et al. Cochrane DSR 2004 & Robinson, et al. J Otolaryngol 1990; 18(6): 263

  30. Who Misleads the Public the Most? • A. Television Dramas • B. Medical Journals • C. Pharmaceutical Industry • D. News Media Schwartz, et al. Annals of Int. Med. 2004; 140(3): 226

  31. Nothing is new…. “Believe nothing that you see in the newspapers… ...if you see anything in them that you know is true, begin to doubt it at once.” Sir William Osler

  32. What Percent of Americans Would Prefer a Total Body CT Scan Over $1000.00 Check? • A. 10% • B. 30% • C. 50% • D. 70% • E. 90% Schwartz, et al. JAMA 2004; 291(1): 71

  33. What are the Actual Causes of Death in the US? • A. Motor Vehicle Accidents • B. Firearms • C. Infectious Disease (including HIV/AIDS) • D. Tobacco • E. Poor Diet & Physical Inactivity ARF = [P0 + ΣPi (RRi)) – 1] / [P0 + Σ Pi (RRi)] Mokdad, et al. JAMA 2004; 291(10): 1238

  34. Leading Diseases to Cause Death in the US: 2000 • Heart Disease 29.6% • Malig. Neoplasm 23.0% • CVA 7.0% • COPD 5.1% • Injuries 4.1% • Diabetes Mellitus 2.9% • Infectious Disease 2.7% Minino, et al. Natl Vital Stat Rep. 2002; 50:1-120

  35. Which had the Best Efficacy for the Acute Treatment of Migraine • A. Ketoprofen 75 mg • B. Ketoprofen 150 mg • C. Zolmitriptan 2.5 mg • D. Placebo Dib, M. et al. Neurology 2002. 58(1): 1660

  36. Ketoprofen 75 mg Equal to Zolmitriptan in Efficacy at 2 hours: • Headache • Associated Headache Symptoms • Impaired Work Capacity • Need for further Rescue Medicine • Recurrence for Relieved Attacks BUT: • 50% less Adverse Events/Side Effects

  37. Which Intervention had the greatest Effect on Fall RiskIn Senior Populations (60 Yrs) • A. Bisphosphonates (Alendronate, etc) • B. Removal of “Throw Rugs” • C. Calcitonin • D. Vitamin D Supplements Bischoff-Ferrari, H. et al. JAMA 2004; 291(16): 1999

  38. Meta Analysis: Vitamin D on Falls 400-800 IU per day

  39. Estimates with 95% confidence intervals Line of no effect Kennedy 1997 Locke 1952A Estimate and confidence interval for each study Lopes 1997 Reynolds 1998 Estimate and confidence for the meta-analysis Seiberth 1994 Scale (effect measure) 0.2 1.0 5 Risk ratio Favours LR Favours control Direction of effect Presentation: the forest plot

  40. Non Specific Aches and Vitamin D • Observational Study of Out Patients with persistent, nonspecific musculoskeletal pain • 93% of population were deficient (</= 20ng/mL) • 100% of African Am, Hispanic & Am. Indians were deficient • 28% were Severely Deficient (< 8ng/mL) • Season was NOT a factor • 55% were UNDER age 30 years • Male = Female; Inc. Risk for Childbearing

  41. Colorectal Adenomas • In patients with History of Colorectal adenomas, • Only in Patients At or Above Median Serum Vit. D, Calcium => Recurrence Relative Risk = 0.71 [95%CI=0.57-.89] • Calcium Supplementation + Vitamin D status reduce risk of Colorectal Adenomas

  42. Which is the WEAKEST Predictor of CAD? • A. C Reactive Protein • B. Total Cholesterol • C. Tobacco Abuse • D. Systolic Blood Pressure Danesh, et al. NEJM 2004; 350(14): 1387

  43. CDC Recommendations 2003 • Predictive Only in Intermediate Risk Patients (10-20% risk over 10 Years) • Low < 1.0 mg/L • High > 3.0 mg/L • Order only the HS-CRP; if elevated, repeat two weeks apart • If > 10 mg/L, repeat and Rule Out Infection • Of NO value in those with Known CAD

  44. True or False: Angioplasty is Better than Exercise at Preventing CAD Progression • TRUE • FALSE

  45. CAD:Cardiac Rehab (exercise) vs Angioplasty w/Stenting • RCT 100 male patients </= 70 c Stable CAD to 12 months Exercise vs Stent • Exercise = 20 min bicycle/day • Event Free Survival: 88% vs 70% • $3400 vs $6900 Hambrecht, et al. Circulation 2004; 109: 1371

  46. So Far: • Introduction & History of EBM • What EBM IS • What EBM is NOT • Patient Oriented Evidence, rather then focusing on intermediate information • Visual representation of evidence (Forest Plot)

  47. 5 Minute Break

  48. Medical Literature DescriptiveExplanatory Case Studies Observational Experimental Cohort Study RCT Case Control Study Cross Sectional Study

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