1 / 57

Paving an EBM Trail; From Journal Club to Publication

Paving an EBM Trail; From Journal Club to Publication. Corey Lyon D.O. Research Family Medicine Residency Kansas City, MO. Objectives. Exposure to a longitudinal EBM curriculum Obtain ideas on how to conduct a “Journal Club” that teach information mastery skills

stephanie-carpenter
Télécharger la présentation

Paving an EBM Trail; From Journal Club to Publication

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Paving an EBM Trail; From Journal Club to Publication Corey Lyon D.O. Research Family Medicine Residency Kansas City, MO

  2. Objectives • Exposure to a longitudinal EBM curriculum • Obtain ideas on how to conduct a “Journal Club” that teach information mastery skills • Discover ways to put these EBM skills into practice with publication opportunities, poster presentations, and Grand Rounds presentations • Introduction to FPIN membership • Introduction to a structured QI project workbook • Time for idea sharing

  3. EBM can be learned

  4. RFM Residency 13-13-13 community program Inner city, tertiary hospital 20 full/part time faculty

  5. The Residency Review Committee Requires That: • All residents must participate in some scholarly activity • The program must provide supervision over this activity • Residents must have practical experience in data searching and grading, statistical methods, and application to practice • The training environment must be in compliance with EBM practices

  6. How we learn • 3 ways we learn • 1. Construct new knowledge and understanding based on what they already know and believe. • 2. Learning tasks need to be structured and organized in some meaningful way to allow effective transfer of knowledge from one context to a new context. • 3. Learning requires multiple exposures to and complex interactions with knowledge.

  7. Where do I want to end up…… • Identify objectives for an EBM curriculum • How to convert information needed into an answerable question • To become better consumers of the medical literature • Learn what to read • Learn critical appraisal skills • Synthesis the evidence – understand what it means • Grade the evidence • Know where to go and how to search for evidence • Put these EBM skills in motion before graduation

  8. Now, how to get there…. • A longitudinal experience • Repeat exposure to the EBM concepts over 3 years • It is how we learn • Journal Club (change the name if you can) • critical appraisal of new research articles • Develop high success/high reward EBM projects • Publication opportunities • Presentation opportunities

  9. Goals of Journal Club • Learn components of EBM • Ask answerable question • Literature search strategies • Determine relevance/validity of the research • Synthesizing the evidence – convert to user friendly statistics • Assigning a level of evidence grade • Determine how apply the evidence

  10. Goals of Journal Club (cont) • Learn about new evidence that may change our practice • Learn about new evidence that influence clinical decisions • Provide a healthy, group learning environment • Continue to refine information mastery skills • Focus on learners needs, not publishers/pushers

  11. Not Goals of Journal Club • How to do research (instead of how to use research) • How to do statistics (instead of how to interpret it) • Only finding flaws in articles • Teach all components of EBM in 1 session • Humiliate or bully learners by not knowing or using EBM skills

  12. Steps in Journal Club • Convert need for information into an answerable question • Track down the best evidence to answer that question • Critically appraise for validity, impact, applicability • Integrate the critical appraisal with clinical experience and patient uniqueness • Evaluate

  13. Components of every JC • PICO • Patient/population, Intervention, Comparison, Outcome • Relevance • Validity • LoE • Synthesis • How to apply? • Strength/weakness • Challenges (not bashing)

  14. Structure of Journal Club • Consistent schedule • Monthly, bi-monthly • Develop process in finding an article • Consistent components • PICO, relevance, validity, LoE, applicability • Use worksheets as a tool • At least 1 teaching point with synthesis • ie Therapy – OR, NNT, CI, etc • Resident participation • Resident leader to help pick articles • Resident summarizes article

  15. Journal Club Topics • Therapy • Diagnosis • Harm • Guidelines • USPSTF • EBM guidelines

  16. More than just articles • Literature searching skills • POC tools • Clinical decision rules • Drug rep evaluation

  17. Finding articles for JC • Always be on the look out • Use pre-synthesised resources • Daily Poems with Essential Evidence Plus • www.essentialevidenceplus.com • ACP Journal Club - www.acpjc.org • PURLs from JFP (FPIN) • AFP briefs • Dynamed- www.ebscohost.com/dynamed/weeklyUpdate.php • Journal Watch - www.jwatch.org • Evidence-Based Practice- www.ebponline.net • News media

  18. EBM skills - PICO • Asking answerable questions • Transform it into PICO

  19. Distill the Clinical Question to P.I.C.O.

  20. PICO Question Exercise • You have a 52 y/o male in your clinic you diagnose with BPH, while discussing treatment options, he asks if Saw Palmetto is a good treatment option • P: Adult males with BPH • I: Saw Palmetto • C: Prescription medications (Flomax, Hytrin, Cardura) • O: Symptom relief, reduction in symptom score • Search terms

  21. EBM Skills - Relevance • Determine Relevance • Can use a worksheet • What questions can you ask to determine relevance? • Is the outcome one that patients care about • Is the problem studied common to your practice • Is the intervention feasible • Will the outcome change/confirm what you are doing

  22. EBM skills - Validity • Determining Validity • Worksheet as a tool • Review the study design • SR – appropriate search, heterogeneity? • RCT – randomization? Similar groups? • Cohort – confounders, similar groups? • Glossary of EBM terms; seeing these terms help assess that the researchers used valid scientific method • www.aafp.org/online/en/home/publications/journals/afp/ebmtoolkit/ebmglossary/afppoems.html

  23. EBM skills - LoE • Grading the evidence • Types of studies • CEBM table

  24. . . .Let the Evidence Pyramid Be Your Guide As you move up the pyramid, the amount of available literature decreases, but increases in relevance to the clinical setting. Meta-Analysis Systematic Reviews Randomized Control Trials Cohort Studies Case-Control Studies Case Series Expert Opinion

  25. Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) http://www.cebm.net/index.aspx?o=1025

  26. LOE Example: Grading the References

  27. LOE Examples, continued

  28. EBM skills - Synthesis • Synthesis • Causes the most fear among faculty • Practice, practice, practice • Utilize resources to help you prepare • Learning is planned • Evidence-Based Medicine; How to Practice and Teach EBM by Straus

  29. EBM Skills - Synthesis • Convert study results into user friendly statistics • Number needed to treat/harm • Confidence Intervals • Likelihood Ratios • Use worksheets, online tools • Create 2X2 table • http://ktclearinghouse.ca/cebm/practise/ca/calculators/statscalc

  30. User-Friendly Stats 2X2 Table for Outcome of Interest - + Experimental Treatment Placebo/ Comparison • a. Control Event Rate: Cer = c / c + d • b. Experimental Event Rate: Eer = a / a + b • c. Absolute Risk Reduction: ARR = Cer – Eer • d. Relative Risk Reduction: RRR = ARR / Cer • e. Relative Risk Ratio = Eer / Cer • Number Needed to Treat: NNT = 1 / ARR • http://ktclearinghouse.ca/cebm/practise/ca/calculators/statscalc

  31. Example: User-Friendly Stats

  32. Example: User-Friendly Stats PrimaryEnd Points (first major cardiovascular events) + - Experimental treatment Placebo/ Comparison Control Event Rate: Cer = c / c + d = 251/251 + 8650 = 0.028 Experimental Event Rate: Eer = a / a + b = 142/142 + 8759 = 0.016 Absolute Risk Reduction: ARR = Cer – Eer = 0.028 – 0.016 = 0.012 Relative Risk Reduction: RRR = ARR / Cer = 0.012/0.028 = 0.43 Number Needed to Treat: NNT = 1 / ARR = 1/0.012 = 83 http://www.cebm.net/index.aspx?o=1160

  33. Example: User-Friendly Stats Non – Fatal Myocardial Infarction Experimental treatment Placebo/ Comparison Control Event Rate: Cer = c / c + d = 62/62 + 8839 = 0.00696 Experimental Event Rate: Eer = a / a + b = 22/22 + 8879 = 0.00247 Absolute Risk Reduction: ARR = Cer – Eer = 0.00696 – 0.00247 = 0.00449 Relative Risk Reduction: RRR = 0.00449/0.00696 = 0.65 Number Needed to Treat: NNT = 1 / 0.00449 = 223 http://www.cebm.net/index.aspx?o=1160

  34. EBM Skills - Assessment • Assessing clinical importance • Discuss whether the treatment/diagnosis effective • Also discuss how effective • P value – likelihood the difference is due to chance • RR – Relative Risk Reduction – magnitude of difference, but not necessarily clinical importance • AR – absolute reduction – better measure of clinical importance • NNT – better understanding of the magnitude of results

  35. Special Sessions – Literature search • PubMed searches as a group • Search terms • Limits • PubMed tools • My NCBI • Collections • Citation matcher • Clinical Query • Mesh terms • Tips for accessing full text

  36. Special Sessions – Literature search • Other Medline tools with your institution • Ovid • EBSCO • Essential Evidence Plus • National Guideline Clearinghouse • Library access

  37. Special Sessions – Literature search • See one – Do one • Look Up Conference • Divide into small groups – 3-4 residents • Present group with question – “Saw Palmeto for BPH” • Convert to PICO – easier to figure out search terms • Assign different EBM Source to each group • PubMed, EE+, Cochran, NGC, JFP, Google, etc • Find best 1-2 articles • As large group – discuss results, assign a LoE, determine answer (if able) • Discuss success/difficulties with different sites

  38. Special Sessions – POC tools • PEPID demonstration • Diagnosis, treatment, calculators, guidelines, etc • Other Clinical Decision Tools • EE+ tools • iPhone apps – MedCalc, Qx Calculate, AHRQ ePSS • FRAX, Framingham CV Risk, etc

  39. Putting Skills in Motion • Scholarly projects with goals in mind • Utilize EBM skills emphasized in JC • Forming an answerable question • Literature search • Assigning a LoE/Grade the evidence • Synthesize the article • Come up with an answer

  40. Putting Skills in Motion • Structure, structure, structure • High yield, high success • Relatively quick, attainable projects • Dedicated time • Not just on top of all other requirements

  41. Project Examples • RFMR utilizes FPIN membership • Family Physicians Inquiries Network • Provides an avenue and tools for publication opportunities • Assist faculty and residents in becoming contributors to the medical literature – utilizing EBM skills • Writing Projects • eMedRef – fast track point of care topic reviews (PEPID) • Help Desk Answers – Concise answers to clinical questions

  42. Help Desk Answers • 500 word manuscript • Resident and faculty co-author • Faculty need to publish first – do one, then teach one. • Work with Local Editor and Editor-in-Chief • Peer reviewed at another FPIN program • Complete in 24 hours over 12 weeks • Published in Evidence-Based Practice

  43. Other Projects – Local Academy • Missouri Academy of Family Physicians Magazine • Quarterly “Resident Grand Rounds” • Resident choose the topic • Case Study, QI project, Review of medical condition (Pediatric Sports Concussion)

  44. Writing Structure • RFMR example • Complete during a 4 week rotation • Give ½ day/week of admin time • Outline the timeline • 1st week – Literature review complete • Meet with faculty to review search, decide which article to pull • 2nd week – Review articles • Meet with faculty, discuss article findings, determine which articles to use by relevance, LoE, etc • 3rd week – write outline to article – meet with faculty • 4th week – Complete 1st draft – give to faculty with articles

  45. Writing Structure - continued • Faculty role • Guide through writing process • Work toward achieving EBM goals – not publication • Literature search, synthesis, assign LoE/SORT, etc • Keep on timeline, scheduled meetings • Once EBM goals achieved, complete the heavy lifting • Edit before turning into editor/peer review • Assist with addressing peer reviewer’s and editors comments • Can be overwhelming • Keep the enthusiasm going

  46. Other Projects-Quality Improvement • Takes a little more time to complete project • Still needs structure • Workbook developed • Focus on key steps of a QI project – PDSA cycle • Emphasize EBM skills • Know that the change is an improvement • Literature review • Synthesis and grade evidence • Utilize EBM guidelines • Develop timeline, keep to it; sustainability • Success is dependant on faculty involvement • Sustain enthusiasm

  47. Keep the momentum going • Turn the project into a poster presentation • State academy’s annual conference • AAFP Scientific Assembly • STFM • NCFMR • Types of posters • Clinical Inquiries • Case Studies • QI/PI projects

  48. RFMR 3 year success • 15 HDAs published in Evidence-Based Practice • 4 other publication types • MAFP, case series, etc • 8 QI projects completed • 12 posters presented at MAFP ASA • Two 1st place • Two 2nd place • One 3rd place • 9 HDAs pending; 1 MAFP pending, 1 QI project pending

  49. Skills carry over • R-3 Grand Round Presentation • EBM expectations • Cite original research • Which means – literature search, synthesis, explain results, etc • Assign a LoE to all cited articles • Give key recommendations at end of talk with SORT grade • Similar to AFP articles • Faculty mentor assigned • Check list and time line followed • Evaluation forms to give feedback on the EBM components of presentation

More Related