LIFE SCIENCES LIBRARY

Evidence-Based Medicine for Obstetrics and Gynecology

Summer 2013

Robin Featherstone, MLIS http://www.slideshare.net/featherr

Why EBM?

Workshop - 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 questions and identify the best studies to answer each question type 5. Select appropriate sources to search for evidence to best answer your questions 6. Identify three fundamental questions to ask when appraising a published study

EBM for Obstetrics & Gynecology

Based on Hematology pilot

EBM program for specialist residents Focused on real-life clinical questions Aimed to integrate EBM principles into journal clubs, everyday practice

EBM Process
ASSESS Evaluating the Process Formulating the clinical question

ASK

Incorporating evidence into decision-making APPLY

Your patient for whom you are uncertain about therapy, diagnosis, or prognosis

Searching the Evidence ACQUIRE

APPRAISE Appraising the Evidence

Should a left atrial mobile mass in an elderly woman with a previous uterine sarcoma be removed?

What are the reported incidences of paraovarian cysts? What are risk factors for pelvic inflammatory disease?
[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.

Background Questions

Sources for Background Questions Textbooks Handbooks Manuals Encyclopedias etc

[1.]

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 babys platelet count. If so, when?

Formulating a Clinical Question

Patient, population, or problem Intervention, prognostic factor, or exposure Comparison or intervention

Outcomes to measure or be achieved

Whats 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 babys platelet count. If so, when?

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

Clinical Question
In newborn patients with suspected immune thrombocytopenia, is a blood test to determine platelet count recommended to diagnose immune thrombocytopenia?

What is the evidence?

Systematic Reviews Case-control studies Randomized control trials

Cohort studies
Editorials

Case reports
Animal research

All types of articles found in PubMed

Question
Cost Diagnosis

Best Evidence
Cost-effectiveness study Diagnostic validation studies Prospective studies / blind comparison to a gold standard

Etiology/Harm Cohort study Case control study Prognosis Quality of life Therapy Cohort study Case control study Qualitative studies Systematic review of Randomized Controlled Trials (RCTs) Single RCT

1 2

Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006. Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/

Levels of Evidence
for Therapy Question
Level of Evidence Type of Study 1a 1b 2a 2b 3a 3b 4 5 Systematic reviews of randomized controlled trials (RCTs) Individual RCTs with narrow confidence interval Systematic reviews of cohort studies Individual cohort studies and low-quality RCTs Systematic reviews of case-control studies Case-control studies Case series and poor quality cohort and case-control studies Expert opinion

Levels of evidence (2001). Centre for Evidence Based Medicine. Retrieved 26 Aug 2008 from http://www.cebm.net/index.aspx?o=1025

15

Information Sources
for Diagnosis Question
Synopsis of synthesis Summaries

Filtered

1b 2a

1b 2a

2b

Unfiltered 3b 3b

2b

Criteria for Selecting an Information Source

1. 2. 3. 4. Soundness of evidence-based approach Comprehensiveness and specificity Ease of use Availability

See also: http://www.jgh.ca/en/hslinteractivepyramid

Information Sources
some examples

}
Filtered

includes: Cochrane Database of Systematic Reviews DARE (Database of Abstracts of Reviews of Effects)

Information Sources
some examples

Filtered

Information Sources
some examples

Filtered

Unfiltered

Information Sources
some examples

Unfiltered

Expert Opinion

Information Sources
some examples

Filtered

Unfiltered

Filtered

Unfiltered

Expert Opinion

Whats the PICO?

A 27-year-old presented for her initial prenatal visit at 10 weeks gestation. Her family and medical histories were unremarkable and she reported healthy behaviours. Her BMI was 22. She has been vegan for the previous 5 years. Her initial prenatal labs revealed mild anemia (hematocrit, 32%; hemoglobin, 10.8 g/dL ). She was asked to bring a 3-day diet history so that her food choices could be evaluated. Evaluation of her diet revealed a deficiency of iron-rich foods and insufficient intake of foods high in folate. You discussed iron supplementation with the patient and she expressed concern over the impact on the health of the baby.

Penney, et. al. (2008). Nutritional Counseling for Vegetarians During Pregnancy and Lactation. Journal of Midwifery & Womens Health. Vol 53. Issue 1. pg 37-44. Retrieved July 23, 2013 from http://dx.doi.org/10.1016/j.jmwh.2007.07.003

Possible PICO 1
P: 27 year old female with prenatal anaemia I: Iron supplementation C: No iron supplementation

O: Adverse pregnancy outcomes

Possible PICO 2
P: 27 year old female with prenatal anaemia I: Diet modification to include iron enriched vegetarian foods C: No diet modification O: Improvement in haemoglobin concentration

Possible PICO 3
P: 27 year old female with prenatal anaemia I: Iron supplementation C: Diet modification to include iron enriched vegetarian foods O: Adverse pregnancy outcomes

Possible PICO 4
P: 27 year old female with prenatal anaemia I: Iron supplementation C: Diet modification to include iron enriched vegetarian foods O: Improvement in haemoglobin concentration

What kind of a question is this?

For a patient with prenatal anemia, does iron supplementation increase the risk of adverse pregnancy outcomes?

Question
Cost Diagnosis

Best Evidence
Cost-effectiveness study Diagnostic validation studies Prospective studies / blind comparison to a gold standard

Etiology/Harm Cohort study Case control study Prognosis Quality of life Therapy Cohort study Case control study Qualitative studies Systematic review of Randomized Controlled Trials (RCTs) Single RCT

1 2

Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006. Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/

Where are you going to look?

Filtered

Unfiltered

Expert Opinion

Search strategies*
Cochrane (anemia OR anaemia) AND pregnan* AND iron

UpToDate
PubMed Clinical Queries

(anemia OR anaemia) AND pregnan* AND iron > Treatment of the adult with iron deficiency anemia > Pregnancy
(anemia OR anaemia) pregnancy iron

TRIP Database
Google Scholar

(anemia OR anaemia) AND pregnan* AND iron

allintext: (anemia OR anaemia) ~pregnancy iron

* Links to all of these resources: http://www.mcgill.ca/library/libraryfindinfo/subjects/health/medicine

EBM Process
ASSESS Evaluating the Process Formulating the clinical question

ASK

Incorporating evidence into decision-making APPLY

Your patient for whom you are uncertain about therapy, diagnosis, or prognosis

Searching the Evidence ACQUIRE

APPRAISE Appraising the Evidence

Summarizing the Evidence (Systematic Reviews)*

1.

Are the results valid?

A. Did the review explicitly address a sensible clinical question?

B. Was the search for relevant studies detailed and exhaustive?

Were sources of evidence and search strategies specified in sufficient detail for replication Was the likelihood and direction of publication bias considered?

C. Were the primary studies of high methodologic quality?

D. Were selection and assessments of studies reproducible?

*. http://jamaevidence.com/criticalAppraisalWorksheet/26

Summarizing the Evidence (Systematic Reviews), cont.

2.

What are the results?

A. Were the results similar from study to study? B. What are the overall results of the review? C. How precise were the results?

Summarizing the Evidence (Systematic Reviews), cont.

3.
A.

How can I apply the results to patient care?

Were all patient-important outcomes considered? B. Are any postulated subgroup effects credible? C. What is the overall quality of the evidence? D. Are the benefits worth the costs and potential risks?

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 ________. 6. The three questions to ask to appraise ANY study are _______, ________, and ________.

Next steps
Some suggestions for your journal clubs (next one: August 21) Start with a patient case Develop a PICO question Search for best available evidence Appraise the article using standard questions for that study design

Slides available: http://www.slideshare.net/featherr