ebm4obsgynjuly2013topost-130807125100-phpapp01.pptx

8/12/2019 ebm4obsgynjuly2013topost-130807125100-phpapp01.pptx

1/38

Evidence-Based Medicine forObstetricsand Gynecology

L I F E S C I E N C E S L I B R A R Y

Summer 2013

Robin Featherstone, MLIS

http://www.slideshare.net/featherr


2/38

Why EBM?


3/38

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 question4. Categorize questions and identify the best studies to

answer each question type

5. Select appropriate sources to search for evidence to best

answer your questions6. Identify three fundamental questions to ask when

appraising a published study


4/38

EBM for Obstetrics & Gynecology

Based on Hematology pilotEBM program forspecialist residents

Focused on real-lifeclinical questions

Aimed to integrate EBMprinciples into journal

clubs, everyday practice


5/38

EBM Process

Appraising

the Evidence

Incorporating

evidence into

decision-making

Evaluating

the Process

Formulating

the clinical

question

Searching

the Evidence

Your patient for whom

you are uncertain about

therapy, diagnosis, or

prognosis

ASK

ACQUIRE

APPRAISEAPPLY

ASSESS


6/38

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.

[1.]

What are the reported

incidences of

paraovarian cysts?

What are risk factors forpelvic inflammatory

disease?

Should a left atrial

mobile mass in an

elderly woman with a

previous uterine

sarcoma be removed?


7/38

[1.]

Sources for Background Questions

Textbooks

Handbooks

Manuals

Encyclopedias

etc

BackgroundQuestions
http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/


8/38

Patient ScenarioYou 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 safedelivery.

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?


9/38

Formulating a Clinical Question

Patient, population, or problem

Intervention, prognostic factor, or exposure

Comparison or intervention

Outcomes to measure or be achieved


10/38

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 thepregnancy, 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 safedelivery.

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?


11/38

PICO

P: Newborns born to mothers with immunethrombocytopenia

I: Blood test to check platelet count

C: No blood test

O: Diagnosis of immune thrombocytopenia


12/38

Clinical Question

In newborn patients with suspected immune

thrombocytopenia, is a blood test to

determine platelet count recommended to

diagnose immune thrombocytopenia?


13/38

What is the evidence?

Systematic Reviews

Randomized control trials

Cohort studies

Case-control studies

Case reports

Editorials

Animal research

All types of articles found in PubMed


14/38

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

1Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit.2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question: www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
http://www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/http://www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/


15/38

Levels of Evidencefor Therapy Question

Level of Evidence Type of Study

1a Systematic reviews of randomized controlled trials

(RCTs)

1b Individual RCTs with narrow confidence interval2a Systematic reviews of cohort studies

2b Individual cohort studies and low-quality RCTs

3a Systematic reviews of case-control studies

3b Case-control studies

4 Case series and poor quality cohort and case-control

studies

5 Expert opinion

15

Levels of evidence (2001). Centre for Evidence Based Medicine. Retrieved 26 Aug 2008 from

http://www.cebm.net/index.aspx?o=1025
http://www.cebm.net/index.aspx?o=1025http://www.cebm.net/index.aspx?o=1025


16/38

Unfiltered

Filtered

2a 2b

543b

4

1b1b

2a

5

2b

3b

Summaries

Information Sourcesfor Diagnosis Question

Synopsisof

synthesis


17/38

1. Soundness of evidence-based approach

2. Comprehensiveness and specificity

3. Ease of use4. Availability

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

Criteria for Selecting an Information

Source
http://www.jgh.ca/en/hslinteractivepyramidhttp://www.jgh.ca/en/hslinteractivepyramidhttp://www.jgh.ca/en/hslinteractivepyramidhttp://www.jgh.ca/en/hslinteractivepyramidhttp://www.jgh.ca/en/hslinteractivepyramidhttp://www.jgh.ca/en/hslinteractivepyramid


18/38

Filtered

Information Sourcessome examples

} includes: Cochrane

Database of

Systematic

Reviews

DARE (Database

of Abstracts of

Reviews of Effects)


19/38

Filtered



20/38

Filtered


Unfiltered


21/38


Unfiltered

Expert Opinion


22/38


23/38

Unfiltered

Expert Opinion

Filtered

Wh t th PICO?
http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/


24/38

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 theprevious 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


25/38

Possible PICO 1

P: 27 year old female with prenatal anaemia

I: Iron supplementation

C: No iron supplementation

O: Adverse pregnancy outcomes


26/38

Possible PICO 2


I: Diet modification to include iron enriched

vegetarian foods

C: No diet modification

O: Improvement in haemoglobin

concentration


27/38


28/38

Possible PICO 4


I: Iron supplementation

C: Diet modification to include iron enriched

vegetarian foods

O: Improvement in haemoglobin

concentration


29/38

For a patient with prenatal anemia, does iron

supplementation increase the risk of adverse

pregnancy outcomes?

What kind of a question is this?


30/38

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

1Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit.2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question: www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/
http://www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/http://www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/


31/38

Unfiltered

Expert Opinion

Filtered

Where are you going to look?
http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/http://www.mcgill.ca/library/library-findinfo/courses/guides/ebm_intro/


32/38

* Links to all of these resources:

http://www.mcgill.ca/library/library-

findinfo/subjects/health/medicine

Search strategies*

Cochrane (anemia OR anaemia) AND pregnan* AND iron

UpToDate (anemia OR anaemia) AND pregnan* AND iron > Treatment of the

adult with iron deficiency anemia > Pregnancy

PubMed ClinicalQueries

(anemia OR anaemia) pregnancy iron

TRIP Database (anemia OR anaemia) AND pregnan* AND iron

Google Scholar allintext: (anemia OR anaemia) ~pregnancy iron
http://www.mcgill.ca/library/library-findinfo/subjects/health/medicinehttp://www.mcgill.ca/library/library-findinfo/subjects/health/medicinehttp://www.mcgill.ca/library/library-findinfo/subjects/health/medicinehttp://www.mcgill.ca/library/library-findinfo/subjects/health/medicinehttp://www.mcgill.ca/library/library-findinfo/subjects/health/medicine


33/38

EBM Process

Appraising

the Evidence

Incorporating

evidence into

decision-making

Evaluating

the Process

Formulatingthe clinical

question

Searching

the Evidence

Your patient for whomyou are uncertain about

therapy, diagnosis, or

prognosis

ASK

ACQUIRE

APPRAISEAPPLY

ASSESS


34/38

i i h id ( i i )


35/38

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?

S i i th E id (S t ti R i )


36/38

Summarizing the Evidence (Systematic Reviews),cont.

3. How can I apply the results to patient care?

A. 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?


37/38

1. UpToDate is a _______ resource. And EMBASE isa ________ resource.

2. The 5 stages in the EBM process are _______.

3. The best evidence to answer a diagnosisquestion is _______.

4. To find systematic reviews of RCTs use _______.

5. PICO stands for ________.

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

Summary Quiz


38/38

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 studydesign

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

Documents

ebm4obsgynjuly2013topost-130807125100-phpapp01.pptx