Introduction: Evidence-Based Medicine for

Haematology

LIFE SCIENCES LIBRARY

Summer 2012

Chantal Cassis, MDRobin Featherstone, MLISFrancesca Frati, MLISRoland Grad, MDCM MSc FCFP

Jewish General Hospital Library

Why EBM?

Workshop 1 - Objectives

By the end of the workshop, you will be able to:1. Describe the five stages of the EBM process2. Differentiate background from foreground

questions3. Develop a well-formed PICO question4. Categorize PICO questions and identify the

best studies to answer each question type5. Select an appropriate source to search for

evidence to best answer your PICO questions

EBM for Haematology

Pilot program designed for specialist residents

Focused on real-life clinical questions

Aims to integrate EBM into your everyday practice

Course Website:

www.jgh.ca/en/hslintroebp

Curriculum Overview

Year-long EBM curriculum for PGY-4 & PGY-5Five workshops (small-group, case-based)Weekly homeworkAssessment: Fresno & course evaluation

Image: http://goodmancenter.stanford.edu/education/postgraduate.html

Integrated EBM journal clubs

Workshops

July 25 - Introduction to EBM for Haematology

Aug 8 - Hands-on Searching WorkshopsAug 22 - Critical AppraisalSept 5 - Resident PresentationsSept 19 - Review

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

Workshop1

Workshop2

Workshop3Workshop

4

Workshop5

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 is pancytopenia?

What is the diagnostic test for meningitis?

Can a 70 year old pancytopenic patient with suspected meningitis receive platelets before undergoing a lumbar puncture?

[1.]

Sources for Background Questions• Textbooks• Handbooks• Manuals• etc

Background Questions

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 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 baby’s 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

What’s 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 baby’s 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

Randomized control trials

Cohort studies

Case-control studies

Case reportsEditorials

Animal research

All types of articles found in PubMed

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 studiesTherapy •Systematic review of Randomized Controlled

Trials (RCTs)•Single RCT

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

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 studies2b Individual cohort studies and low-quality RCTs3a Systematic reviews of case-control studies3b Case-control studies4 Case series and poor quality cohort and case-control

studies5 Expert opinion

18

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

Unfiltered

Filtered

1b

2a 2b

543b

4

1a1a1b

2a

5

2b

3b

Summaries

Information Sourcesfor Diagnosis Question

Synopsis of

synthesis

1. Soundness of evidence-based approach2. Comprehensiveness and specificity3. Ease of use4. Availability

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

Criteria for Selecting an Information Source

Filtered

Information Sourcessome examples

} includes:

• Cochrane Database of Systematic Reviews

• DARE (Database of Abstracts of Reviews of Effects)

Filtered

Information Sourcessome examples

Filtered

Information Sourcessome examples

Unfiltered

Information Sourcessome examples

Unfiltered

Expert Opinion

Unfiltered

Filtered

Information Sourcessome examples

Unfiltered

Expert Opinion

Filtered

What’s the PICO?A 25 year-old female has been recently diagnosed with classical Hodgkin’s lymphoma (nodular sclerosing subtype). Staging reveals that she is a stage IIA (early favorable HL) with a 4.5 cm nodal mass in her neck and mediastinal nodes. You recommend combined modality therapy (chemotherapy /- radiation therapy). The patient has done some reading about therapy and is worried about the long term effects of radiation especially the risk of breast cancer.

She asked you if combined modality therapy is truly superior to chemotherapy alone?

What if she was a stage IIB (early unfavorable)?

She agrees to begin ABVD chemotherapy and asked if she will be getting G-CSF (neupogen) injection to ensure that her white blood cells recover prior to the subsequent chemotherapy cycle. You inquire with your colleagues and realize that some give all their patients neupogen while others never do. Is there a benefit to giving neupogen while getting ABVD?

Possible PICO 1

P: 25 year old female with stage IIA Hodgkin’s Lymphoma

I: Combined modality therapy

C: Chemotherapy alone

O: Risk of breast cancer

Possible PICO 2

P: 25 year old female with stage IIB Hodgkin’s Lymphoma

I: Combined modality therapy

C: Chemotherapy alone

O: Risk of breast cancer

Possible PICO 3

P: Patient undergoing ABVD chemotherapy

I: G-CSF (neupogen) injection

C: No neupogen

O: Recovery of white blood cells prior to chemotheraphy

Possible PICO 4

P: 25 year old female with stage IIA Hodgkin’s Lymphoma

I: Combined modality therapy

C: Chemotherapy alone

O: Most effective treatment

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 ________.

Summary Quiz

Homework

For next workshop (9 am to noon, Aug 8th, JGH A-805) record two PICO formulated clinical questions encountered during practice

Send one PICO to instructor – robin.featherstone@mcgill.ca – by 5 pm on Aug 1.

If you don’t have a PICO, let us know by Aug 1

Bring these PICO questions to the next workshop

Slides available: