Thanks to the creative faculty of Middlesex Health System, Inc. for permission to publish this web site.
Middlesex Health System
Center for Evidence Based Practice
(Developed by Katherine Schneider, MD, MPhil, MHS Czarina of EBP, email@example.com)
(Maintained by Elisabeth Righter, MD, FAAFP) Last updated 5/10/01.
What is Evidence Based Practice? (Also known as Evidence Based Medicine, to non-interdisciplinary thinkers)
EBP or EBM is a process which aims to improve the ability of clinicians to make well informed clinical decisions for and with their patients:
1. Identifying knowledge needs in clinical encounters
2. Translating needs into answerable questions
3. Searching for quantitative answers
4. Appraising the evidence
5. Integrating the evidence into the clinical situation
Even seasoned clinicians generate about 5 knowledge needs for every inpatient encounter and 2 needs for every 3 outpatients. The purpose of this web site is to bring the EBM process closer to the point of care by collating the most useful introductory information and searching tools into one up-to-date location that will be easily accessible during patient care and teaching encounters.
Any underlined blue phrases may be clicked on to link to other sites of interest. The colored buttons at the bottom of each page can help you jump around the site.
Once you have gotten past the hurdle of identifying your knowledge need, the biggest challenge is learning to format your question into a structure that gives you the best chance of finding the quantitative answer you need. This process is for "foreground" questions, such as "In patients with nonvalvular atrial fibrillation, does treatment with warfarin compared to aspirin improve mortality from all causes". This approach should not be used for "background questions", such as "What is hypertrophic pulmonary osteoarthropathy?" which is best answered through traditional means, e.g. a textbook or quick reference manual (also available now on many internet sites such as Dynamed or MDConsult).
The exact structure of the clinical question will vary somewhat depending on whether it is about a therapy, diagnostic test, etiology, prognosis, cost effectiveness, clinical exam finding, etc. However...
...the well built clinical question can be broken down into four parts:
2. Intervention (e.g. treatment or test)
3. Comparison (e.g. placebo or gold standard)
The handy mnemonic "PICO" might help at first, especially helping learners to rephrase questions.
Focusing Clinical Questions
The following is a list, by no means exhaustive, of some of the most useful web based resources that I have found for finding answers to questions. Try the secondary sources first, as they are more likely to give you a quick, pre-digested answer that you can use at the point of care, as opposed to Medline which is better when you have more time to pick through abstracts and evaluate which are valid and relevant.
Click directly on any underlined phrase to get to that site.
Dynamed (free but password required, posted on precepting computers). Dayton users can sign up individually.
MDConsult (password required, posted on the MHS intranet for MHS users only) Available via GDAHIN network to Dayton users. Remember you must be connected via GDAHIN's ISP to access the network.
Secondary Sources (advantage: already synthesized for you)
Cochrane Database Abstracts (no password needed)
Cochrane Library Full Reviews (password needed, posted on MHS intranet). Available to Dayton users via Kettering Medical Center Library. Remember you must be connected via the intranet or KMC's PPP account to access the library. Also available via Wright State University Library. You must connect via WSU's remote dial up to access the Cochrane Library.
ACP-On Line: Look for articles in ACP Journal Club or EBM Journal
Journal of Family Practice "POEMs" index (by date not topic)
If you are not always able to connect to the internet and would like portability of a wide collection of secondary sources, consider purchasing Inforetriever or Best Evidence (CD-ROM) which can be loaded directly onto your desktop or laptop computer. Inforetriever is also available for your pocketpc handheld computer. The combination of these contains all of the above, and is well worth the money you'll spend to update them.
Right Brain " Fuzzy Logic" Medline Search Tool: Knowledgefinder
(If you are good at structuring your questions but bad at Medine searching like me, you'll love this one because you can just type in your sentence and the program figures out how to translate it into Medline-ese)
Left Brain Medline Search Tool for Clinicians: PubMed Clinical Queries
National Guideline Clearinghouse With over 500 practice guidelines ( though supposedly evidence based, most are not strictly so, but at least give you an idea of "standard care".)
Once you have found your "answer", the next step is to understand its validity and relevance to your patient. If it scores low on validity (i.e. it's a lousy study) or relevance (doesn't apply well to your situation), you should probably not waste time going further. If you did your search within secondary sources (e.g. Cochrane, POEMs), you can have some confidence that the validity has already been assessed.
A major goal of the "EBM Process" is to provide quantitative answers so that you and your patients can make better informed decisions about diagnostic tests, treatments, etc., rather than giving you a black and white or cookbook answer. To this end, you should familiarize yourself with some of the basic tools of EBM. You probably already are familiar with sensitivity and specificity, but how about "numbers needed to treat" (NNT), "numbers needed to harm" (NNH), likelihood ratio (LR), and pre-test probability. These were designed to be intuitively understood measures that can summarize the bottom line effect of a treatment or test.
Use of these measures can be mastered with a little practice. The following sites can help you with examples and explanations.
WISDOM Seminars: A web based self study course on Evidence Based Practice
EBP Toolbox: Details on and examples on the process and the math
Teaching Resources for