Strategies for Answering Clinical QueriesIntroduction to Health InformaticsApril 6, 2010

Robin Featherstone, BA, MLISClinical Medicine LibrarianAllyn & Betty Taylor Libraryrfeathe@uwo.ca

Presentation available at: http://www.slideshare.net/featherr

Objectives

1. Develop an understanding of search tools within an EBM framework

2. Introduce a variety of products to support clinical decision making

Agenda• Sources of Medical Evidence (EBM) & PICO• Searching Exercises

1. Medical Literature– Cochrane Library– PubMed (Clinical Queries)– TRIP Database– Natural Standard

2. Point-of-Care Tools– ACP Pier– UpToDate– DynaMed

3. Drug Information Resources– E-CPS– MICROMEDEX– Lexi-Interact

SOURCES OF MEDICAL EVIDENCE & PICO

Level of Evidence Pyramid

Qualitative Studies

Trip searches both

Refine Questions using PICO

P = Patient, Problem or PopulationI = Intervention or ExposureC = ComparisonO = Outcomes

PICO Example

A patient travels frequently and report suffering from the effects of jet lag. They ask about prevention methods. Have you heard of using melatonin? They’ve also read that exercise can be used to prevent symptoms. What do you recommend?

Use PICO to develop your query

P: Jet lagI: MelatoninC: ExerciseO: Prevention of symptoms

Which is more effective in preventing jet lag: melatonin or exercise?

Determine your Question Type1,2

1. Aetiology: What is the cause of the disease and its mode of operation?

2. Diagnosis: How accurate is this diagnostic test?3. Prognosis: What is the probable course of the disease?4. Therapy: Is one intervention more effective than

another?5. Prevention: How to reduce the risk of this disease?6. Cost-effectiveness: Is one intervention more cost-

effective than another?7. Quality of life: What will be the patient’s quality of life?

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/

Studies to Answer Each Type1,2

Type of Question Type of Evidence

Aetiology •Randomized controlled trials•Case-control or cohort studies•Case series

Diagnosis •Diagnostic validation studies•Prospective studies / blind comparison to a gold standard

Prognosis •Inception cohort studies•Case control studies•Case series

Therapy •Randomized controlled trials•Systematic reviews / meta-analyses

Prevention •Randomizes controlled trials•Cohort studies, case control studies•Systematic reviews / meta-analyses

Cost-effectiveness •Economic analyses

Quality of life •Qualitative studies1 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/

Level of Evidence Pyramid

Qualitative Studies

Trip searches both

SEARCHING EXERCISE – MEDICAL LITERATURE

Searching the Medical Literature

• Please search the following sources to answer the question: Are probiotics effective in reducing symptoms of eczema/atopic dermatitis?

1. Cochrane Library2. PubMed (clinical queries) 3. TRIP Database4. Natural Standard

Treatment Question - Results

Source Results

Cochrane Library 2 Cochrane Reviews3 Other Reviews47 Clinical Trials

PubMed 199 Citations total88 Review articles48 citations if searching Clinical Queries – looks for randomized controlled trials

TRIP Database 81 Citations

Natural Standard 1 disease summary 1 drug summary

SEARCHING EXERCISE – POINT OF CARE TOOLS

Searching Point-of-Care Tools

• Search the following sources to answer the question: What is an appropriate second-line topical treatment for atopic dermatitis?

1. ACP Pier2. UpToDate3. DynaMed

– Locate temporary link from: http://taylormedinfo.blogspot.com/

2nd Line Treatment Question - Results

Source Contains

ACP Pier •Evidence rating •Evidence summary•Recommendations

•Link to drug monograph from AHFS DI Essentials (US)

UpToDate •Some evidence ratings•Evidence summary•Recommendations

•Link to detailed drug monograph from Lexi-Comp (US)

DynaMed •Evidence rating•Evidence summary•Links to guidelines

•Link to detailed drug monograph from AHFS DI Essentials (US)

• Search the following tools to answer the question: Should a 53 year old, postmenopausal woman who smokes one pack of cigarettes a day and reports low calcium intake be screened for osteoporosis?

1. ACP Pier2. UpToDate3. DynaMed

– Locate temporary link from: http://taylormedinfo.blogspot.com/

Searching Point-of-Care Tools:2. Screening question

Screening Question - ResultsSource Contains

ACP Pier •Evidence rating •Evidence summary•Links to assessment tools

UpToDate •Detailed screening topic•Screening recommendations•List of risk factors

DynaMed •Prevention and Screening Information together•Evidence rating•Evidence summary

SEARCHING EXERCISE – DRUG INFORMATION

Searching for Drug Information

You consider prescribing Tacrolimus to a patient who is taking Fluconazole, Gabapentin and Aspirin. Search the following tools to identify any potential interactions:

1. Lexi-Interact (UpToDate)2. MICROMEDEX3. E-CPS

Drug Interactions - Results

Source Results

Lexi-Interact •Interaction analysis tool•Risk ratings•Patient Management recommendations

MICROMEDEX •Interaction analysis tool•Risk ratings•Includes other interactions (ex. Drug-Food)•Canadian

E-CPS •Detailed drug monographs•Drug Interactions

Summary

• Use PICO to develop clinical queries• Select the level of evidence to best answer

your query type• Consider using a variety of filtered

information tools based on the information needed

QUESTIONS