Finding and Using Best Evidence

Rebecca Payne, MPHLaura Straw, MPH

Health Analysis DepartmentNavy and Marine Corps Public Health

Center

FOR OFFICIAL USE ONLY2

Disclaimer

The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

Health Analysis Department

Department within the Population Health Directorate of the Navy and Marine Corps Public Health Center, Portsmouth, VA

Highly trained team consisting of: Epidemiologists Program Manager Technical Affairs Officer Biostatistician Physician Lead Navy Tumor Registry Consultant

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Objectives

1. Define “best evidence”2. Describe how one would find

best medical evidence3. List the hierarchy of strength

of evidence4. List examples of best evidence

in Navy Medicine

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“Evidence-Based…”?

• Evidence-based medicine:• “The conscientious, explicit, and judicious use of

current best evidence in making decisions about the care of individual patients.”1

• Evidence-based clinical practice:• “Evidence-based clinical practice is an approach to

decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option that suits the patient best” 2

• Evidence-based practice in health care:• Evidence-based health care “takes place when

decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information”

3

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Levels of Evidence

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Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

Background Info/ Expert Opinion

• Quick references• Medscape Reference• 5 Minute Clinical Consult

• Textbooks• Internet• Colleagues/experts

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Example: Medscape Reference

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Levels of Evidence

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Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

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• Reports• Case series: Descriptive study of group with

common exposures or outcomes• Case-controlled studies: People with a

specific health outcome are matched with people who do not have the outcome to compare if the groups differ with respect to potential causes

• Cohort studies: People exposed to a cause or a treatment are compared to those not exposed to determine if they differ with respect to risk of some outcome

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Unfiltered Information

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• Randomized Controlled Trials• “Gold standard”• Experimental design• Participants are

randomly assigned to a control condition or to an experimental condition

• Minimizes bias• Drawbacks: Expensive

and time consuming

Unfiltered Information Resources

• PubMed http://www.ncbi.nlm.nih.gov/pubmed

• Ovid MEDLINE http://www.ovid.com/site/catalog/DataBase/901.jsp

• PsychINFOwww.apa.org/psycinfo/

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Example: PubMed

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Example: PubMed

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Levels of Evidence

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Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

Filtered Evidence

Critically Appraised Individual Articles• Synopsis and evaluation of individual

research studies• Critically Appraised Topics• Synthesis and evaluation of multiple

research studies

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CAIA Resources

• ACP Journal Clubhttp://acpjc.acponline.org/

• Evidence Updates- from the BMJ Evidence Centerhttp://plus.mcmaster.ca/evidenceupdates/

• Any “Evidence-Based…” Journal series (i.e. Evidence-Based Nursing)

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CAT Resources

• AHRQ National Guideline Clearinghouse

http://guideline.gov/index.aspx

• Clinical Evidence http://clinicalevidence.bmj.com/x/index.html

• Essential Evidence Plus- POEMshttp://www.essentialevidenceplus.com/

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Example: AHRQ National Guideline Clearinghouse

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Example: AHRQ National Guideline Clearinghouse

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CAT Resources

• The VHA/ MHS have their own Clinical Practice Guidelines• http://www.healthquality.va.gov/• VA/DoD Evidence-Based Practice Guideline

Work Group (EBPWG) include representatives from all military branches and the VA

• EBPWG selects topics based on cost, volume, risk, and feasibility.

Example: VA/DoD CPGs

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Levels of Evidence

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Source: Adapted from http://www.ebmpyramid.org/samples/complicated.html

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Systematic Review: • Searching for, recording, analyzing and interpreting the

existing evidence 4

Meta-Analysis:• Applying a statistical formula to measure the effect, size,

and impact of treatment programs 4

Example From Cochrane:• Exercise or Exercise and Diet for preventing

type 2 diabetes7

• 8 trials, with ~5,000 participants• Conclusion: Exercise and diet can decrease

type 2 diabetes

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Systematic Review Resources

• Cochrane Database of Systematic Reviews • www.cochrane.org

• The Database of Abstracts of Review of Effects (DARE)• http://www.ovid.com/site/products/ovidguide/

daredb.htm• PUBMED• http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?

otool=yalelib&dr=citation• Ovid MEDLINE

Source: http://www.ebmpyramid.org/samples/complicated.html

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Example: USPSTF

• US Preventive Services Task Force (USPSTF)• http://www.uspreventiveservicestaskforce.org/

• Independent group of prevention and EBM experts that makes recommendations about clinical preventive services

Example: USPSTF

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Evidence Based Applications and

Examples

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The 5-Minute Clinical Consult 2009OR UptoDate

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Restless Leg Syndrome

Cervical Cancer Screening

• What is the evidence for routine cervical caner screening in women?

• US Preventive Services Task Force

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Source: Whitlock, E.P., Vesco, K.K., Eder, M., Lin, J., Senger, C., Burda, B., Liquid Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cencer: A Systematic Review for the US Preventive Services Task Force. Annals of Internal Medicine. 2011. Vol 155 No 10. p 687-697

Cervical Cancer, Ctd

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Cervical Cancer, ctd.

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• Does everyone agree?

Source: http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf

PTSD• What is the best evidence available about

treatment for PTSD?• VA/DOD Clinical Practice Guideline:

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Source: VA/DOD Clinical Practice Guideline: Management of Post Traumatic Stress Disorder and Acute Stress Reaction (2010). http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp

PTSD Cont’d

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PTSD Cont’d

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Cochrane Review: PTSD• Psychological and psychosocial interventions

• “Some types of psychological treatment (individual trauma-focused cognitive behavioural therapy/exposure therapy [TFCBT], eye movement desensitisation and reprocessing [EMDR], stress management, and group TFCBT) were effective in the treatment of PTSD, and individual TFCBT and EMDR appeared to be superior to stress management at two to five months. Insufficient evidence was available to determine whether psychological treatment is harmful, but there was greater drop-out in active treatment groups. Caution is needed in interpreting these results because of considerable unexplained heterogeneity, and the potential impact of publication bias”

• Pharmacotherapy for post-traumatic stress disorder• “Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms,

as well as associated depression and disability. The findings of this review support the status of selective serotonin reuptake inhibitors as first-line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.”

Source: http://www.thecochranelibrary.com/details/collection/1045825/Cochrane-Evidence-Aid-resources-for-post-traumatic-stress-disorder-following-nat.html

HEDIS• NCQA’s Health Effectiveness Data and

Information Set (HEDIS)• Widely used set of health performance

indicators• Desirable attributes for HEDIS

measures are:• Relevance • Scientific Soundness –Clinical

Evidence! (There should be evidence documenting the link between clinical processes and outcomes that measures address)

• Feasibility

Source: HEDIS Technical Specification Manual

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Evidence Applications

• In Military Medicine: Population Health Navigator/CarePoint

Analysis Application

How could we apply best evidence when measuring healthcare?

1. Look for best evidence: systematic reviews, CPGs, research

2. Assess evidence3. Look for existing measures; if none

exist, look for “measurable points” in evidence.

4. Ensure proposed measure is meaningful and feasible

5. Develop measure

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Application Example: mTBI Metrics

Wounded, Ill, and Injured (WII) Program: Navy Medicine effort to monitor and improve the care

offered to wounded, ill, and injured service members and their families

mTBI MetricsTBI Screening: Percent of Coded Head Injury/Trauma

Patients Coded as Screened for TBICo-Occurring Conditions Screen: Percent of Coded

mTBI Patients Coded as Screened for Co-Occurring Conditions

Six Week Follow Up Visit: Percent of Coded mTBI Patients with Follow-Up within Six Weeks

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mTBI Metrics Example (cont’d)

Metric Definitions: The Department of Veterans

Affairs (VA) and Department of Defense (DoD) Concussion and mTBI Clinical Practice Guideline (CPG)

Coding Guidance: Defense Centers of Excellence

for Psychological Health and Traumatic Brain Injury (DCoE PH/TBI)

Navy Medicine TBI subject matter experts (SMEs) 41

General Coding Guidance & CPG Recommendation

mTBI Metrics Example (cont’d)

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CPG Recommendation:

“Regardless of the time that has elapsed

since injury, management should

begin with the patient’s first

presentation for treatment,” and head injury cases should be

screened for TBI.

All Head Injury Cases: 5%

Active Duty Only: 7%

mTBI Metrics (cont’d)

Not using codes?Not screening for

TBI?Actual process different than

recommendation?43

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References1. Sackett,D., Richardson, W., Rosenberg, W., & Haynes, R. (1997). Evidence-

based medicine: How to practice and the EBM. New York:Churchill Livingston.

2. Muir Gray, J.A. (1997) Evidence-based healthcare: How to make health policy and management decisions. London:Churchill Livingstone.

3. Hicks, N. (1997). Evidence based healthcare. Bandolier, 4(39),8. 4. Roberts, A., Yeager, K. (2004). Evidence-Based Practice Manual. New

York, NY: Oxford University Press. 5. Whitlock, E.P., Vesco, K.K., Eder, M., Lin, J., Senger, C., Burda, B. (2011).

Liquid Based Cytology and Human Papillomavirus Testing to Screen for Cervical Cencer: A Systematic Review for the US Preventive Services Task Force. Annals of Internal Medicine. 155 (10),687-697.

6. Framingham Heart Study http://www.framinghamheartstudy.org/about/history.html

7. Orozco LJ, Buchleitner AM, Gimenez-Perez G, Roqué i Figuls M, Richter B, Mauricio D. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD003054. DOI: 10.1002/14651858.CD003054.pub3

Navy and Marine Corps Public Health Center

Health Analysis

CAPT Paul Rockswold, MD, MPHHead, Health Analysis

P: 757-953-0690Email: paul.rockswold@med.navy.mil

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web: http://www-nehc.med.navy.mil/Data_Statistics/Health_Analysis/ha_overview.aspx