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Evidence Based GynObs ???
Ward - Clinic
Information Overload
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Different messages
Guideline 1
Guideline 2
Article 1
CME
Article 2
Expert
Textbook
Whats the truth??
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• Which information brings your patient?
• What is IPOS?

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CASE

• 48 year old woman
• Hot flushes
• No estrogens (mother died endometrial carcinoma)
• What about phytoestrogens?

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Searching on the Internet

• Searchmachines
• very a-selective (gt 900,000 hits are no
  exception)
• no filtering on quality
• not always up-to-date (newer sites)
• (high ranking for sale)
• meta-tags and tricks

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Searching on the Internet

• Your patient
• Prefers own language
• Doesnt always know right spelling
• Does not have a reference
• Cannot always recognize quality of information

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www.hon.ch
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www.hon.ch
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Searching on the Internet

• Your patient
• Prefers own language
• Doesnt always know right spelling
• Does not have a reference
• Cannot always recognize quality of information
• and doesnt know the evidence-based method

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Evidence-based method

• Structured process in several steps
• Formulate clinical question
• State-of-the-Art searching
• Critical appraisal
• Conclude on the base of results
• Apply the results in practice

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The 4 elements of the question
PICO
Oxford EBM group
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Our Case

• 1. Patient/Problem hot flushes
• 2. Intervention phyto-estrogens
• 3. Comparison(s) placebo
• 4. Outcome(s) effect on endometrium

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Domains

• Diagnosis
• Etiology
• Prognosis
• Therapy
• Side Effects

question domain search strategy
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Levels of evidence therapy
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• Where to find evidence?

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For searching 5xS
Computerized decision support systems
Systems
Evidence-based journal abstracts
Synopses
Cochrane reviews
Syntheses
Original published articles in journals
Studies
Studybooks
Textbooks
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Textbooks
Systems
Synopses
Syntheses
Studies
Studybooks

• Background information
• Extended summaries of knowledge
• Lag behind 1-2 years for therapy and diagnosis

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Studies (1)
Systems
Synopses
Syntheses
Studies
Studybooks

• Cochrane Controlled Trial Register

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Cochrane Controlled Trial Register

• In Cochrane Library
• For interventions only
• Largest database RCT/CCTs (400,000)

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Studies (2)
Systems
Synopses
Syntheses
Studies
Studybooks

• Cochrane Controlled Trial Register
• Medline / Pubmed

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Medline

• National Library of Medicine (USA)
• From 1966
• 4900 journals, 12 million articles
• 12 search systems, Pubmed free
• 65 of RCTs found in Medline
• Restriction on journals

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Studies (3)
Systems
Synopses
Syntheses
Studies
Studybooks

• Cochrane Controlled Trial Register
• Medline / Pubmed
• Embase

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Embase

• European alternative for Medline
• Focus on biomedical sciences and pharmacology
• From 1988 3500 journals
• www.embase.com

Medline Embase 90 RCTs
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Studies (4)
Systems
Synopses
Syntheses
Studies
Studybooks

• Cochrane Controlled Trial Register
• Medline / Pubmed
• Embase
• Specific internet sites (SumSearch)

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SumSearch

• Searches several databases
• Medline (via Pubmed)
• Cochrane database of Systematic Reviews
  (abstracts)
• Database of Abstracts of reviews of effects
  (DARE)
• National Guideline Clearinghouse
• Books
• Free via internet
• http//sumsearch.uthscsa.edu/

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Syntheses
Systems
Synopses
Syntheses
Studies
Studybooks

• Databases with Systematic Reviews
• Cochrane Library
• Cochrane Database of Systematic Reviews CDSR
• Cochrane Controlled Trials Register CCTR
• Database of Abstracts of Reviews of Effects DARE

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http//www.york.ac.uk/inst/crd/darehp.htm
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Synopses
Systems
Synopses
Syntheses
Studies
Studybooks

• EBM sources
• Evidence reviewed abstract en comments on
  selected good research
• Evidence-based Obstetrics Gynecology
• Best Evidence ACP Journal Club Evidence-Based
  Medicine
• TRIP

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Systems the thing
Systems
Synopses
Syntheses
Studies
Studybooks

• Information system
• summary of all existing evidence about one
  clinical question
• linked to the electronic medical record of the
  individual patient
• newest evidence continuously added

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Existing Systems

• Some electronic textbooks linking best evidence
  and clinical questions
• UpToDate
• Clinical Evidence
• www.controlled-trials.com

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http//www.clinicalevidence.com
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Summary

• Ask your questions in daily practice (PICO)
• Search strategy (question and domain)
• Remember 5xS
• Start in Cochrane library
• Integrate EPR with EBM
• No evidence without the Internet

Systems
Synopses
Syntheses
Studies
Studybooks
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Evidence Based GynObs ???
Ward - clinic
Evidence Overload
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Thank you very much for your attention
hans_at_obgyn.nl
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