Online Resources for EvidenceBased Clinical Care
Elizabeth Eckstrom, MD, MPH
Oregon Health & Science University
Carol Howe, MD, MLS
University of Arizona
Today we will:
Discuss levels of evidence and how to
efficiently find the highest level of evidence
for your question
 Differentiate foreground and background
questions and find the best evidence for each
 Practice using some of these resources

Mr. Drake


Mr. Drake is a 72 year old new patient to your practice.
He has a history of HTN and CAD, both medically
managed and stable. He exercises regularly, and is
enjoying retirement; doing lots of travel with his wife.
He wants to plan well for his wife’s future, so is
wondering what is his risk of having a heart attack in
the next five years?
He has never had a pneumovax, so you recommend
one today. He states he has read the literature and
doesn’t think he needs one. You have always followed
the recommendation to vaccinate your patients over
65, but decide to review the evidence yourself so you
can show him why he needs vaccination.
Foreground vs Background
questions
5
year prognosis for patients with stable
HTN and CAD
 Pneumonia risk reduction with
pneumovax in a fairly healthy 72 year
old
What is the best evidence you could find to
answer these questions?
pyramid modified from: Navigating the Maze, University of Virginia, Health
Sciences Library. From The University of Washington
https://healthlinks.washington.edu/ebp/ebptools.html
Background Questions
 Background
questions tend to be
general questions about a disease such
as
–
–
–
–
typical clinical presentation
epidemiology
natural history
treatment.
For Background questions….
Textbooks
 Textbook databases : Stat!Ref; MD Consult;

AccessMedicine

UptoDate -essentially a continuously updated online
textbook

Clinics of North America-quarterly journal of review
articles


eMedicine- part of Medscape-regularly updated point of
care reference. (FREE For health care providers)
Other resources you find useful and reliable?
Foreground Questions
 Foreground
questions are much more
focused, targeted questions.
 PICO is an ideal mnemonic for helping
to build an answerable question.
 The nature of the question will help you
determine the best strategy for how to
answer it.
PICO
 P-patient,
population or problem
 I-Intervention (diagnostic test,
exposure, prognostic factor, therapy)
 C-Comparison- (population without
that disease, placebo drug, comparison
drug)
 O-outcome-Measurable outcome such
as improvement in symptoms, adverse
effects, mortality.
Clinical questions usually fall into
these categories:
 Etiology
(can also include Cause and
Harm)
 Diagnosis
 Therapy (also includes Prevention)
 Prognosis
What is the best evidence you could find to
answer these questions?
pyramid modified from: Navigating the Maze, University of Virginia, Health
Sciences Library. From The University of Washington
https://healthlinks.washington.edu/ebp/ebptools.html
Type Of Question
Suggested best type of study
Diagnosis
prospective, blind comparison to a gold standard
Therapy
RCT > cohort > case control > case series
Prognosis
cohort study > case control > case series
Harm/Etiology
RCT > cohort > case control > case series
Prevention
RCT > cohort > case control > case series
Clinical Exam
prospective, blind comparison to a gold standard
Cost Benefit
economic analysis
From Introduction to Evidence-Based Practice, Duke university Medical Center Library
and Health Sciences Library, UNC-Chapel Hill
http://www.hsl.unc.edu/services/tutorials/ebm/welcome.htm
For most foreground
questions:
 Look
in first in “filtered” or “preappraised sources” such as the
Cochrane Library ,ACP Medicine
(available also from Stat!Ref), or BMJ
Clinical Evidence (to name just a few!)
 If there is no recent review, PubMed
has some excellent options —which we will
spend most of the rest of our time reviewing
Sources for further exploration:





Introduction to Evidence-Based Practice, Duke university Medical
Center Library and Health Sciences Library, UNC-Chapel Hill . Fifth
Edition. (updated July 2010)
http://www.hsl.unc.edu/services/tutorials/ebm/index.htm
University of Illinois: Evidence Based Medicine: Finding the Best
Clinical Literature . Last updated 2008
www.uic.edu/depts/lib/lhsp/resources/ebm.shtml
SUNY Downstate Medical Center Evidence Based Tutorial (last
updated 2004) http://library.downstate.edu/EBM2/contents.htm
Centre for Evidence-Based Medicine Toronto
http://ktclearinghouse.ca/cebm
Buckingham J, Fisher B, Saunders D. Evidence-Based Medicine: mini
manual. Based in part on the Evidence-Based Medicine Toolkit,
http://ebm.med.ualberta.ca/ . Last updated July, 2009.
http://www.med.ualberta.ca/dsme/documents/Minimanual2009.pdf