The 5 A’s of EBCP 1. ASK = Develop a clinically relevant question 2. ACQUIRE = Search the literature to find the best available evidence to answer your question 3. APPRAISE = Evaluate the evidence for validity and applicability to the clinical circumstances 4. APPLY = Use the relevant evidence in the clinical situation 5. ASSESS = Evaluate your effectiveness in carrying out steps 1 through 4 and revise if necessary
Ask Patient dilemma Acquire Evidence Cycle Assess the results of the action with patient Appraise Apply
PICO A format for developing clinical questions P: I: C: O: Patient, population Intervention or therapy Comparison, control Outcome
Patient Scenario • You have an 8 year old female patient diagnosed with ADHD brought in by her mother, as she would prefer to treat her child with more natural, holistic methods • At a recent visit, Mom tells you that she saw something in a pamphlet that suggested a diet restricting dairy and sugar would help her daughter’s symptoms • She asks you if you think this is something she should do or if you can make any other diet/supplement recommendations
PICO: Focused Clinical Question Consider Your Question P Patient or problem Describes patient (age, gender, race, condition/symptom, etc) • 8 year old/pediatric • Female • ADHD I Intervention What treatment, diagnostic test, intervention is being considered? • Diet restricting dairy and sugar C Comparison Compared to what? Another intervention, Gold Standard, Nothing • Other dietary changes • Supplementation O Outcomes What is the desired effect of the intervention? (decreased symptoms, improved function, etc) • Reduction of symptoms • Reduced need for medication
Ask Patient dilemma Acquire Evidence Cycle Assess the results of the action with patient Appraise Apply
Acquire • Quick database search – Some of my favorites • Index to Chiropractic Literature • Pub. Med • Natural Standard Database • Dynamed • Rehabilitation Reference Center
Hierarchy of Evidence Randomized Controlled Double Blind Studies Systematic Reviews and Meta-analyses
Review… Strong… More recent publication… Let’s look at this one
Ask Patient dilemma Acquire Evidence Cycle Assess the results of the action with patient Appraise Apply
JTASS Journal Title Author Site Summary Adapted from: Department of Clinical Epidemiology & Biostatistics, Mc. Master University Health Sciences Center. How to read clinical journals: I. Why to read them and how to start reading them critically. CMAJ 1981; 124: 555 -8.
JTASS Journal Expert Review of Neurotherapeutics Peer reviewed, indexed in Pub. Med Title Relevant to our question Looks interesting Keywords: • Supplementation • Treatment of ADHD Authors Rucklidge, Julia J Primary author, 25 articles 18 of 25 re: ADHD Site Review, so multiple sites Summary Most evidence is sparse and conflicting Best evidence: Zinc (2 RCTs) Mixed evidence: carnitine, pycnogenol, EFAs Population similarity, able to reproduce intervention if valid Inconclusive: vitamins, Mg, Fe, Sam-e, tryptophan, Ginko biloba w/Ginseng No support: St John’s Wort, tyrosine, phenylalinine
Ask Patient dilemma Acquire Evidence Cycle Assess the results of the action with patient Appraise Apply
APPLY • Consider the best available evidence, combine Best this with your clinical experience, and Evidence incorporate the patient’s preferences into the final recommendations • present the pros and cons of the different options to patients in a way they can understand, and let them choose how they would like to proceed Clinical Expertise Patient Values
APPLY • Shared with Mom that there is little evidence to support dietary restriction • Recommended supplementation with Zinc to help decrease symptoms of ADHD and perhaps reduce need for stimulant medication – Evidence suggests approx. 15 mg of Zinc/day • Mom excited to receive the information, going to try Zinc on a trial basis – Good use of EBCP, incorporating patient values
Student Assessment • Students were then given 4 clinical scenarios to choose from • Had to go through process (“Ask, Acquire, Appraise, Apply”) • Completed worksheets for each step of process • Turned in worksheets along with chosen article
Additional Samples of Clicker Questions…
The hormone that most directly influences Na+ balance in the body is 1. 2. 3. 4. 5. Vasopressin Angiotensin Rennin Aldosterone Atrial natriuretic peptide
A 65 -year-old man has difficulty rising from a seated position and straightening his trunk, but he has no difficulty flexing his leg. Which of the following muscles is most likely to have been injured? 1. Gluteus maximus 2. Gluteus minimus 3. Hamstrings 4. Iliopsoas 5. Obturator internus
What is the most likely Dx? 1. Lytic metastasis 2. Osteoporosis 3. Multiple myeloma 4. Paget’s Disease 5. lymphoma
Both pleural effusion and lobar pneumonia are characterized by _____ heard on percussion. 1. 2. 3. 4. Tympany Dullness Resonance Hyperresonance
