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Session 214
Tips for keeping current even when you’re overworked
Mary Barger CNM, MPH, FACNM
Boston University School of Public Health
Department of Maternal and Child Health
Objectives
1. Review the important aspects you need to look for in evaluating the literature
2. Provide ways you can quickly read the literature
3. Identify a method for updating your knowledge for key issues relevant to you
4. Provide a list of resources to help you keep up to date or find the information.
Review of Statistical Measures
1. Absolute measures
· Absolute risk: the baseline risk of the outcome
· Absolute risk difference: difference in the proportion with and without the outcome
2. Relative measures
· Relative risk (RR): Ratio of risk (incidence) between exposed to the unexposed.
• RR=1 means no difference in outcome between those with and without exposure
• RR>1 means exposure is associated with outcome
• RR

· Sample size
If there were no differences found, was the sample size large enough to find a
clinically meaningful difference?
2. Cohort studies
Start with a group of people who are ‘healthy’ and assess their exposures or risk factors
and follow them over time and record if and when they experience various
outcomes/diseases.
· Complete recording of outcomes is essential
· Loss of follow-up of members of the cohort can bias the results.
· This design allows researchers to study multiple exposures and outcomes
· Very expensive study design.
3. Case- control studies
· Excellent for studying rare outcomes
· Choosing controls who represent the population at risk for the outcome
independently of the exposure or risk factor understudy is key to study validity
· Odds ratio is the statistical measure
Levels of Evidence*
The U.S. Preventative Health Services Task Force as well as several other organizations
(ACOG) and journals use the following schema to evaluate the strength of evidence for an
intervention strategy.
Levels of Evidence – Research Design Rating
I Evidence from randomized controlled trial(s)
II-1 Evidence from controlled trial(s) without randomization
II-2 Evidence from cohort or case-control analytic studies preferably from more than one group
II-3 Evidence from comparisons between times or places with or without the intervention; dramatic
results in uncontrolled experiments could be included here
III Opinions of respected authorities, based on clinical experience; descriptive studies or reports of
expert committees
Quality of Evidence
The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative
populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is
limited by the number, quality, or consistency of the individual studies, generalizability to routine
practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or
power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack
of information on important health outcomes.

Strength of Recommendations for Clinical Preventive Service
The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, I)
reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).
A. The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. There is
good evidence that [the service] improves important health outcomes and concludes that benefits
substantially outweigh harms.
B. The USPSTF recommends that clinicians provide [this service] to eligible patients. There is at least
fair evidence that [the service] improves important health outcomes and concludes that benefits
outweigh harms.
C. The USPSTF makes no recommendation for or against routine provision of [the service]. There is at
least fair evidence that [the service] can improve health outcomes but concludes that the balance of
benefits and harms is too close to justify a general recommendation.
D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. There is
at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely
providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or
conflicting and the balance of benefits and harms cannot be determined.
POEMS – patient oriented evidence that matters
Process which allows you to ignore most of the medical literature and focus on what
really matters.
Free tutorial available at: www.poems.msu.edu/infomastery
1. Identify the most common , important conditions you encounter in your practice.
- Keep a piece of paper in your pocket and write down issues as they come up during the
day.
- You will find there are a limited number you see a lot
2. Spend a little time each month, researching one of these or in your practice group assign each
person one of them to research.
3. Where to start?
- Look for systematic reviews on the subject or evidenced-based guidelines– see chart
- Use a reliable source that does systematic review of the literature and make sure these are
regularly updated
- How to read a journal article quickly? PP-ICONS
- Problem – Is it a problem I see in my practice?
- Patient population – Does the study’s patient population look like mine?
- Intervention – What is the intervention and is it realistic in my setting?
- Comparison – What is the intervention being compared to, and is it a reasonable
comparison?
- Outcomes – Would the outcomes matter to my patients?
- Numbers – How many patients in the study?
- Statistics
- How are the findings presented?
- Relative vs absolute risk?

- Number needed to treat (NNT) is the reciprocal of absolute risk reduction may
be more valuable
Example: If NNT = 100 that means your patient has a 1% chance of benefiting
from the intervention.
4. Other ways to keep abreast with hot articles
- JMWH Journal Reviews and Evidence-Based Practice Columns
- Subscribe to Medscape for updates sent to your email
- Subscribe to ObGynLinx ( www.mdlinx.com/obgynlinx/index.cfm)
- ORGYN.com_Daily [Orgyn_Daily_Int@mailing.orgyn.com]
References / Resources
Genuis SK, Genuis SJ. Exploring the continuum: medical information to effective clinical
practice. Paper I: the translation of knowledge into clinical practice. J Eval Clin Pract 2005;
12(1):49-62.
Grimes DA, Atkins D. The U.S. Preventive Services Task Force: putting evidence-based
medicine to work. Clin Obstet Gynecol 1998; 41(2):332-42.
Grimes DA, Schulz KF. Clinical research in obstetrics and gynecology: more tips for busy
clinicians. Obstet Gynecol Survey 2005; 60(9):S53-69.
Grimes DA, Schulz KF. Clinical research in obstetrics and gynecology: a Baedeker for busy
clinicians. Obstet Gynecol Survey 2002; 57(9):S35-53.
Grimes DA, Schulz KF. Uses and abuses of screening tests. Lancet 2002; 359:881-4.
Timmermans S, Mauck A. The promises and pitfalls of evidence-based medicine. Health Affairs
2005; 24(1):18-28.
Steinberg EP, Luce BR. Evidence based? Caveat emptor! Health Affairs 2005; 24(1):80-92.
*U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of
Evidence. Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003.
Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/3rduspstf/ratings.htm
White B. Making evidence-based medicine doable in everyday practice. Fam Pract Manag 2004;
11(2):51-8.

Clinical Guidelines
Name Description Cost Sponsor
Institute for Clinical Systems
Improvement(ICSI)
www.icsi.org
Guidelines for preventive
services and disease
management
Free online
ICSI
US Preventive Services Task Force
www.ahrq.gov/clinic/uspstfix.htm
National Guideline Clearinghouse
www.guidelines.gov
Clinical preventive
services based on
systematic review
Compilation of guidelines
from many sources
Free
Free
USPSTF
AHRQ
Canadian Task Force for
Preventative Health Care
http://www.ctfphc.org/
Recommendations of
interventions on many
topics including perinatal
Free
CTFPHC
Evidence Summaries
Cochrane Database of Systematic
Reviews
www.cochrane.org
BMJ Clinical Evidence
www.clinicalevidence.com
Most extensive collection
of reviews
Compendium of
systematic reviews
updated every 6 months
Free for abstracts
Online $239
($120 stu)
PDA $50
Concise hard copy $198
Cochrane
Collaboration
BMJ
Publishing
Group
www.unitedhealthfoundation.org/
registration.cfm
DynaMed
www.dynamicmedical.com
InforRetriever
www.infopoems.com
FIRST Consult
www.firstconsult.com
SUMSearch
http://sumsearch.uthscsa.edu/
TRIP Database (Turning Research
into Practice)
www.tripdatabase.com
Database of summaries
from Cochrane and
Clinical Evidence
Search engine to
databases eg Cochrane,
BMJ Clinic Evd,
POEMS. Daily emails
Database of summaries
from several sources
Search engine from
DARE, Medline,
Clearinghouse
Search engine using
multiple EBM sources
Providers receive free
hard copy thru United
Healthcare Foundation
$220/yr online
access????
CD version available
$249/yr for online, CD
or PDA
$149/yr ($89 stu)
online, CD or PDA
Free
Free online
DynaMed
InfoPOEMS,
Inc.
Elsevier
Univ Tex
Gwent, Wales
York Database of Abstracts of
Reviews and Effects (DARE)
www.york.ac.uk/inst/crd/darehp.ht
m
Collection of abstracts of
systematic reviews
Free Online
Nat’l Health
Services
Reviews;
York, UK
Bandolier
www.jr2.ox.ac.uk/bandolier
Monthly journal searches
PubMed, Cochrane and
other meta-analyses
summarizes the
Free online
Oxford Univ
Pain Research

interesting