Editorials

Following up on Evidence-based Medicine

Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal

These quotes are taken from the editorial accompanying a previous issue of the Wisconsin Medical Journal dealing with Evidence-based Medicine. They were, in turn, lifted from the articles in that 1999 issue, which was designed as a primer in the use of EBM. It seemed appropriate to the Editorial Board to have a “follow-up issue” devoted to the same topic, and we are grateful to Dr Feldstein and his colleagues for providing the substance of this issue.

Author Affiliations: Medical Editor

Corresponding Author: Wisconsin Medical Society 330 E. Lakeside St Madison, WI 53715

Evidence-based practice is here to stay

David A. Feldstein, MD

The term “Evidence-Based Medicine” (EBM) has become ubiquitous throughout the medical community. There is just no way to avoid it. Some practitioners become nervous at the mere mention of the words and others may struggle with putting the concepts into practice. There have been dramatic changes in the practice of EBM since the Wisconsin Medical Journal first published an EBM issue 6 years ago. The goals of this issue are to clarify the EBM process, describe the advances that have taken place in the past six years, address some of the major issues health care professionals face in integrating evidence into their practices, and discuss areas for future research.



Author Affiliations: Doctor Feldstein is an assistant professor (CHS) in the Department of Medicine at the University of Wisconsin-Madison and an academic hospitalist at the University of Wisconsin Hospital and Clinics, Madison, Wis.

Corresponding Author: David Feldstein, MD, J5/210c Clinical Science Center, MC 2454, 600 Highland Ave, Madison, WI 53792; phone 608.265.8116; fax 608.265.5834; e-mail df2@medicine.wisc.edu

Commentaries

Communicating Evidence: The Final Frontier

Christine S. Seibert, MD; Laura J. Zakowski, MD

Evidence-based medicine (EBM) has been described as “the integration of the best research evidence with clinical expertise and patient values.”1 Since EBM came on the scene, there has been significant emphasis on the steps of EBM that include framing an evidence-based question, retrieving and appraising the evidence, and understanding the results. However, finding and evaluating research evidence is only part of the task. The real challenge may lie in the clinician’s ability to communicate research evidence to patients to help them make informed decisions.



Author Affiliations: The authors are associate professors of Medicine at the University of Wisconsin Medical School and teach evidence-based medicine. They also practice general internal medicine at UW-Health East Clinic in Madison.

Corresponding Author: Christine S. Seibert, MD, 1194 Health Sciences Learning Center, 750 Highland Ave, Madison, WI 53705; phone 608.263.7840; fax 608.262.4446; e-mail cseibert@wisc.edu.

Original Research

Evidence-Based Practice: What a Start and ‘Oh, the Possibilities’

David A. Feldstein, MD

Evidence-based medicine (EBM) was introduced in the early 1990s. In less than 15 years, it has dramatically changed the way that medicine is practiced and taught. Improvements in informatics and evidence resources have helped overcome some of the initial problems and allowed busy clinicians to use EBM in practice. Many barriers to using EBM still remain. Further work on translating evidence into patient care decisions and understanding patients’ preferences is required in order to realize the improvements that EBM’s early proponents envisioned.



Author Affiliations: Doctor Feldstein is an assistant professor (CHS) in the Department of Medicine at the University of Wisconsin-Madison and an academic hospitalist at the University of Wisconsin Hospital and Clinics, Madison, Wis

Corresponding Author: David Feldstein, MD, J5/210c Clinical Science Center, MC 2454, 600 Highland Ave, Madison, WI 53792; phone 608.265.8116; fax 608.265.5834; e-mail df2@medicine.wisc.edu.

Finding the Best Available Evidence: What’s New?

Christopher Hooper-Lane, MA; Ann M. Combs, MA; David Feldstein, MD

The voluminous growth of the health literature paired with time constraints of practitioners can make it difficult to implement evidence-based medicine (EBM). New and better resources that summarize and/or synthesize the literature are available to facilitate the integration of evidence into practice. Understanding how such resources work and how to use them is an important step in finding evidence for patient care. By using a clinical scenario concerning abdominal aortic aneurysm screening, this article describes 3 types of EBM resources from the “4S” model: systems, synopses, and syntheses. The common features of each resource type are discussed and comparisons of selected examples are provided.



Author Affiliations: Mr Hooper-Lane and Ms Combs are senior academic librarians at the Ebling Library at the University of Wisconsin-Madison. Mr Hooper-Lane is the instructional services coordinator and Ms Combs is a health science librarian. Doctor Feldstein is an assistant

Corresponding Author: Christopher Hooper-Lane, MA, Room 2338, Ebling Library, 750 Highland Ave, Madison, WI 53705-2221; phone 608.263.9324; fax 608.262.4732; e-mail chooper@library.wisc.edu

Making Evidence-Based Practice a Reality

Beth Potter, MD; Eric Rotert, MD

Busy doctors need answers, and quickly. Ely and colleagues observed that primary care clinicians generate approximately 3 questions every 10 patient visits.1 Additionally, the body of medical literature is growing exponentially. To keep up with primary care literature, it would be necessary to review 7287 articles per month, which would take approximately 29 hours per day.2 In 1992, the Journal of the American Medical Association introduced a formula for applying evidence-based medicine (EBM) in User’s Guide to the Medical Literature. With this method, a physician develops a clinical question from a patient encounter, performs a literature search, selects relevant articles, and critically appraises them to find the answer. Although rigorous, this approach is too cumbersome to use during a busy clinical day. Instead of critically appraising primary literature, most physicians seek information that has been pre-appraised—critically analyzed and summarized by someone else.3 In the Ely study, physicians attempted to answer only 40% of the 1101 questions they generated, spent less than 2 minutes looking, and did formal literature searches for only 2 questions. Physicians need to have a method for finding answers at the point-of-care.



Author Affiliations: Authors are with the Department of Family Medicine, University of Wisconsin – Madison. Doctor Potter is an assistant professor and also has a clinical practice at Wingra Clinic in Madison, Wis; Dr Rotert is a faculty development fellow and clinical

Corresponding Author: Beth Potter, MD, 777 S Mills, Madison, WI 53715; phone 608.263.4550; fax 608.263.6663; e-mail bepotter@wisc.edu.

Clinician’s Guide to Systematic Reviews and Meta-Analyses

David A. Feldstein, MD

Systematic reviews answer clinical questions by finding and evaluating all available evidence. The systematic review is a powerful tool to help clinicians use evidence for patient care decisions. There are many sources for high-quality systematic reviews. Like all scientific studies there are potential biases, but systematic reviews have many benefits over narrative reviews. To ensure appropriate use of systematic reviews, clinicians must evaluate them in a logical, step-by-step manner. This article will review the benefits of systematic reviews, how to locate them, and how to evaluate their quality and results.



Author Affiliations: Doctor Feldstein is an assistant professor (CHS) in the Department of Medicine at the University of Wisconsin-Madison and an academic hospitalist at the University of Wisconsin Hospital and Clinics, Madison, Wis

Corresponding Author: David Feldstein, MD, J5/210c Clinical Science Center, MC 2454, 600 Highland Ave, Madison, WI 53792; phone 608.265.8116; fax 608.265.5834; e-mail df2@medicine.wisc.edu

Using Clinical Practice Guidelines to Improve Patient Care

Tosha B. Wetterneck, MD; Mary H. Pak, MD

Clinical practice guidelines incorporate the best available evidence for the management of a disease or an aspect of disease treatment or prevention into a single document for health care providers. The quality of practice guidelines has improved by adopting standard approaches to the development of guidelines and reviewing their quality for use in patient care. Implementing guidelines into clinical practice can improve quality and efficiency of care and will likely benefit from a multidisciplinary, multifaceted approach.



Author Affiliations: Doctor Wetterneck is an assistant professors of medicine and Doctor Pak is an associate professor of medicine with the University of Wisconsin Medical School; both are academic hospitalists at the University of Wisconsin Hospital and Clinics, Madison, Wis

Corresponding Author: Tosha Wetterneck, MD, Assistant Professor of Medicine, University of Wisconsin Hospital and Clinics, 600 Highland Ave, J5/214b CSC, MC 2454, Madison, WI 53792; phone 608.263.9355; fax 608.262.6743; e-mail tbw@medicine.wisc.edu.

Evidence-Based Medicine for Medical Students: Introducing EBM in a Primary Care Rotation

William E Cayley, Jr, MD, MDiv

Background and Objectives: Evidence-based medicine (EBM) seeks to improve patients’ lives by applying the best available evidence to decisions affecting health outcomes. Since medical students often do not appreciate the value of an evidence-based approach to medicine when they enter third-year clinical training, a curriculum was developed introducing third-year students to the practice of EBM during a primary care clinical rotation.

Methods: Twenty-seven students over 4 rotations participated in the series of 6 hour-long seminars, and 8 items from a 27-item questionnaire were used to measure the impact on students’ self reported understanding and use of EBM. Results: Responses to questionnaires given before and after completion of the curriculum documented improved self-reported understanding of EBM and improved self-reported comfort with critical appraisal.

Conclusions: A seminar series introducing EBM in a primary care rotation improved students’ familiarity with and receptivity to use of EBM.

Author Affiliations: Doctor Cayley is an assistant professor in the University of Wisconsin Department of Family Medicine, teaching at the Eau Claire Family Medicine Residency and the Augusta Family Medicine Rural Training Site. Preliminary data was presented at UME 21 Nation

Corresponding Author: William E Cayley, Jr, MD, MDiv, University of Wisconsin, Eau Claire Family Medicine Residency, 617 West Clairemont Ave, Eau Claire, WI 54701; phone 715.839.5175; fax 715.839.5176; e-mail bcayley@yahoo.com

Meningococcal Disease Incidence and Mortality in Wisconsin, 1993–2002

Mark J. Sotir, PhD, MPH; Susann Ahrabi-Fard, MS; Donita R. Croft, MD, MS; James Kazmierczak, DVM, MS; Timothy A. Monson, MS; Mark V. Wegner, MD, MPH; Jeffrey P. Davis, MD

Neisseria meningitidis is a major cause of sepsis and meningitis in children and young adults in the United States. To examine recent epidemiologic features of meningococcal disease in Wisconsin, we evaluated Wisconsin case surveillance data collected during 1993–2002. Surveillance data for cases with onsets during this time were analyzed; statistical trends were assessed. Mortality was examined with regard to age, sex, serogroup, college student status, and young adult status by unadjusted and adjusted analyses. During 1993-2002, 462 cases of meningococcal disease were reported in Wisconsin; 55% of case patients were aged <19 years. The annual incidence was 0.9 cases per 100,000 persons per year, and incidence was highest among children aged <2 years. Two seasonal peaks in cases were observed during January–April and September–October. The annual mortality rate during the 10-year interval was 0.09 deaths per 100,000 persons per year. Adjusted analysis indicated that serogroup C infection, young adult, and college student status (but not sex) were associated with mortality. Meningococcal disease remains uncommon and sporadic in Wisconsin. Incidence and mortality rates are highest among young children, but young adults who acquire the disease appear to be at an increased mortality risk.



Author Affiliations: All authors except Mr Monson are with the Bureau of Communicable Diseases, Wisconsin Division of Public Health. Mr Monson is with the Bacteriology Laboratory, Wisconsin State Laboratory of Hygiene. Dr Sotir is also with the Epidemic Intelligence Service,

Corresponding Author: Mark J. Sotir, PhD MPH, Bureau of Communicable Diseases, Wisconsin Division of Public Health, 1 W Wilson St, PO Box 2659, Madison, WI 53701-2659; phone 608.261.8354; fax 608.261.4976; e-mail sotirmj@dhfs.state.wi.us.

Case Reports

Transcatheter Closure of Atrial Septal Defect (Secundum Type): The Role of Echocardiography in Evaluating Interatrial Defects

Tahir Tak, MD, PhD, FACC; Anand Khurana, MD; Sumeesh Dhawan, MD

Atrial septal defects are among the most common congenital heart defects seen in the adult population. The diagnosis is usually made in children and closure is attempted before they are school age. In other cases, where the diagnosis is missed until adulthood, atrial arrhythmias and congestive heart failure are commonly seen. We report the case of an atrial septal defect (secundum type), which was diagnosed in a 72-year-old woman with paroxysmal atrial fibrillation. She also had a history of hypertension and hyperlipidemia. Transthoracic and transesophageal findings were consistent with right-sided volume overload and an atrial septal defect of approximately 1 cm in size. This was corroborated by the findings on cardiac catheterization with a shunt ratio of 1.8. The pulmonary artery pressures were within normal limits. The patient was referred for closure of the atrial septal defect. Presently, the options for septal defect closure are direct suture repair, Dacron patch repair depending on the size of the defect, and percutaneous transcatheter closure. Transcatheter closure is also available in treating selected patients with patent foramen ovale.



Author Affiliations: Doctor Tak is a cardiologist with the Department of Cardiology and Drs Khurana and Dhawan are hospitalists with the Department of General Internal Medicine, Marshfield Clinic, Marshfield, Wis

Corresponding Author: Tahir Tak, MD, PhD, Department of Cardiology, Marshfield Clinic, 1000 N Oak Ave, Marshfield, WI 54449; phone 715.389.3885; fax 715.389.3808; e-mail ttak@hsc.unt.edu

Your Practice

Clinical Questions #1

Mihailo Lalich, MD; David A. Feldstein, MD

This is the first installment of a new series in the Wisconsin Medical Journal. Readers will be presented with a case and clinical question. An evidence-based answer will be provided on the following page. The answer will include how the evidence was found and evaluated.


Author Affiliations: Wisconsin Medical Society


Corresponding Author: Wisconsin Medical Society 330 E. Lakeside St Madison, WI 53715

The DEA issues new clarification regarding prescribing Schedule II controlled substances

Ruth Heitz, JD

Physicians who write multiple prescriptions for Schedule II controlled substances (such as Ritalin) with instructions to pharmacists to fill the prescriptions on different dates should discontinue that practice, as it might be deemed to violate federal law. The Drug Enforcement Agency (DEA), which previously appeared to endorse the practice, has recently published clarification that instead suggests that the practice violates federal law prohibiting refills of Schedule II controlled substances.



Author Affiliations: Ms Heitz is the Associate General Counsel for the Wisconsin Medical Society.

Corresponding Author: For more information about this issue, contact the Society’s Legal Department at 866.442.3800.

Meeting the mandate for the HIPAA Security Rule: Are you ready?

Susan C. Manning, JD, RHIA, CPC

The HIPAA deadline is here, and unless you are one of just a handful of health care professionals in Wisconsin, you must comply with its requirements.



Author Affiliations: Ms Manning is a Health Care Consultant with Wisconsin Medical Society Consulting, Inc.

Corresponding Author: For more information on the HIPAA Security Rule, contact the HIPAA Hotline at 608.442.3780 or 800.975.3717 or e-mail hipaa@wismed.org.

A gift for their lifetime: Helping your grandchildren pay for college

Debbie Oswald, Financial Consultant

Are you interested in giving your grandchildren a gift they can truly appreciate? One of the best gifts you can give them is an education. According to a survey by AIG SunAmerica Mutual Funds, 54 percent of today’s grandparents are already helping pay college costs or plan to do so. Yet, for all these good intentions, many grandparents don’t know the most effective methods for providing financial assistance. There are many options to be considered if you are currently assisting grandchildren or wish to do so in the future.



Author Affiliations: Based in Madison, Wis, Ms Oswald is a fee-only financial consultant with SVA Planners Inc., Registered Investment Advisor

Corresponding Author: Wisconsin Medical Society Insurance and Financial Services, Inc. toll free at 866.442.3810

Spreading the practice of Evidence-Based Medicine: MetaStar’s raison d’etre

Jay A. Gold, MD, JD, MPH; Eric M. Streicher, MD

We at MetaStar are delighted that the Wisconsin Medical Journal has adopted evidence-based medicine as the theme of this issue. For over a decade, spreading the practice of evidence-based medicine has been the foundation of MetaStar’s work.



Author Affiliations: Authors are associated with MetaStar, Inc. Doctor Gold is senior vice president and principal clinical coordinator; Doctor Streicher is medical director. This material was prepared by MetaStar, Inc., the Quality Improvement Organization for Wisconsin, und

Corresponding Author: Wisconsin Medical Society 330 E. Lakeside St Madison, WI 53715

Your Profession

Teaching, integrating and enhancing EBM

Michael J. Dunn, MD

Physicians who practice evidence-based medicine learn from controlled clinical studies to make better clinical decisions. By examining the collective experiences of our peers and predecessors documented through research, we use history to our advantage—a particularly valuable lesson for the medical students and residents trained at the Medical College of Wisconsin.



Author Affiliations: Dean and Executive Vice President, Medical College of Wisconsin


Corresponding Author: Wisconsin Medical Society 330 E. Lakeside St Madison, WI 53715

Your Society

General Practice in Northern Wisconsin

Joseph P. Cox, MD, Spooner, Wis

About one-sixth of the State Medical Society of Wisconsin is composed of men who have to deal with the peculiar conditions existing in Northern Wisconsin. During a residence there the past twenty long and eventful years, I have come to the conclusion that a general practice must be conducted on lines somewhat different from the practice in other localities...



Author Affiliations: Excerpted from the Wisconsin Medical Journal, 1905;3:643-647.


Corresponding Author: Wisconsin Medical Society 330 E. Lakeside St Madison, WI 53715