FINDING THE BEST EVIDENCE: AN OVERVI OF THE RESOURCES SPRING 2010 “…conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients…” -- Sackett, DL
Dec 17, 2015
FINDING THE BEST EVIDENCE: AN OVERVIEW OF THE RESOURCESSPRING 2010
“…conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients…” -- Sackett, DL
THIS SESSION WILL COVER
What do we mean by evidence-based health care Steps in practicing evidence-based care Types of literature Key resources for finding evidence-based
information
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Clinically relevant research, the literature
Practitioner’s knowledge& experience
Patient’s characteristics & values
THREE PRONGED APPROACH
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Need for current clinical information Updates info in textbooks, journals, experts Skills/experiences increase over time, current
knowledge may decrease Increase in clinical research and literature Conflicting clinical research [at times] Limited time to find and evaluate research
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WHY USE AN EVIDENCE-BASED APPROACH?
1. Convert need for information into focused clinical question
2. Track down the best evidence3. Critically appraise the evidence4. Integrate evidence with clinical expertise and
patient values5. Evaluate the process and adjust as needed
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STEPS IN PRACTICING EBP
Evidence-based Medicine:How to Practice and Teach EBMBy Straus SE, et alThird Edition.Churchill Livingstone: Edinburgh, 20050-443-07444-5, 299 pages. Includes CD-ROM
Your patient is a 14-yr old boy with a weight
problem (obesity). He has tried lifestyle changes and they have not been
effective, so he and his parents ask you about other weight loss options for an adolescent.
Pho
to f
rom
CD
C: C
hild
hoo
d o
verw
eig
ht
CLINICAL SCENARIO
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Background vs. Foreground questions
Background questions – getting up to speed on a topic.General knowledge about a disorder. Look for info in textbooks, summary material.
Foreground questions – specific knowledge about managing a patient or disorder. Apply EBP techniques, use EBP resources
USING THE LITERATURE IN PRACTICE
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UpToDate Clinical Evidence MDConsult STAT!Ref MICROMEDEX Specialty texts via Ebling Library
websiteHarrisons
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BACKGROUND SOURCES
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Medical topics in internal medicine (particularly strong), pediatrics, ob/gyn and family medicine
Designed to provide a quick way to get up to speed An updated version of UpToDate is released every four
months “What’s New” tab highlight changes with each major release.
For use in EBM is a mixed bag (use cautiously to answer clinical questions (i.e. PICO questions)
Articles are a mixture of medical conclusions based on data from studies and expert opinions of individual authors…not always clear which statements are evidence-based and which are not
EVIDENCE-BASED CLINICAL SUMMARY
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Background vs. Foreground questions
Background questions – general knowledge about a disorder. Look for info in Reference sources
Foreground questions – specific knowledge about managing a patient or disorder. Apply EBP techniques, use EBP resources
In a 14 year old obese male, how effective is the drug Meridia for long term weight loss?
USING THE LITERATURE IN PRACTICE
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P I C O helps to formulate the question
Patient/Population/Problem
Intervention
Comparison
Outcome
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CONVERT THE CLINICAL QUESTION TO PICO
In a 14 year old obese male,how effective is the drug Meridia for long term weight loss?
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PI
O
C – no comparison/placebo
CONVERT THE CLINICAL QUESTION TO PICO
P = In a 14 yo obese maleI = is Meridia C = O = effective and safe for long term weight loss?
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P
obeseobesityoverweight
I
Meridia
sibutramine
CREATING A SEARCH QUERY
adolescentadolescenceteenteenageryouth
P = In a 14 yo obese maleI = is Meridia
14
Pobese
obesityoverweight
IMeridiasibutramine
CREATING A SEARCH QUERY
adolescentadolescenceteenteenageryouth ORANGE = MeSH term
adolescent adolescence teen teenager youth child
obese obesity overweight
meridia sibutramine
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Place an “OR” between synonyms of the same concept and surround concept terms with parentheses
Place an “AND” between concepts
( OR OR OR OR OR )
( OR OR )
( OR )
AND
AND
CREATING A SEARCH QUERY
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(adolescent OR adolescence OR teen OR teenager OR youth OR child) AND (obesity OR obese OR overweight) AND (meridia OR sibutramine)
(adolescen* OR teen* OR youth OR child) AND (obes* OR overweight) AND (meridia OR sibutramine)
Use truncation character, if available:
CREATING A SEARCH QUERY
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1. Convert need for information into focused clinical question
2. Track down the best evidence3. Critically appraise the evidence4. Integrate evidence with clinical expertise and
patient values5. Evaluate the process and adjust as needed
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STEPS IN PRACTICING EBP
Clinical summariesMeta analyses/Systematic reviews
Randomized control trials (RCTs)Prospective cohort studiesCase-control (retrospective cohort) studiesCase studiesOpinion of authorities, editorials
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Level of
Evid
ence
low
high
EVIDENCE HIERARCHY
A compendium of short summaries of the current state of the knowledge (and uncertainty) about clinical conditions (prevention, treatment, and/or diagnosis)
Entries are explicitly based on thorough searches and appraisals of the literature and created from the best available evidence from systematic reviews, RCTs and observational studies
EVIDENCE-BASED CLINICAL SUMMARY
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Examples:
BMJ Clinical Evidence http://clinicalevidence.bmj.com/
Essential Evidence Plushttp://www.essentialevidence.com/
UpToDate http://www.uptodate.com
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EVIDENCE-BASED CLINICAL SUMMARIES
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Collection of brief reviews focusing on primary care and covering over 3,000 clinical interventions with 570 clinical questions answered.
Looks at current state of knowledge & ignorance about prevention and treatment. Describes the best available evidence and if there is no good evidence, it says so.
Each review focuses on single condition and is displayed in a tabbed structure:
• Single page summary of the review• Ranked list of interventions with discussion
(benefits/harms)• Background info on the condition• A list of material published since the review search
date• Links to major guidelines relevant to the review
EVIDENCE-BASED CLINICAL SUMMARY
Clinical summariesMeta analyses/Systematic reviews
Randomized control trials (RCTs)Prospective cohort studiesCase-control (retrospective cohort) studiesCase studiesOpinion of authorities, editorials
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Level of
Evid
ence
low
high
EVIDENCE HIERARCHY
Summarize a particular topic by using explicit methods to perform a thorough literature search and critical appraisal of individual studies to identify the valid and applicable evidence
Uses appropriate techniques to combine these valid studies
Published in many journals and found in a variety of other electronic sources
SYSTEMATIC REVIEWS
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Examples:
Cochrane Database of Systematic Reviewshttp://www.cochrane.org/
DAREhttp://www.crd.york.ac.uk/crdweb/
TRIP Databasehttp://www.tripdatabase.com
MEDLINE (PubMed)http://www.pubmed.gov
SYSTEMATIC REVIEWS
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5,600 systematic reviews and meta-analyses Rigorous, highly-regarded, reviews Focused on therapy/prevention, now covering diagnostic
tests Database includes protocols -- plans or sets of steps to be
followed in creating a systematic review When searching within the Cochrane Library:
use the “Title, Abstract, Keywords” drop down to reduce irrelevant records
Contains 15,000 reviews of systematic reviews. Complements the CDSR -- quality-assesses and summarizes
reviews that have not yet been carried out by Cochrane When searching within the Cochrane Library:
use the “The full review (Search All Text)” drop down to reduce irrelevant records
SYSTEMATIC REVIEWS
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Often overlooked secondary source for evidence on any type of foreground question
Reviews the best original and review articles from over 100 of the top clinical journals
If included, it is important! Unlike DARE, clinical experts provide commentaries on the
context, methods, and clinical applications of the findings of each article
SYSTEMATIC REVIEWS
New interface Includes only records/abstracts of journal articles (20
million) Very current info (sometimes pre-pub) Use MeSH terms for more efficient searching Use Boolean operators (AND, OR) Searching for systematic reviews:
• Use the “Find Systematic Reviews” box in Clinical Queries OR Apply the Subsets limit “Systematic Reviews”
1990 1995 2000 2005
2500
12,500
5000
10,000
7500
# pu
blis
hed
per
year
15,000
2010
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SYSTEMATIC REVIEWS
2828
Many conditions, interventions, diagnostic tools without good SRs
Need constant maintenance. Half will need to be updated each year
Garbage in; garbage out FAAT handout http://www.cebm.net/index.aspx?o=1157
SYSTEMATIC REVIEWS
Clinical summariesMeta analyses/Systematic reviews
Randomized control trials (RCTs)Prospective cohort studiesCase-control (retrospective cohort) studiesCase studiesOpinion of authorities, editorials
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Level of
Evid
ence
low
high
EVIDENCE HIERARCHYS
tud
ies
Examples:
MEDLINE (PubMed)http://www.pubmed.gov
Google Scholarhttp://scholar.google.com
Other health databases
CINAHL http://www.cinahl.com/
PsycINFO http://www.apa.org/psycinfo/
INDIVIDUAL STUDIES
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Includes only records/abstracts of journal articles (20 million)
Very current info (sometimes pre-pub) Use MeSH terms for more efficient searching Use Boolean operators (AND, OR) Searching for single studies:
• Use the “Search by Clinical Study Category” box in CQ• OR use the type of article limit: randomized controlled
trials or other appropriate level
Subset of larger Google: journal articles, technical reports, preprints, theses, books and other documents and web pages deemed “scholarly”
Covers a great range of disciplines (strong in sciences and medicine)
It is particularly helpful for users who want:• something good enough for the task at hand (not
comprehensive)• grey literature--sources outside of published journals• info from sources across many disciplines
Limitations: rudimentary search features, lack of transparency of database content, uneven coverage (time and scope) and a delay in indexing
INDIVIDUAL STUDIES
Identify synonyms Check MeSH database via PubMed Use generic and trade names for drugs and tests Use full names along with common abbreviations
OR between synonyms OR between synonyms Surround OR terms with parentheses
Enter concepts as separate sets AND between P,
I,C
common cold AND (vitamin c OR ascorbic acid)
GENERAL SEARCH HINTS
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1. Converting need for information into focused clinical question
2. Tracking down the best evidence3. Critically appraising the evidence4. Integrating evidence with clinical expertise
and patient values5. Evaluating the process
STEPS IN PRACTICING EBP
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Centre for EBM (Toronto)http://www.cebm.utoronto.ca
Centre for EBM (Oxford)http://www.cebm.net
Users’ Guides series in JAMAhttp://www.userguides.org
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CRITICALLY APPRAISING THE EVIDENCE