Maryam Okhovati Associate Prof Medical Library amp Information science Kerman University of Medical Sciences Okhovatimaryamgmailcom outline A brief introduction to Evidence Based Medicine ID: 932684
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Slide1
Evidence-based medicine-Databases
Maryam
Okhovati
Associate Prof.
Medical Library & Information science
Kerman University of Medical Sciences
Okhovati.maryam@gmail.com
Slide2outline
A brief introduction to Evidence Based Medicine
Databases
CochraneUpToDateClinicalKey
OVID
PubMed
Clinical Queries
AskMedline
TRIP
Slide3Archie cochrane
In 1979, Archie Cochrane wrote “it is surely a criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically of all relevant randomized controlled trials”
Slide4where
does EBM
come from?
1980’s
: McMasters University in Ontario, Canada
Dr. David
Sackett
and colleagues proposed Evidence Based Medicine (EBM) as a new way of teaching, learning and practicing medicine
.
“…
The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
(
Sackett
DL, et al. Evidence-based medicine: what it is and it isn’t. BMJ 1996;312:71-2
.
)
Slide5In the practice of Evidence Based
Medicine …
it
is the physician’s
duty
to find the best and most current information and apply it judiciously for the benefit of the patient.
Slide6Evidence-Based Practice
"Evidence-Based Practice requires that decisions about health care are based on the
best available, current, valid and relevant evidence
. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources."
Sicily statement on evidence-based practice
. BMC Medical Education, 2005 Jan 5;5(1
).
Slide7Good clinical practice
Knowledge from best external evidence based on clinical research
Judgement from experience.
Understanding of patient's beliefs & preferences.
Slide8Why ebm
?
To improve care
To bridge the gap between research & practice“Kill as few patients as possible” (O. London)A new treatment might have fewer side effects.A new treatment could be cheaper or less invasiveA new treatment may be necessary in case people develop resistance to existing therapies, etc.
To keep knowledge and skills current (continuing education)
To save time to find the best information
Slide9Benefits of ebm
Minimize
the errors in patient care
Reduces the cost of treatment to the patient Optimizes the quality of patient care Skills learnt in practicing EBM are the very same ones needed for being a lifelong, self-directed learner Habit
of accessing literature on a daily basis is the best guarantor of ensuring advancement of knowledge and keeping abreast of scientific progress
Slide10PATIENT
PHYSICIAN
INFORMATION
Question
or
Problem
THREE MAJOR COMPONENTS of EBM
Medical Decision
Slide11PATIENT
Values, Concerns Preferences, Expectations
Life predicament
PHYSICIAN
Training & Experience
Current Expertise
Continued learning
Demand for proof
INFORMATION
Clinically relevant
Proven by research
Best up-to-date evidence
EBM
THE ADDED DETAILS
Slide12THE FIVE BASIC STEPS OF
EBM
1. Clinical Question:
Patient-focused
, problem-oriented
2.
Find Best
Evidence:
Literary
Search
3.
Critical
Appraisal
:
Evaluate
evidence for quality and usefulness
4.
Apply the
Evidence
:
Implement useful findings in clinical practice
5.
Evaluate
: The information, intervention,
&
EBM process
Slide13Evidence Based Medicine
Identify a clinical problem
Ask
a relevant, focused questionAcquire
the necessary resources to answer the question
Appraise
the evidence obtained
Apply
to patient care
E
valuate
patient
Answerable questions
R
esources
Evidence
Slide14Slide15ASK/
background
questions
Background QuestionsInformation can be found in textbooks and review articlesGeneral questions about conditions, illnesses, syndromes and patterns of disease, pathophysiology
Slide16ASK/
Foreground
questions
Foreground QuestionsInformation found in evidence-based extraction service, guidelines, or systematic reviewsQuestions about issues of care,
i.e
diagnostic tests or therapies, needed for clinical decision-making
Slide17BACKGROUND and FOREGROUND
QUESTIONS
FOREGROUND
QUESTIONS
BACKGROUND QUESTIONS
NEW POSSIBILITIES
INDEFINITE ANSWERS
“Where do we want to go,
and how else might
we get there?”
EXPERT
GRAD
STUDENT
“
Where are we now?
And which way are we headed?”
BASIC & CONCRETE
Slide18Background vs. Foreground
What
causes gastroenteritis?
/ BackgroundIs oral rehydration as effective as IV rehydration? /Foreground3. What
are the symptoms of otitis media
?/
Background
Can I effectively treat otitis media with a shorter course of antibiotics
?/
Foreground
Can this febrile infant be safely treated as an outpatient
?/
Foreground
Slide19ASK/
Formulate the clinical question
PICO
Patient or PopulationInterventionC
omparison Group
O
utcome
of Interest
Slide20Pico
In pediatrics patients with dental fear does playing music reduce anxiety?
Population
: Pediatrics patients with dental fear Intervention: playing musicComparison: treatment as usualOutcome: reduce anxiety
Slide21ASK/
Formulate the clinical question
Is oral rehydration in the emergency room more cost-effective than IV rehydration?
Patient/Population – Not identified. Examples: infants, infants with vomiting.Intervention – Oral rehydration.
C
omparison – IV rehydration.
O
utcome – Cost-effectiveness.
Slide22ASK/
Formulate the clinical question
Will
atrovent help prevent hospitalization of my 2 year old patient with an acute asthma exacerbation?Patient/Population – Child w/ acute asthmaIntervention – Atrovent
C
omparison - Not identified. Examples: standard therapy, albuterol alone.
O
utcome – Prevent hospitalization.
Slide23ASK/
Formulate the clinical question
Is 10 days of antibiotic therapy better than 5 days of antibiotic therapy for treating an infant with acute otitis media?
Patient/Population – Infant with AOMIntervention – 10 days of antibiotic therapyC
omparison – 5 days of antibiotic therapy
O
utcome – Not identified. Examples: Resolution of symptoms, recurrence risk, persistent effusion.
Slide24Ask clinical questions
Slide25Acquire
Select
initial search
terms (Population, Intervention)Narrow search (C
omparison,
O
utcome), using limiters (Date
of
publication, Type
of
study, Language, Human, Specific age,…)
Use
MeSH
terms
Slide26Decide
on the best type of study for question
For each type of question there is a hierarchy of evidence
Therapy/Prevention
What should I do about this problem?
RCT
>cohort > case control > case series
Diagnosis
Does this person have the problem?
cross-sectional study
with blind comparison to a gold standard
Etiology/Harm
What causes the problem?
RCT
> cohort > case control > case series
Prognosis/Prediction
Who will get the problem?
RCT
>cohort study > case control > case series
Frequency and Rate
How common is the problem?
cohort study
> cross-sectional study
Slide27Hierarchy of Evidence
Track Down
Filtered & Critically Appraised
Expert Opinion and Not Filtered
Background info.
Slide28Acquire/ Evidence-based sources
MedlinePlus
Clinical Queries
AskmedlineUptoDateClinicalKey
Cochrane
Pubmed
OVID
Trip Database
Slide29MedlinePlus
Slide30MedlinePlus
Slide31CLINICAL QUERIES
Slide32askmedline
Slide33Trip database
Slide34uptodate
Slide35uptodate
a
comprehensive clinical decision support resource used by professionals around the world to diagnose and treat specific health issues.
includes
more than
7700
peer-reviewed topics;
fully-referenced, and illustrated topic reviews.
more than 6,900 physician authors, editors, and peer reviewers use their deep clinical domain expertise to critically evaluate available medical literature to produce original content in a succinct, searchable format that can be quickly and easily accessed at the
point of care
.
Medline
abstracts and a complete drug information database
.
An updated version of
UpToDate
is released every four months.
Slide36uptodate
Slide37uptodate
Content
By specialty
Patient informationDrug interactionsCalculatorsPathwayLan interpretations
Slide38uptodate
Slide39Uptodate/search
Slide40Uptodate/search/filters
Slide41Uptodate/results
Slide42Uptodate/grade
Slide43Uptodate/grade types
Slide44Uptodate/drug interactions
Slide45Uptodate/drug interactions/risk rating
Slide46Uptodate/drug interactions/
risk
rating types
Slide47Uptodate/features
Slide48Uptodate/calculators
Slide49Uptodate/Patient education
Slide50Uptodate/Topics by specialty
Slide51Uptodate/Practice changing updates
Slide52Uptodate pathways
Slide53Uptodate/
labinterpretations
Slide54clinicalkey
Slide55clinicalkey
a clinical search engine that supports clinical decisions by making it easier to find and apply relevant knowledge.
ClinicalKey
drives better care by delivering fast, concise answers when every second counts, and deep access to evidence whenever, wherever you need it.
Slide56Clinicalkey/search browse
Search
browse
Slide57clinicalkey
Slide58ClinicalKey can narrow results by source type, study type, specialty and date
Slide59ClinicalKey can narrow results by source type, study type, specialty and date
Slide60Slide61Cochrane
collaboartion
Cochrane Database of Systematic Reviews / CDSR / Cochrane DSR Full-text of completed systematic reviews carried out by the Cochrane Collaboration, plus protocols for reviews currently in preparation. Reviews are updated in the light of new evidence and the date of the latest update is given. Database of Abstracts of Reviews of Effects (formerly Database of Abstracts of Reviews of Effectiveness) Especially written structured abstracts of quality-assessed systematic reviews published elsewhere in the medical literature. Cochrane Central Register of Controlled Trials / CCTR / CENTRAL References to
randomised
control trials (RCTs) identified through hand searching of journals and databases.
Slide62Independent
non-for-profit international collaboration
Reviews are among the studies of highest scientific evidence
Minimum Bias: Evidence is included/excluded on the basis of explicit quality criteriaReviews involve exhaustive searches for all RCT, both published and unpublished, on a particular topic1995-The Cochrane Library ( The Cochrane
Collaboration)
Slide63Cochrane/Search Rules
1. Expand your search using the truncation symbol * e.g. depress* finds depression or depressive, depressed etc. The truncation symbol can be used at the beginning and the end of your term.
2
. * is also a wildcard to signify letter(s) within a word e.g. p*
ediatric
finds
paediatric
or pediatric. Note that singular and plural alternatives are automatically searched.
3
. A question mark ? can be used to search for a single character.
4
. To search phrases, put terms in quotes.
5
. Combine and separate your search terms using the Boolean Operators AND or
OR
or
NOT
.
6. If combining phrases in the same line, enclose combination threads in parentheses.
Slide64Cochrane/ Search
for your term(s) using
MeSH
terms
Natural
language
Slide65Searching for your term using natural language
Advanced Search, Type
your first term into the search box. Select Title, Abstract or Keywords from the drop-down menu on the left. If you wish to add another term, click on the + sign, situated to the left of the drop down menu, and another search box and drop down menu of Boolean operators will appear. Click on Go
.
OR
Enter the
keywords one by one
&
click on Add to Search Manager after each word.
Navigate
backwards and forwards between the Search tab
& the
Search Manager until all your terms are present in the Search Manager,
then combine
them in the Search Manager. This option
is useful
if you intend to combine terms in Natural Language with your
MeSH
terms in your search
strategy.
Slide66Cochrane
Slide67Searching for the term
using the Medical Subject Headings (
MeSH
Descriptor)click on Advanced Search. Click on the Medical Terms (MeSH) search tab. Enter your first term into the Enter
MeSH
term box, and select any appropriate subheadings/ qualifiers from the drop-down menu in the Select
MeSH
qualifiers box.
Click
on Look Up.
When
you search for a term using the
MeSH
Thesaurus button, the database will search for all of the
MeSH
descriptors that contain your term. By selecting the
MeSH
descriptor through the thesaurus, the database will retrieve results containing the
MeSH
descriptor and related narrower terms
the
MeSH
descriptor:
Myocardial Infarction
Anterior
Wall Myocardial Infarction; Inferior Wall Myocardial Infarction; Myocardial Stunning; Shock, Cardiogenic etc.).
Slide68Searching for the term using the Medical Subject Headings (
MeSH
Descriptor)
The next screen (see caption above) displays a definition of your search term, and Thesaurus matches, including synonyms of your search term, on the left. The central column shows you where your term sits in the MeSH tree, and enables you to explode one or more
MeSH
trees. 3. If you wish to search for the descriptor only, select the Single
MeSH
term (unexploded) option. If you wish to search for the descriptor and its narrower terms, select the Tree Number * box (
es
), and Explode either the selected trees or all the trees. 4. The box on the right shows you how many results in total there are for that specific search. Click on Add to Search Manager. 5. Repeat this procedure until you have entered all your search terms and are ready to combine your searches in the Search Manager
tab
Slide69Slide70Combining Search Terms
Slide71Ovid/search
Slide72ovid
Basic search
Advanced search
Multi-filed search Find citations
Slide73Ovid/basic search
Slide74Ovid/results page
Slide75Ovid/search results
Slide76Ovid/search/find citations
Slide77Ovid/search fields
Slide78Ovid/advanced search
Slide79Ovid/multifield
search
Slide80PUBMED
Slide81Other Databases/ TRIP
Slide82TRIP
Turning Research Into
Practice
From 1997How the TRIP algorithms work?Text scorePublication scoreDate
Slide83TRIP
Slide84Limitations of evidence-based medicine
“Evidence-based medicine in practice defines the likelihood of something happening
. It is never 100%. It is not absolute truth. Evidence never tells you what to do. The same evidence applied in one case may not apply in another. The circumstances of the individual may be different, r the circumstances may be the same but patients may refuse one treatment in favor of another. What evidence-based medicine does is inform one about what their best options are—but it doesn’t make the decision.”Brian
Haynes MD, McMaster University at the Canadian Medical Association September 30, 2003
Slide85conclusion
Slide86National guideline clearinghouse
Slide87Clinical practice guidelines
CPG
Infobase
Canadian
Medical
Association
(
Cancer Care
Ontario
)
NICE Clinical
Guidelines
National
Institute for Health and Clinical Evidence, UK
Evidence-Based Guidelines (Programs in Evidence-Based Care
)
Best
Practice
Guidelines: Registered
Nurses Association of Ontario (RNAO
)
Guidelines (Through Clinical Key)
Slide88Other resources
BMJ best practice
BMJ clinical evidence
EvidenceAlertCinahl
Slide89Evidence based abstract journals
Evidence-Based Medicine
ACP Journal ClubEvidence-Based Mental HealthCancer Treatment ReviewsEvidence-Based Nursing
Slide90appraise
Critical appraisal is the process of carefully and systematically assessing the outcome of scientific research (evidence) to judge its trustworthiness, value and relevance in a particular context. Critical appraisal looks at the way a study is conducted and examines factors such as internal validity, generalizability and relevance.
Slide91appraise
1. Is the evidence from a known, reputable source?
2. Has the evidence been evaluated in any way? If so, how and by whom?
3. How up-to-date is the evidence?1. How was the outcome measured?2. Is that a reliable way to measure?
3. How large was the effect size?
4. What implications does the study have for your practice? Is it relevant?
5. Can the results be applied to your organization?
Slide92appraise
Validity
Can I trust this information?
Clinical ImportanceIf true, will the use of this information make an important difference?ApplicabilityCan I use the information in this instance?
Slide93appraise
Key Criteria:
blindness of
randomisationblindness of interventioncompleteness of follow upblinding of outcome measurementFor individual trials, mean differences (and 95% confidence intervals) were reported for continuous variablesFor categorical outcomes the relative risk and risk difference (and 95% confidence intervals) were reported
Slide94appraise
Critical appraisal tools
…- CASP
Slide95Apply the evidence
Consider the patient preferences
Slide96Evaluate the process
Slide97THANKS FOR YOUR ATTENTION