Evidence-based medicine-Databases - PowerPoint Presentation

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Evidence-based medicine-Databases

Maryam

Okhovati

Associate Prof.

Medical Library & Information science

Kerman University of Medical Sciences

Okhovati.maryam@gmail.com

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outline

A brief introduction to Evidence Based Medicine

Databases

CochraneUpToDateClinicalKey

OVID

PubMed

Clinical Queries

AskMedline

TRIP

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Archie 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”

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where

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

.

)

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In 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.

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Evidence-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

).

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Good clinical practice

Knowledge from best external evidence based on clinical research

Judgement from experience.

Understanding of patient's beliefs & preferences.

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Why 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

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Benefits 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

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PATIENT

PHYSICIAN

INFORMATION

Question

or

Problem

THREE MAJOR COMPONENTS of EBM

Medical Decision

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PATIENT

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

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THE 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

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Evidence 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

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ASK/

background

questions

Background QuestionsInformation can be found in textbooks and review articlesGeneral questions about conditions, illnesses, syndromes and patterns of disease, pathophysiology

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ASK/

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

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BACKGROUND 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

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Background 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

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ASK/

Formulate the clinical question

PICO

Patient or PopulationInterventionC

omparison Group

O

utcome

of Interest

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Pico

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

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ASK/

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.

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ASK/

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.

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ASK/

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.

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Ask clinical questions

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Acquire

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

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Decide

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

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Hierarchy of Evidence

Track Down

Filtered & Critically Appraised

Expert Opinion and Not Filtered

Background info.

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Acquire/ Evidence-based sources

MedlinePlus

Clinical Queries

AskmedlineUptoDateClinicalKey

Cochrane

Pubmed

OVID

Trip Database

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MedlinePlus

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MedlinePlus

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CLINICAL QUERIES

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askmedline

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Trip database

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uptodate

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uptodate

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.

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uptodate

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uptodate

Content

By specialty

Patient informationDrug interactionsCalculatorsPathwayLan interpretations

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uptodate

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Uptodate/search

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Uptodate/search/filters

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Uptodate/results

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Uptodate/grade

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Uptodate/grade types

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Uptodate/drug interactions

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Uptodate/drug interactions/risk rating

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Uptodate/drug interactions/

risk

rating types

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Uptodate/features

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Uptodate/calculators

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Uptodate/Patient education

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Uptodate/Topics by specialty

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Uptodate/Practice changing updates

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Uptodate pathways

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Uptodate/

labinterpretations

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clinicalkey

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clinicalkey

 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.

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Clinicalkey/search browse

Search

browse

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clinicalkey

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ClinicalKey can narrow results by source type, study type, specialty and date

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ClinicalKey can narrow results by source type, study type, specialty and date

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Cochrane

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.

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Independent

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)

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Cochrane/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.

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Cochrane/ Search

for your term(s) using

MeSH

terms

Natural

language

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Searching 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.

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Cochrane

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Searching 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.).

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Searching 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

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Combining Search Terms

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Ovid/search

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ovid

Basic search

Advanced search

Multi-filed search Find citations

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Ovid/basic search

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Ovid/results page

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Ovid/search results

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Ovid/search/find citations

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Ovid/search fields

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Ovid/advanced search

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Ovid/multifield

search

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PUBMED

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Other Databases/ TRIP

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TRIP

Turning Research Into

Practice

From 1997How the TRIP algorithms work?Text scorePublication scoreDate

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TRIP

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Limitations 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

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conclusion

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National guideline clearinghouse

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Clinical 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)

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Other resources

BMJ best practice

BMJ clinical evidence

EvidenceAlertCinahl

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Evidence based abstract journals

Evidence-Based Medicine

 

ACP Journal ClubEvidence-Based Mental HealthCancer Treatment ReviewsEvidence-Based Nursing 

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appraise

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.

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appraise

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?

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appraise

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?

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appraise

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

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appraise

Critical appraisal tools

…- CASP

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Apply the evidence

Consider the patient preferences

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Evaluate the process

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THANKS FOR YOUR ATTENTION