Evidence Based Practice&

Health Sciences Librarianship

Lorie KlodaMLIS, PhD candidate, School of Information Studies

Associate Librarian, Life Science Library

October 6, 2010Health Sciences Information GLIS-671

McGill University

http://www.slideshare.net/lkloda

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Objectives

1. Definition and evolution of EBP2. EBP process3. Question framing 4. Levels of evidence5. Critical appraisal and grading6. Sources of evidence7. Systematic reviews8. Role of the librarian

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Definition & History of EBM

Evidence-based medicine (EBM)“Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. BMJ, 312, 71-72. (p.71)

“…a new paradigm for medical practice is emerging.” Evidence-Based Medicine Working Group (1992). Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA: The Journal of the American Medical Association, 268, 2420-2425. (p. 2420)

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Definition of EBMComponents

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Definition of EBPThe Sicily Statement

“Evidence-based practice (EBP) 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.”

Dawes, M., Summerskill, W., Glasziou, P., Cartabellotta, A., Martin, J., Hopayian, K. et al. (2005). Sicily statement on evidence-based practice. BMC Medical Education, 5.

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EBP Process

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Question Framingor, Asking Answerable Questions

Patient, population, or problem

Intervention, prognostic factor, or exposure

Comparison

Outcomes to measure or be achievedRichardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. (1995). The well-built

clinical question: A key to evidence-based decisions. ACP Journal Club, 123(3), A12-3.

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PICO Problem/Person

InterventionComparisonOutcome

(Richardson, Wilson, Nishikawa, & Hayward, 1995)

PESICO PersonEnvironmentStakeholdersInterventionComparisonOutcome

(Schlosser, Koul, & Costello, 2007)

PICO + Problem/PersonClient’s settingClient’s valuesInterventionComparisonOutcome

(Bennett & Bennett, 2000)

Framing Clinical Questions

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PICO Problem/Person

InterventionComparisonOutcome

(Richardson, Wilson, Nishikawa, & Hayward, 1995)

ECLIPSE ExpectationClient groupLocationImpactProfessionalsService

(Wildridge & Bell, 2002)

COPESClient type &

problemWhat you might doAlternate course of

actionWhat you want to

accomplish

(Gibbs, 2003)

Framing Clinical Questions

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Question FramingExercise 1

As part of your nursing practice, infants and children with fever are often given tepid baths to lower their temperature. A parent asks you whether or not this actually makes a difference in reducing the child’s fever. You decide to look at the literature to substantiate the intervention.

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Levels of EvidenceEvidence Hierarchy

(SUNY Downstate Medical Center, Medical Research Library of Brooklyn, n.d.)

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Question FramingQuestion & Study Types (Quantitative)

Types of clinical questions: Types of studies:

Therapy Randomized controlled trial (RCT); cohort; case control

Diagnosis RCT (rare); Blind comparison to gold standard

Prognosis Cohort; case control

Harm/Etiology Cohort; case control

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Question FramingQuestion & Study Designs (Qualitative)

Research Question Qualitative Approach

What is the meaning attached to this phenomenon?

Phenomenology

What is life like for this group? Ethnography

What is happening?Why is it happening?

Grounded theory

What are they communicating? How are they communicating?

Discourse analysis

Gibson, B. E. & Martin, D. K. (2003). Qualitative research and evidence-based physiotherapy practice. Physiotherapy, 89, 350-358.

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Levels of Evidencefor Question of Therapy

Level of Evidence Type of Study1a Systematic reviews of randomized controlled trials

(RCTs)1b Individual RCTs with narrow confidence interval2a Systematic reviews of cohort studies2b Individual cohort studies and low-quality RCTs3a Systematic reviews of case-control studies3b Case-control studies4 Case series and poor quality cohort and case-control

studies5 Expert opinion

Levels of evidence (2001). Centre for Evidence Based Medicine. Retrieved 26 Aug 2008 from http://www.cebm.net/index.aspx?o=1025

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Question FramingExercise 2

You have recently begun working as a physical therapist in a rehabilitation centre. Your most recent patient is an 8-year-old girl with spastic cerebral palsy. Her parents heard that a weight-bearing physical activity program may be beneficial. You decide to search the literature for evidence to substantiate the claim.

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Question FramingExercise 3

As a nurse in a primary health care practice, you see many adult patients with asthma. The primary health care team wants to discuss strategies to improve care for these patients. They are particularly interested in whether both regular review by a health practitioner and patient education should be continued or whether giving patients written materials is just as effective. You offer to search the literature on the topic and report back at the next team meeting.

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Question FramingExercise 4

You are a public health nurse who has been visiting an elderly man with Alzheimer’s disease who is living at home. His daughter is his primary caregiver. As his condition deteriorates, she is increasingly worried about his safety and finds the situation physically and emotionally draining. The daughter is experiencing anguish and guilt as she realizes that her father will soon need to be placed in a special care unit. She asks you whether others in this situation have similar feelings and what she can expect to fell once he is placed in the special care unit.

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Question FramingExercise 5

Your first new patient in general medicine clinic is a 68 year old male who comes in for a routine physical examination. You find that he is hypertensive and decide to prescribe nifedipine, (a calcium antagonist) to control his high blood pressure. The patient discovers that nifedipine is a calcium channel blocker and remembers that there was something in the news several years ago about this group of drugs causing cancer. He calls you and wants to know if these drugs can cause cancer.

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Question FramingExercise 6

You are working in an urban community hospital. The head of the infectious disease department and the community outreach officer are trying to set up a pilot program to improve the screening and counseling process for identifying and helping AIDS infected people within the community. One of the problems is that the results of the standard test for AIDS, which are very accurate, are not available for up to three weeks. You have read about a new rapid assay test that provides results within ten minutes. You wonder if this test is as accurate.

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Research on Clinical Questions• Few physicians' clinical questions followed the recommended

PICO structure for EBP

• Using an EBM-structured form results in more precise searching by librarians.

• Allowing a free form question good for eliciting details that might enhance retrieval relevance (e.g., context)

Booth, A., O'Rourke, A. J. & Ford, N. J. (2000). Structuring the pre-search reference interview: A useful technique for handling clinical questions. Bulletin of the Medical Library Association, 88 (3):239-246.

Huang, X., Lin, J. & Demner-Fushman, D. (2006). Evaluation of PICO as a knowledge representation for clinical questions. In Proceeding of the 2006 Annual Symposium of the American Medical Informatics Association (AMIA 2006), pp. 359-363, Washington, D.C.

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Sources of EvidenceThe 5S Model

Haynes, B. (2006). Of studies, syntheses, synopses, summaries, and systems: The "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145, A8-A10.

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Critical Appraisal

Assessing the validity of the research (using guidelines or checklists), e.g., • Guidelines for Critical Review: Qualitative Studies

(qualitative studies)• JAMA Users’ Guides to the Medical Literature (medicine)• PEDro scale (physical & occupational therapy)

Determining clinical significance

Searching & Screening the Literature

for Systematic Reviews

Systematic Reviews

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“…reviews of a clearly formulated question that use explicit methods to identify, select, and critically appraise relevant research and to collect and analyse data from the studies that are included in the review.”

Cochrane Collaboration

Systematic Review Nonsystematic ReviewQuestion • Usually narrow question • Usually broad question

Search Strategy • Explicitly stated• May be performed in duplicate

• Not stated

Study Identification

• Criteria explicitly stated• May be performed in duplicate

• Not stated

Methods • Methods & outcomes of interest explicitly stated• May include study quality assessment, sensitivity analyses

• Not stated

Presentation of Results

• Typically by study characteristics so that equivalent components are compared

• Typically by study

Conclusions • Typically confined to what the data could infer

• May include personal approaches, opinions not supported by data

From: Wong R. (2003). Systematic reviews and the Cochrane Collaboration. Oncology Rounds, 5(10). [Available from www.oncologyrounds.ca].

Knowledge Syntheses

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• Systematic review• Meta analysis• Scoping review• Evidence mapping• Mixed methods synthesis• Meta-synthesis approaches• Realist synthesis approaches• Rapid evidence assessment

Cochrane Reviews

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• Electronic retrieval of health information by healthcare providers to improve practice and patient care

• Motivational interviewing for smoking cessation

Steps in a Systematic Review

1. Define the clinical question (PICO)2. Identify all relevant research

(published and unpublished)3. Select studies for inclusion4. Assess the quality of each study5. Synthesize the findings (meta-analysis or meta-

synthesis, if possible)6. Interpret the findings and present an unbiased

summary

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McGowan, J. & Sampson, M. (2005). Systematic reviews need systematic searchers. Journal of the Medical Library Association, 93(1), 74-80.

Steps in a Comprehensive Literature Search

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– Database /trial registry searches – Grey literature search– Hand searches

• Conference proceedings• Major journals

– Bibliographies

– Citation searches– “Related citations” – Snowball searches (Reference harvesting)

• Review papers• All included studies

– Contact researchers

Initial searches

Supplemental searches

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“Conducting a comprehensive, objective and reproducible search for studies can be the most time consuming and challenging task in preparing a systematic review.”

Higgins, J. P. T. & Green, S. (eds.) (2009). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2. The Cochrane Collaboration. Available from www.cochrane-handbook.org.

Selection of Sources

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Databases– Several required (+ clinicial trial registries)– Unpublished trials contribute ~20% of the weight in meta-

analysisFries, J. F., & Krishnan, E. (2004). Equipoise, design bias, and randomized controlled trials: The

elusive ethics of drug development. Arthritis Research Therapy, 6, R250-R255.

Grey literature– “unpublished,” fugitive,” “in-house,” “non-commercial”– Definition/distinction not important; as long as it’s relevant, it

should be included– Reduces publication bias

Hopewell, S., McDonald, S., Clarke, M. J., & Egger, M. Grey literature in meta-analyses of randomized trials of health care interventions. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: MR000010. doi: 10.1002/14651858.MR000010.pub3

Search Strategy Development

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• Keywords (natural language)– Truncation, synonyms, alternative spelling

• Subject Headings– Explode

• Limitations– Languages, date, publication type

• Boolean (logical operators),• Field searching

– Title, abstract• Hedges (optimal search strategies; filters)• Peer reviewMcGowan, J., Sampson, M. & Lefebvre, C. (2010). An evidence based checklist for the

peer review of electronic search strategies (PRESS EBC). Evidence Based Library and Information Practice 5 (1),149-154.

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“Terms within social sciences are often ambiguous, poorly defined and constantly changing. Unfortunately, the use of controlled vocabularies and indexing is not applied across the social sciences databases with the same rigour as in medical databases.”

Papaioannou, D., Sutton, A., Carroll, C., Booth, A. & Wong, R. (2010). Literature searching for social science systematic reviews: Consideration of a range of search techniques. Health Information and Libraries Journal, 27(2),114-122.

Record Keeping

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PRISMA Statement for Reporting SRs: • Databases with dates of coverage, date last searched,

platform/provider• Who developed and conducted the search• Supplementary methods: hand searches, citation searches,

snowball searches, contacting known researchers• Full electronic search strategy for at least one database, such

that it can be repeated• Use of hedges or any peer reviewed search strategies• Additional limitationsMoher. D., Liberati, A., Tetzlaff, J., Altman, D.G., & The PRISMA Group. (2009). Preferred

Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine 6(6), e1000097. doi:10.1371/journal.pmed1000097

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Health Sciences Librarians & EBP

What roles can the health sciences librarian play in teaching and promoting EBP?

To fulfill these roles, what skills do we need?