Finding The Best Evidence An Overview of the Resources

FINDING THE BEST EVIDENCE: AN OVERVIEW OF THE RESOURCESSPRING 2008

“…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




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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.

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CLINICAL SCENARIO

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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

USING THE LITERATURE IN PRACTICE

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Online and print textbooks MDConsult, STAT!Ref Harrisons Specialty texts via Ebling Library website

Electronic clinical summaries UpToDate, Clinical Evidence

Drug compendia MICROMEDEX

Consultants, colleagues9

BACKGROUND SOURCES

http://ebling.library.wisc.edu/




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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/ProblemIntervention ComparisonOutcome

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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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Pobese

obesityoverweight

IMeridiasibutramine

CREATING A SEARCH QUERY

adolescentadolescenceteenteenageryouth

P = In a 14 yo obese maleI = is Meridia

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Pobese

obesityoverweight

IMeridiasibutramine

CREATING A SEARCH QUERY

adolescentadolescenceteenteenageryouth ORANGE = MeSH term

http://www.ncbi.nlm.nih.gov/sites/entrez?myncbishare=uwisclib&otool=uwisclib

(obese OR obesity OR overweight) AND (adolescent OR teen OR teenager OR adolescence OR youth) AND (meridia OR sibutramine)

Place an “OR” between synonyms of the same concept and surround concept terms with parentheses

Place an “AND” between concepts

POTENTIAL SEARCH QUERY

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(obes* OR overweight) AND (adolescen* OR teen* OR youth) AND (meridia OR sibutramine)

Place a wildcard (if allowed by database) to get variations of a word stem

USING TRUNCATION WILDCARDS

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See the Ebling Library EBM tutorial for more help with creating PICOs:

Finding Answers to Clinical Questions

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PICO HELP AND PRACTICE





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Clinical summariesSurveillance tools/synopsesMeta analyses/Systematic reviews

Randomized control trials (RCTs)Prospective cohort studiesCase-control (retrospective cohort) studiesCase studiesOpinion of authorities, editorials

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EVIDENCE HIERARCHY



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Stud

ies

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high

EVIDENCE HIERARCHY

5S MODEL

Haynes , RB. 2006. Evid Based Med; 11(6):162-421



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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/

ACP PIER http://pier.acponline.org/

Essential Evidence Plushttp://www.essentialevidence.com/

UpToDate http://www.uptodate.com

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EVIDENCE-BASED CLINICAL SUMMARIES

BMJ Clinical Evidence Includes entries for 250 medical conditions and 2500+

treatments Looks at current state of knowledge & ignorance about

prevention and treatment Describes the best available evidence from systematic

reviews, RCTs and observational studies where appropriate, and if there is no good evidence, it says so

Includes some good background info such as prevalence

Focuses on primary care Organized by clinical question

EVIDENCE-BASED CLINICAL SUMMARY

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EVIDENCE HIERARCHY

Survey/monitor the voluminous health literature and select or highlight the articles that meet specific standards and warrant the attention of its readers

Articles are summarized and the context, methods, and clinical applications are often discussed by experts

SYNOPSES/SURVEILLANCE TOOLS

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Examples:

ACP Journal Clubhttp://www.acpjc.org/

Database of Abstracts of Reviews of Effects (DARE)http://www.crd.york.ac.uk/crdweb/

bmjupdates+http://www.bmjupdates.com/


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ACP Journal Club

Scans 200 clinical journals for high impact clinical studies or reviews that “warrant the attention of clinicians”

Gives abstracts with results and commentary for each article highlighted

Includes ratings for clinical relevance and newsworthiness (based on McMaster Online Rating of Evidence system)


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Leve

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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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Cochrane Database of Systematic Reviews High quality, constantly updated systematic

reviews (meta-analyses) created by ~50 groups Includes ~5000 reviews involving therapy and

prevention. Strict quality control and review and give

extensive information about individual trials included

DARE Scans 60 clinical journals and 7 databases for high

impact systematic reviews on topics not covered in the Cochrane database

Includes a structured abstract with commentary (review) for each systematic review

SYSTEMATIC REVIEWS

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PubMed

Covers 5,000 journals in all aspects of the health sciences, and includes 17 million journal articles and over 90,000 systematic reviews.

Searching for Systematic Reviews:

1. Use the “Find Systematic Reviews” box in Clinical Queries

2. Use the Subsets limit: Systematic Reviews3. Use the Type of Article limit: Meta-Analysis

SYSTEMATIC REVIEWS

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EVIDENCE HIERARCHYSt

udie

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Examples:

MEDLINE (PubMed)http://www.pubmed.gov

Cochrane CENTRAL Databasehttp://www.cochrane.org/

EMBASEhttp://www.embase .com

Other health databasesCINAHL http://www.cinahl.com/

PsycINFO http://www.apa.org/psycinfo/

INDIVIDUAL STUDIES

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PubMed Covers 5,000 journals in all aspects of the health

sciences, and includes 17 million journal articles including 500,000+ clinical trials

Searching for Individual trials:

1. Use the “Search by Clinical Study” box in Clinical Queries

2. Select a Category and a Scope

INDIVIDUAL STUDIES

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Identify synonyms Check MeSH database via PubMed Use generic and trade names for drugs and tests Use common abbreviations along with full names

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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Use truncation wildcards * or $ or : (depends on database)

Look for resource-specific limits/filters

GENERAL SEARCH HINTS

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Use truncation wildcard (*) only on terms that are not MeSH terms

Use filters: Clinical Queries: Systematic Reviews Clinical Queries: Clinical Study

Use limits sparingly

PUBMED 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


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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

Statistics Toolkit

By Perera R, et alBMJ Books2008ISBN: 978-1-4051-6142-8120 pages

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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


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THANKS QUESTIONS???

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Finding The Best Evidence An Overview of the Resources

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