Sources of the evidence Akbar Soltani. MD, Endocrinologist Tehran University of Medical Sciences...

Sources of the Sources of the evidenceevidence

Akbar Akbar SSoltani. MD, Endocrinologistoltani. MD, EndocrinologistTehran University of Medical Sciences (TUMS)Tehran University of Medical Sciences (TUMS)

Endocrine and Metabolism Research Center (EMRC)Endocrine and Metabolism Research Center (EMRC)Shariati HospitaShariati Hospitall

www.soltaniebm.comwww.ebm.ir

In The Name of In The Name of GodGod

An Introduction to An Introduction to

RResearch esearch Hamideh Moosapour, MD.Hamideh Moosapour, MD.

Student of Medical Education, Shahid Beheshti University of Student of Medical Education, Shahid Beheshti University of Medical Science (DLN Program)Medical Science (DLN Program)

Evidence Based Medicine Working Team, Evidence Based Medicine Working Team, Endocrinology & Metabolism Research Center,Endocrinology & Metabolism Research Center,Tehran University of Medical Sciences (TUMS)Tehran University of Medical Sciences (TUMS)

Shariati HospitaShariati Hospitall

EBMRC Dr.Soltani RDC

““I’m sorry doctor, but again I I’m sorry doctor, but again I have to disagree.”have to disagree.”

Internet Downloads

S/he can be a student, resident…


EBM: five linked ideasEBM: five linked ideas

Ask a clinical questionAsk a clinical question Search evidencesSearch evidences

Appraise those evidencesAppraise those evidences Translated into actionsTranslated into actions

Evaluate our performanceEvaluate our performance


We’ve identified 3 We’ve identified 3 different modes of different modes of

practicepractice ““Searching & appraising”Searching & appraising”

provides E-B care, but is expensive in time provides E-B care, but is expensive in time and resourcesand resources

““Searching only”Searching only” much, quicker, and if carried out among E-much, quicker, and if carried out among E-

B resources, can provide E-B careB resources, can provide E-B care ““Replicating” the practice of expertsReplicating” the practice of experts

quickest, but may not distinguish evidence-quickest, but may not distinguish evidence-based from ego-based recommendationsbased from ego-based recommendations


Resources consulted when Resources consulted when participants had a clinical participants had a clinical

questionquestion

Members of Healthcare Team 49%

Cochrane Collaboration 4%

Journals 13%

Policies & Procedures, Clinical Pathways/Care Plans 11%

Textbooks 11%

Internet Resources 10%

Patient 2%Clinical Practice/Best

Practice Guidelines 3.5%


Should I ask a colleague?Should I ask a colleague?

12 occupational therapy questions12 occupational therapy questions E.g., Is a 38-year old sewage worker subject E.g., Is a 38-year old sewage worker subject

to a higher risk of contracting Hepatitis A to a higher risk of contracting Hepatitis A as a result of occupational exposure? (No)as a result of occupational exposure? (No)

Obtain advice from 2 professionals on 3 Obtain advice from 2 professionals on 3 cases each.cases each.

37% wrong answers37% wrong answers 17% wrong if based on literature17% wrong if based on literature 65% wrong if not65% wrong if not

Schaafsma BMC Health Services Research 2005


Information masteryInformation mastery

Usefulness of medical information

=Relevance × Validity

Work


Finding The Evidence• Bibliographic DatabasesBibliographic Databases• Search EnginesSearch Engines• Evidence-Based JournalsEvidence-Based Journals• Evidence-Based Evidence-Based Databases• Evidence-Based Guidelines• Textbooks and narrative reviews

• Expert opinions


MEDLINEMEDLINE National Library of Medicine USANational Library of Medicine USA Bias:Bias: English Language, English Language, Strong American BiasStrong American Bias Thesaurus:Thesaurus: Uses Medical Subject Headings (MeSH) Uses Medical Subject Headings (MeSH) Subject Coverage:Subject Coverage: All Specialties of Medicine All Specialties of Medicine Materials Indexed:Materials Indexed: Letters, Editorials, Research Letters, Editorials, Research

Articles from 1966 onwardsArticles from 1966 onwards 60% of References contain Abstracts60% of References contain Abstracts UpdateUpdate: Updated Monthly but can be 3 or more : Updated Monthly but can be 3 or more

months behindmonths behind Type of Database:Type of Database: Bibliographic Bibliographic To complicate matters a bit, different systems provide To complicate matters a bit, different systems provide

"add-ons" and "adjustments" to the basic database i.e "add-ons" and "adjustments" to the basic database i.e PubmedPubmed, , OVIDOVID, , SilverPlatterSilverPlatter. .

More about PubMed: More about PubMed: PubMedPubMed, though it seems like , though it seems like one database, is actually a collection of citations from one database, is actually a collection of citations from multiple sources; e.g., multiple sources; e.g., BIOETHICSLINEBIOETHICSLINE, , AIDSLINEAIDSLINE, , etc.etc. There is a core MEDLINEThere is a core MEDLINE–– it remains the same, no matter it remains the same, no matter

what system you usewhat system you use


Using the question to Using the question to guide searchingguide searching

Scenario - You are interested in checking the Scenario - You are interested in checking the hearing of elderly patients, and have heard that hearing of elderly patients, and have heard that the ‘whispered voice test’ is good.the ‘whispered voice test’ is good.

QuestionQuestion PPopulation – in elderly patients doesopulation – in elderly patients does IIndicator – a ‘poor’ whispered voice testndicator – a ‘poor’ whispered voice test CComparator – a ‘normal’ whispered voice testomparator – a ‘normal’ whispered voice test OOutcome – predict abnormal audiogramutcome – predict abnormal audiogram

1. Underline the key terms2. Number the order of importance from 1-43. Think of alternate spellings, synonyms, & truncations


Using the question to Using the question to guide searchingguide searching

Scenario - You are interested in checking the Scenario - You are interested in checking the hearing of elderly patients, and have heard that hearing of elderly patients, and have heard that the ‘whispered voice test’ is good.the ‘whispered voice test’ is good.

QuestionQuestion PPopulation – in opulation – in elderelderly patients doesly patients does IIndicator – a ‘poor’ ndicator – a ‘poor’ whisperwhispered voice tested voice test CComparator – a ‘normal’ whispered voice omparator – a ‘normal’ whispered voice

testtest OOutcome – predict poor utcome – predict poor hearhearing (ing (audiogram)audiogram)

1. Underline the (root of the) key terms2. Number the order of importance from 1-43. Think of alternate spellings, synonyms, & truncations

1

2

3


* Means any other letters

AND means both terms required

Check the question type

Check the emphasis


General structure of searchGeneral structure of search

((PPopulation OR synonym 1 OR …) ANDopulation OR synonym 1 OR …) AND ((IIntervention OR synonym 1 OR …) ANDntervention OR synonym 1 OR …) AND ((CComparator OR synonym 1 OR …) ANDomparator OR synonym 1 OR …) AND ((OOutcome OR synonym 1 OR …)utcome OR synonym 1 OR …) AND AND

FILTER (FILTER (for best study typefor best study type))


Other tips:Other tips:

Search on Title onlySearch on Title onlyEg Eg [[titi]](Others are [au] - author; [so], [yr], …)(Others are [au] - author; [so], [yr], …)

‘‘Related ARelated Articlesrticles’ button’ button(PubMed)(PubMed)

previously identified study (PubMed)previously identified study (PubMed)Look for the MeSH termsLook for the MeSH termsMeSH browserMeSH browser





• Expert opinions


Search EnginesSearch Engines

EBM search engine – EBM search engine – TRIPTRIP Medical search enginesMedical search engines

SUMSearch -alpersSUMSearch -alpers General search enginesGeneral search engines

GoogleGoogle


TRIP DatabaseTRIP Database The TRIP Database is produced by TRIP Database The TRIP Database is produced by TRIP Database

Ltd. (Ltd. (TTurning urning RResearch esearch IInto nto PPractice)ractice) The aims of the TRIP Database :allowing health The aims of the TRIP Database :allowing health

professionals to easily find the professionals to easily find the highest-qualityhighest-quality material material available on the web. available on the web.

The content of the site is reviewed The content of the site is reviewed monthlymonthly and new and new material from the publications covered is added to the material from the publications covered is added to the site. site.

Typically 300-400 new articles are added Typically 300-400 new articles are added monthlymonthly. .


TRIP Database (Turning Research Into Practice)

www.tripdatabase.com














• Expert opinions


EBM and Systematic EBM and Systematic ReviewReview

EBMEBM (quick & dirty) (quick & dirty) StepsSteps

Answerable QuestionAnswerable Question SearchSearch AppraiseAppraise

ApplyApply

Time: Time: 990 seconds0 seconds < 20 articles< 20 articles ThisThis patient survives! patient survives!

Systematic ReviewSystematic Review StepsSteps

Answerable QuestionAnswerable Question Search ++++Search ++++ Appraise x 2Appraise x 2 SynthesizeSynthesize ApplyApply

Time: 6 monthsTime: 6 months < 2,000 articles< 2,000 articles ThisThis patient is dead patient is dead

Find a systematic review!!


Evidence Based Evidence Based DatabasesDatabases

Cochrane Library Cochrane Library UpToDateUpToDate


What is The Cochrane What is The Cochrane Collaboration?Collaboration?

The Cochrane Collaboration is an international The Cochrane Collaboration is an international non–profit and independent organization, non–profit and independent organization, dedicated to making dedicated to making up–to–dateup–to–date, , accurateaccurate information about the effects of healthcare readily information about the effects of healthcare readily available worldwide. available worldwide.

It produces and disseminates It produces and disseminates systematic reviewssystematic reviews of of healthcare interventions and promotes the search healthcare interventions and promotes the search for evidence in the form of clinical trials and other for evidence in the form of clinical trials and other studies of interventions. studies of interventions.

The Cochrane Collaboration was founded in 1993 The Cochrane Collaboration was founded in 1993 and named for the British epidemiologist, and named for the British epidemiologist, Archie Archie CochraneCochrane


Cochrane LibraryCochrane Library1.1. Cochrane Database of Systematic Cochrane Database of Systematic

Reviews (CDSR)Reviews (CDSR)

2.2. Database of Reviews of Effects Database of Reviews of Effects (DARE)(DARE)

3.3. Cochrane Controlled Trials Cochrane Controlled Trials Registry (CCTR)Registry (CCTR)




Search Cascade


Evidence Based Evidence Based DatabasesDatabases

Cochrane Library Cochrane Library UpToDateUpToDate


UpToDateUpToDate

UpToDate is a UpToDate is a well-referencedwell-referenced online online textbook that is carefully updated every 4 textbook that is carefully updated every 4 months. It exists in digital format because it months. It exists in digital format because it is too large to print. is too large to print.

Although UpToDate, unlike Best Evidence Although UpToDate, unlike Best Evidence and the Cochrane Database of Systematic and the Cochrane Database of Systematic Reviews, Reviews, does not have a set of explicit does not have a set of explicit methodologic quality criteriamethodologic quality criteria that included that included articles must meet, it does reference many articles must meet, it does reference many high-quality studies chosen by its section high-quality studies chosen by its section authorsauthors


UpToDateUpToDate


UpToDateUpToDate


Search strategy?Appraisal strategy?Not multidisciplinary authorities, SO:Select facts instead of opinionAppraise yourselves



• Expert opinions


About NICE About NICE

The The National Institute for Health National Institute for Health and Clinical Excellenceand Clinical Excellence (NICE) is (NICE) is the independent organisation the independent organisation responsible for providing responsible for providing national guidance on the national guidance on the promotion of good health and the promotion of good health and the prevention and treatment of ill prevention and treatment of ill health. health.


Scottish Scottish Intercollegiate Intercollegiate

Guidelines Guidelines NetworkNetwork (SIGN) (SIGN)


Guidelines:Guidelines:

National Guideline National Guideline ClearinghouseClearinghouse

www.guideline.govwww.guideline.gov


About NGCAbout NGC

The The NGC mission is to provide is to provide physicians, nurses, and other health physicians, nurses, and other health professionals, health care providers, professionals, health care providers, health plans, integrated delivery health plans, integrated delivery systems, purchasers and others systems, purchasers and others an an accessible mechanism for obtaining accessible mechanism for obtaining objective, detailed information on objective, detailed information on clinical practice guidelines and to clinical practice guidelines and to further their dissemination, further their dissemination, implementation and use. implementation and use.




BMJUPDATESBMJUPDATES To provide clinical practitioners with To provide clinical practitioners with

the best new evidence concerning the best new evidence concerning important advances in health care, important advances in health care, exactly tailored to their interests. exactly tailored to their interests.

www.bmjupdates.com All articles are assessed for All articles are assessed for relevancerelevance and and newsworthinessnewsworthiness on on 7 point scales via the McMaster 7 point scales via the McMaster Online Rating of Evidence (MORE) Online Rating of Evidence (MORE) system system


McMaster Online Rating of McMaster Online Rating of Evidence (MORE) systemEvidence (MORE) system


McMaster Online Rating of Evidence: >6000 practicing clinicians



McMaster Online Rating of McMaster Online Rating of Evidence (MORE) system Evidence (MORE) system






http://bmjupdates.mcmaster.ca




• Expert opinions


Authority/Expert opinion Authority/Expert opinion

Need relevant knowledgeNeed relevant knowledge Need relevant expertise Need relevant expertise Mastery of reasoningMastery of reasoning Mastery of informationMastery of information No conflict of interest No conflict of interest No conflict with others No conflict with others

(authorities/fact)(authorities/fact)

Logic and critical thinking in medicine 2005

SEARCH SEARCH STRATEGYSTRATEGY

1.1. Search an appraise Search an appraise 2weeks2weeks

2.2. Search only 2w—Search only 2w—6months6months

3.3. Replicate Replicate 6months6months


Recommendations Recommendations (necessary but not (necessary but not

sufficient)sufficient) Low turnover information (Background Q,.), rare diseases, no Low turnover information (Background Q,.), rare diseases, no timetime TextbooksTextbooks Expert opinionExpert opinion ……

Rare cases (especially to write case reports) Rare cases (especially to write case reports) Pubmed and other bibliographic databases, Google, ask experts Pubmed and other bibliographic databases, Google, ask experts

sites,…sites,… Specific clinical questions (during round, MR, journal club…)Specific clinical questions (during round, MR, journal club…)

TRIPTRIP CDSR for therapy Q, (Listen to audio summaries of selected CDSR for therapy Q, (Listen to audio summaries of selected

reviews) reviews) Up-to-dateUp-to-date PubMed: Clinical QueriesPubMed: Clinical Queries

International presentationsInternational presentations CDSR for therapy QCDSR for therapy Q PubMed: Clinical QueriesPubMed: Clinical Queries

Register BMJ updateRegister BMJ update

Updating general knowledge/common topics/broad questionsUpdating general knowledge/common topics/broad questions Narrative reviews Narrative reviews


ReferencesReferences

Evidence-Based Medicine: A Framework for Evidence-Based Medicine: A Framework for Clinical Practice by Friedland et. alClinical Practice by Friedland et. al

Evidence-Based Medicine: How to Practice Evidence-Based Medicine: How to Practice and Teach EBM by David Sackettand Teach EBM by David Sackett

How to Read a Paper: The Basics of How to Read a Paper: The Basics of evidence based medicine by Trisha evidence based medicine by Trisha GreenhalghGreenhalgh

Studying a Study and Testing a Test by Studying a Study and Testing a Test by Richard Riegelman and Robert HirschRichard Riegelman and Robert Hirsch

Smith R: Where is the wisdom...? The Smith R: Where is the wisdom...? The poverty of medical evidence. BMJ poverty of medical evidence. BMJ 1991;303:798-9.1991;303:798-9.


ReferencesReferences Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers

TC: A comparison of results of meta-analyses of TC: A comparison of results of meta-analyses of randomised control trials and recommendations of randomised control trials and recommendations of clinical experts. JAMA 1992;268:240-8clinical experts. JAMA 1992;268:240-8

Bero L, Rennie D. The Cochrane Collaboration. Bero L, Rennie D. The Cochrane Collaboration. JAMA JAMA 1995;274:1935–8. 1995;274:1935–8.

Haynes RB. Clinical review articles. BMJ. Haynes RB. Clinical review articles. BMJ. 1992;304:330-1.1992;304:330-1.

Oxman AD, Cook DJ, Guyatt GH. Users’ guides to the Oxman AD, Cook DJ, Guyatt GH. Users’ guides to the medical literature. VI. How to use an overview. medical literature. VI. How to use an overview. Evidence-Based Medicine Working Group. JAMA. Evidence-Based Medicine Working Group. JAMA. 1994;272:1367-71.1994;272:1367-71.

Evidence-based Medicine Working Group. Evidence-Evidence-based Medicine Working Group. Evidence-based medicine: a new approach to teaching the based medicine: a new approach to teaching the practice of medicine. practice of medicine. JAMAJAMA 1992;268:2420-5 1992;268:2420-5

Guyatt GH, Rennie D. Users' guides to the medical Guyatt GH, Rennie D. Users' guides to the medical literature. literature. JAMAJAMA 1993;270:2096-7 1993;270:2096-7

Oxman AD, Sackett DL, Guyatt GH. Users' guides to the Oxman AD, Sackett DL, Guyatt GH. Users' guides to the medical literature. I. How to get started. medical literature. I. How to get started. JAMAJAMA 1993;270:2093-5. 1993;270:2093-5.


ReferencesReferences Trisha Greenhalgh: How to read a paper: Papers that Trisha Greenhalgh: How to read a paper: Papers that

summarise other papers (systematic reviews and meta-summarise other papers (systematic reviews and meta-analyses) analyses) BMJBMJ 1997;315:672-675 (13 September) 1997;315:672-675 (13 September)

The Cochrane CentreThe Cochrane Centre. Cochrane Collaboration Handbook . Cochrane Collaboration Handbook 20072007

Mulrow C. The medical review article: state of the science. Mulrow C. The medical review article: state of the science. Ann Intern MedAnn Intern Med 1987;106: 485-8. 1987;106: 485-8.


Useful resourcesUseful resources Teaching EBM wikiTeaching EBM wiki

http://tebm-libs.wikispaces.com/ Wetpaint EBM Librarian wikiWetpaint EBM Librarian wiki

http://ebmlibrarian.wetpaint.com Teaching on the Run series by Medical Journal of Teaching on the Run series by Medical Journal of

AustraliaAustraliahttp://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/

Create your own EBM siteCreate your own EBM sitehttp://www.ebmpyramid.org/home.php

Exploring the evidence baseExploring the evidence basehttp://clinicallibrarian.wordpress.com/2008/08/

Evidence-based nursing resources – useful for all Evidence-based nursing resources – useful for all disciplinesdisciplineshttp://muhc.ebn.mcgill.ca/EBN_tools.htm


Good Search!Good Search!

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Sources of the evidence Akbar Soltani. MD, Endocrinologist Tehran University of Medical Sciences...

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