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FINDING THE BEST EVIDENCE: AN OVERVIEW OF THE RESOURCES SPRING 2010 “… 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

THREE PRONGED APPROACH Clinically relevant research, the literature Practitioner’s knowledge & experience Patient’s characteristics & values

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
WHY USE AN EVIDENCE-BASED APPROACH?

Convert need for information into focused clinical question
Track down the best evidence
Critically appraise the evidence
Integrate evidence with clinical expertise and patient values
Evaluate the process and adjust as needed
STEPS IN PRACTICING EBP Evidence-based Medicine: How to Practice and Teach EBM By Straus SE, et al Third Edition. Churchill Livingstone: Edinburgh, 2005 0-443-07444-5, 299 pages. Includes CD-ROM

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.
Photo from CDC: Childhood overweight CLINICAL SCENARIO

Background vs. Foreground questions Background questions – getting up to speed on a topic. General knowledge about a disorder. Look for info in textbooks, summary material. Foreground questions – specific knowledge about managing a patient or disorder. Apply EBP techniques, use EBP resources
USING THE LITERATURE IN PRACTICE

UpToDate
Clinical Evidence
MDConsult
STAT!Ref
MICROMEDEX
Specialty texts via Ebling Library website
Harrisons
BACKGROUND SOURCES

Medical topics in internal medicine (particularly strong), pediatrics, ob/gyn and family medicine
Designed to provide a quick way to get up to speed
An updated version of UpToDate is released every four months “What’s New” tab highlight changes with each major release.
For use in EBM is a mixed bag (use cautiously to answer clinical questions (i.e. PICO questions)
Articles are a mixture of medical conclusions based on data from studies and expert opinions of individual authors…not always clear which statements are evidence-based and which are not
EVIDENCE-BASED CLINICAL SUMMARY

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

P I C O helps to formulate the question
P atient/ P opulation/ P roblem
I ntervention
C omparison
O utcome
CONVERT THE CLINICAL QUESTION TO PICO

In a 14 year old obese male, how effective is the drug Meridia for long term weight loss?
P I O C – no comparison/placebo CONVERT THE CLINICAL QUESTION TO PICO

P = In a 14 yo obese male
I = is Meridia
C =
O = effective and safe for long term weight loss?
P obese obesity overweight I Meridia sibutramine CREATING A SEARCH QUERY adolescent adolescence teen teenager youth

P = In a 14 yo obese male
I = is Meridia
P obese obesity overweight I Meridia sibutramine CREATING A SEARCH QUERY adolescent adolescence teen teenager youth ORANGE = MeSH term

Place an “OR” between synonyms of the same concept and surround concept terms with parentheses
Place an “AND” between concepts
adolescent adolescence teen teenager youth child obese obesity overweight meridia sibutramine ( OR OR OR OR OR ) ( OR OR ) ( OR ) AND AND CREATING A SEARCH QUERY

(adolescent OR adolescence OR teen OR teenager OR youth OR child) AND (obesity OR obese OR overweight) AND (meridia OR sibutramine) (adolescen* OR teen* OR youth OR child) AND (obes* OR overweight) AND (meridia OR sibutramine) Use truncation character, if available: CREATING A SEARCH QUERY

Convert need for information into focused clinical question
Track down the best evidence
Critically appraise the evidence
Integrate evidence with clinical expertise and patient values
Evaluate the process and adjust as needed
STEPS IN PRACTICING EBP

Clinical summaries
Meta analyses/Systematic reviews
Randomized control trials (RCTs)
Prospective cohort studies
Case-control (retrospective cohort) studies
Case studies
Opinion of authorities, editorials
Level of Evidence low high 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

Examples:
BMJ Clinical Evidence http://clinicalevidence.bmj.com/
Essential Evidence Plus http://www.essentialevidence.com/
UpToDate http://www.uptodate.com
EVIDENCE-BASED CLINICAL SUMMARIES

Collection of brief reviews focusing on primary care and covering over 3,000 clinical interventions with 570 clinical questions answered.
Looks at current state of knowledge & ignorance about prevention and treatment. Describes the best available evidence and if there is no good evidence, it says so.
Each review focuses on single condition and is displayed in a tabbed structure:
Single page summary of the review
Ranked list of interventions with discussion (benefits/harms)
Background info on the condition
A list of material published since the review search date
Links to major guidelines relevant to the review

Clinical summaries
Case studies
Level of Evidence low 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

Examples:
Cochrane Database of Systematic Reviews
http://www.cochrane.org/
DARE
http://www.crd.york.ac.uk/crdweb/
TRIP Database
http://www.tripdatabase.com
MEDLINE (PubMed) http://www.pubmed.gov
SYSTEMATIC REVIEWS

5,600 systematic reviews and meta-analyses
Rigorous, highly-regarded, reviews
Focused on therapy/prevention, now covering diagnostic tests
Database includes protocols -- plans or sets of steps to be followed in creating a systematic review
When searching within the Cochrane Library: use the “Title, Abstract, Keywords” drop down to reduce irrelevant records
Contains 15,000 reviews of systematic reviews.
Complements the CDSR -- quality-assesses and summarizes reviews that have not yet been carried out by Cochrane
When searching within the Cochrane Library: use the “The full review (Search All Text)” drop down to reduce irrelevant records
SYSTEMATIC REVIEWS

Often overlooked secondary source for evidence on any type of foreground question
Reviews the best original and review articles from over 100 of the top clinical journals
If included, it is important!
Unlike DARE, clinical experts provide commentaries on the context, methods, and clinical applications of the findings of each article
SYSTEMATIC REVIEWS
New interface
Includes only records/abstracts of journal articles (20 million)
Very current info (sometimes pre-pub)
Use MeSH terms for more efficient searching
Use Boolean operators (AND, OR)
Searching for systematic reviews:
Use the “Find Systematic Reviews” box in Clinical Queries OR Apply the Subsets limit “Systematic Reviews”

1990 1995 2000 2005 2500 12,500 5000 10,000 7500 # published per year 15,000 2010 SYSTEMATIC REVIEWS

Many conditions, interventions, diagnostic tools without good SRs
Need constant maintenance. Half will need to be updated each year
Garbage in; garbage out FAAT handout http://www.cebm.net/index.aspx?o=1157
SYSTEMATIC REVIEWS

Clinical summaries
Case studies
Level of Evidence low high EVIDENCE HIERARCHY Studies

Examples:
MEDLINE (PubMed) http://www.pubmed.gov
Google Scholar http://scholar.google.com
Other health databases
CINAHL http://www.cinahl.com/ PsycINFO http://www.apa.org/psycinfo/
INDIVIDUAL STUDIES

Includes only records/abstracts of journal articles (20 million)
Very current info (sometimes pre-pub)
Use MeSH terms for more efficient searching
Use Boolean operators (AND, OR)
Searching for single studies:
Use the “Search by Clinical Study Category” box in CQ
OR use the type of article limit: randomized controlled trials or other appropriate level
Subset of larger Google : journal articles, technical reports, preprints, theses, books and other documents and web pages deemed “scholarly”
Covers a great range of disciplines (strong in sciences and medicine)
It is particularly helpful for users who want:
something good enough for the task at hand (not comprehensive)
grey literature--sources outside of published journals
info from sources across many disciplines
Limitations: rudimentary search features, lack of transparency of database content, uneven coverage (time and scope) and a delay in indexing
INDIVIDUAL STUDIES

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

Converting need for information into focused clinical question
Tracking down the best evidence
Critically appraising the evidence
Integrating evidence with clinical expertise and patient values
Evaluating the process

Centre for EBM (Toronto) http://www.cebm.utoronto.ca
Centre for EBM (Oxford) http://www.cebm.net
Users’ Guides series in JAMA http://www.userguides.org
CRITICALLY APPRAISING THE EVIDENCE

Statistics Toolkit By Perera R, et al BMJ Books 2008 ISBN: 978-1-4051-6142-8 120 pages

Converting need for information into focused clinical question
Tracking down the best evidence
Critically appraising the evidence
Integrating evidence with clinical expertise and patient values
Evaluating the process

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