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FINDING THE BEST
EVIDENCE: AN
OVERVIEW
OF THE RESOURCES
SPRING 2010
“…conscientious, explicit and judicious use of the cur...
THIS SESSION WILL COVER
 What do we mean by evidence-based health care
 Steps in practicing evidence-based care
 Types ...
3
Clinically relevant research,
the literature
Practitioner’s knowledge
& experience
Patient’s characteristics &
values
TH...
 Need for current clinical information
 Updates info in textbooks, journals, experts
 Skills/experiences increase over ...
1. Convert need for information into focused clinical
question
2. Track down the best evidence
3. Critically appraise the ...
Your patient is a 14-yr
old boy with a weight
problem (obesity). He
has tried lifestyle
changes and they have not been
eff...
7
Background vs. Foreground questions
Background questions – getting up to speed on a topic.
General knowledge about a dis...
 UpToDate
 Clinical Evidence
 MDConsult
 STAT!Ref
 MICROMEDEX
 Specialty texts via Ebling Library
website
Harrisons...
9
9
 Medical topics in internal medicine (particularly strong), pediatrics,
ob/gyn and family medicine
 Designed to prov...
10
Background vs. Foreground questions
Background questions – general knowledge about a disorder.
Look for info in Referen...
P I C O helps to formulate the question
Patient/Population/Problem
Intervention
Comparison
Outcome
11
CONVERT THE CLINICAL...
In a 14 year old obese male,
how effective is the drug Meridia for
long term weight loss?
12
P
I
O
C – no comparison/place...
P = In a 14 yo obese male
I = is Meridia
C =
O = effective and safe for long term weight loss?
13
P
obese
obesity
overweig...
P = In a 14 yo obese male
I = is Meridia
14
P
obese
obesity
overweight
I
Meridia
sibutramine
CREATING A SEARCH QUERY
adole...
adolescent adolescence teen teenager youth
child
obese obesity overweight
meridia sibutramine
15
 Place an “OR” between s...
16
(adolescent OR adolescence OR teen OR teenager OR youth
OR child) AND (obesity OR obese OR overweight) AND
(meridia OR ...
1. Convert need for information into focused clinical
question
2. Track down the best evidence
3. Critically appraise the ...
Clinical summaries
Meta analyses/Systematic reviews
Randomized control trials (RCTs)
Prospective cohort studies
Case-contr...
 A compendium of short summaries of the current
state of the knowledge (and uncertainty) about
clinical conditions (preve...
Examples:
 BMJ Clinical Evidence
http://clinicalevidence.bmj.com/
 Essential Evidence Plus
http://www.essentialevidence....
21
21
 Collection of brief reviews focusing on primary care and covering
over 3,000 clinical interventions with 570 clini...
Clinical summaries
Meta analyses/Systematic reviews
Randomized control trials (RCTs)
Prospective cohort studies
Case-contr...
 Summarize a particular topic by using explicit
methods to perform a thorough literature search and
critical appraisal of...
Examples:
 Cochrane Database of Systematic Reviews
http://www.cochrane.org/
 DARE
http://www.crd.york.ac.uk/crdweb/
 TR...
25
25
 5,600 systematic reviews and meta-analyses
 Rigorous, highly-regarded, reviews
 Focused on therapy/prevention, n...
26
26
 Often overlooked secondary source for evidence on any type of
foreground question
 Reviews the best original and ...
1990 1995 2000 2005
2500
12,500
5000
10,000
7500
#publishedperyear
15,000
2010
27
SYSTEMATIC REVIEWS
28
28
 Many conditions, interventions,
diagnostic tools without good SRs
 Need constant maintenance. Half will
need to b...
Clinical summaries
Meta analyses/Systematic reviews
Randomized control trials (RCTs)
Prospective cohort studies
Case-contr...
Examples:
 MEDLINE (PubMed)
http://www.pubmed.gov
 Google Scholar
http://scholar.google.com
 Other health databases
CIN...
31
31
 Includes only records/abstracts of journal articles (20 million)
 Very current info (sometimes pre-pub)
 Use MeS...
 Identify synonyms
 Check MeSH database via PubMed
 Use generic and trade names for drugs and tests
 Use full names al...
1. Converting need for information into focused
clinical question
2. Tracking down the best evidence
3. Critically apprais...
 Centre for EBM (Toronto)
http://www.cebm.utoronto.ca
 Centre for EBM (Oxford)
http://www.cebm.net
 Users’ Guides serie...
Statistics Toolkit
By Perera R, et al
BMJ Books
2008
ISBN: 978-1-4051-6142-8
120 pages
35
1. Converting need for information into focused
clinical question
2. Tracking down the best evidence
3. Critically apprais...
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  • Welcome and introductionsNew course that provides an overview of the EBP resources availablePlease complete evals!!!
    Basic design:
    -what ebp is
    -developing a focused question-using ebp resources to track down the evidence
  • This class focuses on the important first two steps only.
    These are the standard steps from Straus’s book
  • 90% of questions that arise in clinic are background.
  • We have many resources at the library to help these background questions.
    It is a good idea to develop/have an “reference shelf” of current resources at your fingertips to quickly answer background questions.
    Here are some of our favorites
    SHOW:
    MDConsult or STATRef – collections of clinical texts
    UptoDate or Clinical Evidence -- consumable paragraphs about potential diseases
  • 90% of questions that arise in clinic are background.
  • Take your specific clinical scenario and place it into the PICO formula.
    The P can contain more than one type of information – think of patient or problem
    I is what are you thinking of applying to the patient—an intervention—diagnostic test, specific therapy. (what is the drug treatment for instance).
    C=Comparison of I to C—What are you comparing the potential intervention to? Would one test be more accurate than another (often times there is not C or it could be a placebo).
    O=what are the desired results of the intervention?
    So let’s create a PICO for our clinical scenario (NEXT SLIDE)
  • So let’s create a PICO for our clinical scenario
  • The beauty of the PICO is that it translates very nicely into your search query for use in EBP databases.
    No comparison (shouldn’t search the term PLACEBO)
    Also mention that rarely do you search using terms associated with the outcome, that is what you hope to discover from your search. Drrop that off (often implied by author and not found in the abstract).
    (3) Next, take the P and I terms and think of synonyms and abbreviations. If a drug/herbal, always search the generic name along with the trade name.
  • A good place to find search terms is PubMed’s MeSH database.
  • This class focuses on the important first two steps only.
    These are the standard steps from Sackett’s book
  • Not all journal articles are created equal—many different types of articles.
    (1) Go through the Single Studies first and REFER TO THE MORE ABOUT STUDY TYPES link…spend a moment explaining the differences between observational/experimental
    RCT is the strongest single study.
    (2) Go through the EBM Literature and REFER TO THE MORE ABOUT EBM LIT link…spend a moment explaining the differences between Clinical summaries/sys reviews/metaanalysis/synopses
  • Transcript of "Session Slides"

    1. 1. 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
    2. 2. 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 2
    3. 3. 3 Clinically relevant research, the literature Practitioner’s knowledge & experience Patient’s characteristics & values THREE PRONGED APPROACH 3
    4. 4.  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 4 WHY USE AN EVIDENCE-BASED APPROACH?
    5. 5. 1. Convert need for information into focused clinical question 2. Track down the best evidence 3. Critically appraise the evidence 4. Integrate evidence with clinical expertise and patient values 5. Evaluate the process and adjust as needed 5 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
    6. 6. 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. PhotofromCDC:Childhoodoverweight CLINICAL SCENARIO 6
    7. 7. 7 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 7
    8. 8.  UpToDate  Clinical Evidence  MDConsult  STAT!Ref  MICROMEDEX  Specialty texts via Ebling Library website Harrisons 8 BACKGROUND SOURCES
    9. 9. 9 9  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
    10. 10. 10 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 10
    11. 11. P I C O helps to formulate the question Patient/Population/Problem Intervention Comparison Outcome 11 CONVERT THE CLINICAL QUESTION TO PICO
    12. 12. In a 14 year old obese male, how effective is the drug Meridia for long term weight loss? 12 P I O C – no comparison/placebo CONVERT THE CLINICAL QUESTION TO PICO
    13. 13. P = In a 14 yo obese male I = is Meridia C = O = effective and safe for long term weight loss? 13 P obese obesity overweight I Meridia sibutramine CREATING A SEARCH QUERY adolescent adolescence teen teenager youth
    14. 14. P = In a 14 yo obese male I = is Meridia 14 P obese obesity overweight I Meridia sibutramine CREATING A SEARCH QUERY adolescent adolescence teen teenager youth ORANGE = MeSH term
    15. 15. adolescent adolescence teen teenager youth child obese obesity overweight meridia sibutramine 15  Place an “OR” between synonyms of the same concept and surround concept terms with parentheses  Place an “AND” between concepts ( OR OR OR OR OR ) ( OR OR ) ( OR ) AND AND CREATING A SEARCH QUERY 15
    16. 16. 16 (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 16
    17. 17. 1. Convert need for information into focused clinical question 2. Track down the best evidence 3. Critically appraise the evidence 4. Integrate evidence with clinical expertise and patient values 5. Evaluate the process and adjust as needed 17 STEPS IN PRACTICING EBP
    18. 18. Clinical summaries Meta analyses/Systematic reviews Randomized control trials (RCTs) Prospective cohort studies Case-control (retrospective cohort) studies Case studies Opinion of authorities, editorials 18 LevelofEvidence low high EVIDENCE HIERARCHY
    19. 19.  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 19
    20. 20. Examples:  BMJ Clinical Evidence http://clinicalevidence.bmj.com/  Essential Evidence Plus http://www.essentialevidence.com/  UpToDate http://www.uptodate.com 20 EVIDENCE-BASED CLINICAL SUMMARIES
    21. 21. 21 21  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 EVIDENCE-BASED CLINICAL SUMMARY
    22. 22. Clinical summaries Meta analyses/Systematic reviews Randomized control trials (RCTs) Prospective cohort studies Case-control (retrospective cohort) studies Case studies Opinion of authorities, editorials 22 LevelofEvidence low high EVIDENCE HIERARCHY
    23. 23.  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 23
    24. 24. 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 24
    25. 25. 25 25  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
    26. 26. 26 26  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”
    27. 27. 1990 1995 2000 2005 2500 12,500 5000 10,000 7500 #publishedperyear 15,000 2010 27 SYSTEMATIC REVIEWS
    28. 28. 28 28  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
    29. 29. Clinical summaries Meta analyses/Systematic reviews Randomized control trials (RCTs) Prospective cohort studies Case-control (retrospective cohort) studies Case studies Opinion of authorities, editorials 29 LevelofEvidence low high EVIDENCE HIERARCHY Studies
    30. 30. 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 30
    31. 31. 31 31  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
    32. 32.  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 32
    33. 33. 1. Converting need for information into focused clinical question 2. Tracking down the best evidence 3. Critically appraising the evidence 4. Integrating evidence with clinical expertise and patient values 5. Evaluating the process STEPS IN PRACTICING EBP 33
    34. 34.  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 34 34 CRITICALLY APPRAISING THE EVIDENCE
    35. 35. Statistics Toolkit By Perera R, et al BMJ Books 2008 ISBN: 978-1-4051-6142-8 120 pages 35
    36. 36. 1. Converting need for information into focused clinical question 2. Tracking down the best evidence 3. Critically appraising the evidence 4. Integrating evidence with clinical expertise and patient values 5. Evaluating the process STEPS IN PRACTICING EBP 36
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