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Introduction to EBM
Resources
Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS
Consultant Physician & Pulmonologist...
What is Evidence-based
Medicine


“ Evidence-based medicine is the



integration of:
 best available research evidence...
Three Pronged Approach

The
Patient

Patient’s characteristics,
preferences & values

EBP!
Best
Evidence
Clinically releva...
Integrates Evidence With


Clinical expertise


Experience



Judgment



Patient values and preferences



Quality o...
Patient Values
and
Preferences

Clinical
Expertise
Best
Available
Evidence

Quality
of Life

Cost/
Availability
What is Evidence-based
Practice
EBP is about asking questions and

searching for answers in the body of
medical research, ...
Evidence-based Practice
Ask clinical

Acquire the

Questions

best evidence

Assess

5A’s !!

Appraise

effectiveness,
eff...
Evidence-based Practice
Acquire the

Ask clinical

best evidence:
Literature Searching

Questions: PICO

Assess

5A’s !!

...
Self-Education & Training in
EBM


EBM Resources:






CEBM Website:





http://guides.mclibrary.duke.edu/content...
Objectives


Why do Healthcare Professionals need to be
competent in Literature Searching?



Who should be competent in...
Rule 31 –
Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London

Medical Articles pe...
The Decline in Knowledge and Patient
Outcomes
Competency in Literature
Searching for Professionals






Dealing with the daily “challenge” to one’s
knowledge.
Life...
For
Whom?
Chairman

Resident

Quality

Nursing
Manager

Clinical
Director

Nurse
Competency in Literature
Searching: For Whom?
Healthcare
Professionals Including
Policymakers etc
 Patients!

Competency in Literature
Searching for Patients


For successful incorporation of:




1. Values and Preferences
2. Pat...
The 6 Prerequisites for
successful Literature Searching
1
2
3
4
5
6

• Know how to use a computer/electronic device.
• Kno...
Know how to use a
computer/electronic
device.
Prerequisites for successful
Literature Searching


Know how to use a computer/electronic
device.

Computer Literacy
Prerequisites for successful
Literature Searching


Know the Internet Jargon of Terms e.g.






What is a Website?
W...
What is a Website?

• An internet site and an information resource on the

World Wide Web. Websites may provide informatio...
What is a Database?
• A Database is an organized collection of information
records that can be accessed electronically e.g...
What is a Search
Engine?
• A web-based computer-program that allows users to

electronically search and retrieve specific ...
What is a Meta-search Engine?
• A search engine that queries other search engines
and then combines the results that are r...
“turning research into practice”
Prerequisites for successful
Literature Searching


Know the EBM Jargon of Terms.
EBM Terminology
• Knowledge: Foreground/Background
• Types of Literature Articles: Primary
(Original)/Secondary (Pre-appra...
Ask clinical question
Background /Foreground questions
•

Background Question

•

Asks for general knowledge about a disor...
Background versus Foreground
Information


Case discussion: 27 year old woman with right lower
quadrant (RLQ) abdominal p...
Ask clinical question

Foreground
questions
Background
question

novice

expert
Types of Literature



Primary (Original)



Secondary (Pre-appraised)
Types of Literature



Primary (Original)


Research publications e.g. in




Pubmed
Embase
CINAHL
The Pre-appraised Literature
• Pre-appraised = The Secondary Literature
• Useful for point-of-care searches
• Databases wi...
Important Outcomes


Patient Oriented Outcomes: PO Evidence
outcomes patients actually care about








Death (over...
Comparing DOE and POE
Example

DiseaseOriented
Evidence

Patient-Oriented
Evidence that
Matters

Comment

Anti-arrhythmic
...
What is a Systematic
Review?
What is a Systematic Review?
• Systematic Reviews (SRs)
– Use a systematic methodology to ide...
Comparison Chart
Systematic vs. Narrative Review

Systematic Review Article
Narrow focus, answers foreground
questions
Sys...
What is a Meta-analysis?
• Meta-analyses
– Uses studies from a Systematic Review and
applies statistical techniques for co...
Evidence-based Practice Guidelines
• Systematically gather and “grade” evidence on a topic
• Developed by professional gro...
What is a Clinical Practice Guideline?
Level of evidence/Grades of
Recommendations
Grades of
Recommendations

Validity/Strength of Inference

Oxford Centre of EB...
What is Critical Appraisal?





Critical Appraisal:
The process of assessing and interpreting the
evidence by systemat...
Critically-Appraised Topic (CAT):
What is a Critically Appraisal Topic?
A standardized one-page summary of the
evidence.
I...
What is the Best Evidence? Hierarchy of
Levels of Evidence
Randomized Controlled Clinical Trial
(RCT)
What is a Randomised Controlled Trial?
A group of patients is randomized into a...
Prerequisites for successful
Literature Searching


Know how to formulate your question.
Evidence-based Practice
Ask clinical

Acquire the

questions

best evidence

Assess

5A’s !!

Appraise

effectiveness,
eff...
Evidence-based Practice

Ask clinical
questions

PICO

Ask: Refine ability to convert need for information (e.g.,
therapy,...
Ask clinical question
Ask Clinical Questions: PICO
Components of Clinical Questions
Patient/
Population

Intervention/
Exposure

Comparison

Out...
Prerequisites for successful
Literature Searching


Know where to go.
Evidence-based Practice

Acquire the
best evidence

Literature
Search

Acquire: Select “best evidence” resources to answer...
Types of Resources
Characteristics of a Good
Resource
“Finding Evidence”: Sources


Primary: PubMed, EmBase, Cinahl, Pyschlit
Primary Resources
Primary Resources
“Finding Evidence”: Sources







Secondary:
Systematic Reviews: Cochrane Library, PubMed
Guidelines websites: Guide...
Secondary Resources
Secondary Resources
Secondary Resources
“Finding Evidence”: Sources


Tertiary resources (meta search engines, databases of
databases):


TRIP+ (Translating Res...
Tertiary Resources
Know what to do when you
get there: the site’s technical
language/know-how.
Resources For EBM Knowledge Translation

EBM Hunting Tools

EBM Resources

Advanced EBM Skills

Point of Care
Clinical
Res...
Types of Resources
1.

2.
3.

4.

5.
6.
7.
8.

Point of Care Clinical Resources/Decision
Support Systems
Up-Dates & New Ev...
Resources For EBM Literature
Searching
1
2
3
4

• Point of Care Clinical
Resources/Decision Support Systems
• Up-Dates & N...
Resources For EBM Literature
Searching
5
6
7
8

• Critical Appraisal Tools
• EBM Audiovisual Training

• Innovations Excha...
5S Information Resources: Information in top 4 are used
Computerized Decision
Support System (CDSS)

Systems
Evidence base...
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
Part 1 Introduction to Evidence-based Medicine Literature Searching
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Part 1 Introduction to Evidence-based Medicine Literature Searching

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Basics of Evidence-based Medicine Literature Searching

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Transcript of "Part 1 Introduction to Evidence-based Medicine Literature Searching"

  1. 1. Introduction to EBM Resources Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS Consultant Physician & Pulmonologist Chairman, Knowledge Translation Committee Department of Medicine KAMC Riyadh Kingdom of Saudi Arabia imadsahassan@gmail.com
  2. 2. What is Evidence-based Medicine  “ Evidence-based medicine is the  integration of:  best available research evidence with  clinical expertise and  patient values”  Sackett, et al 2001
  3. 3. Three Pronged Approach The Patient Patient’s characteristics, preferences & values EBP! Best Evidence Clinically relevant research, the literature Clinical Expertise 3 Practitioner’s knowledge & experience 3
  4. 4. Integrates Evidence With  Clinical expertise  Experience  Judgment  Patient values and preferences  Quality of life  Costs  Other important factors
  5. 5. Patient Values and Preferences Clinical Expertise Best Available Evidence Quality of Life Cost/ Availability
  6. 6. What is Evidence-based Practice EBP is about asking questions and searching for answers in the body of medical research, and having found a likely source of information appraising the paper for its scientific validity and then applying the result to your problem.
  7. 7. Evidence-based Practice Ask clinical Acquire the Questions best evidence Assess 5A’s !! Appraise effectiveness, efficiency of EBM process the evidence Apply evidence to your patient
  8. 8. Evidence-based Practice Acquire the Ask clinical best evidence: Literature Searching Questions: PICO Assess 5A’s !! effectiveness, efficiency of EBM process Appraise the evidence: Critical Appraisal Apply evidence to your patient: Knowledge Translation (Implementation)
  9. 9. Self-Education & Training in EBM  EBM Resources:    CEBM Website:    http://guides.mclibrary.duke.edu/content.php?pid= 274373&sid=2262393 http://www.med.yale.edu/library/education/guides/ feature/finditfast http://www.youtube.com/user/cebmed, http://www.cebm.net/index.aspx?o=1965 YouTube:  http://www.youtube.com/watch?v=odfo9CQGi0c
  10. 10. Objectives  Why do Healthcare Professionals need to be competent in Literature Searching?  Who should be competent in Literature Searching?  Prerequisites for completing a successful Literature Searching exercise.
  11. 11. Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London Medical Articles per Year 2500000 5,000? per day 2000000 1500000 1000000 55 per day 1,400 per day 500000 0 Trials MEDLINE BioMedical
  12. 12. The Decline in Knowledge and Patient Outcomes
  13. 13. Competency in Literature Searching for Professionals     Dealing with the daily “challenge” to one’s knowledge. Life-long learning. Evidence-based practice Valuable employee.
  14. 14. For Whom?
  15. 15. Chairman Resident Quality Nursing Manager Clinical Director Nurse
  16. 16. Competency in Literature Searching: For Whom? Healthcare Professionals Including Policymakers etc  Patients! 
  17. 17. Competency in Literature Searching for Patients  For successful incorporation of:   1. Values and Preferences 2. Patient-centered Care
  18. 18. The 6 Prerequisites for successful Literature Searching 1 2 3 4 5 6 • Know how to use a computer/electronic device. • Know the Internet Jargon of Terms. • Know the EBM Jargon of Terms. • Know how to formulate your question. • Know where to go. • Know what to do when you get there: the site’s technical language/know-how.
  19. 19. Know how to use a computer/electronic device.
  20. 20. Prerequisites for successful Literature Searching  Know how to use a computer/electronic device. Computer Literacy
  21. 21. Prerequisites for successful Literature Searching  Know the Internet Jargon of Terms e.g.     What is a Website? What is a Database? What is a Search Engine? What is a Meta-search Engine?
  22. 22. What is a Website? • An internet site and an information resource on the World Wide Web. Websites may provide information on any topic. • A collection of files that are arranged on the World Wide Web under a common address and allows retrieval via a browser. • Examples: Pubmed, Yahoo, Guidelines Websites etc
  23. 23. What is a Database? • A Database is an organized collection of information records that can be accessed electronically e.g. Medline (Pubmed), Cochrane etc
  24. 24. What is a Search Engine? • A web-based computer-program that allows users to electronically search and retrieve specific information online. • It searches documents and databases for specified keywords and returns a list of the documents where the keywords were found. • Internet search engines help users find web pages on a given subject. • General: e.g. Google, Yahoo etc • Specialized: Google Scholar, Pubmed
  25. 25. What is a Meta-search Engine? • A search engine that queries other search engines and then combines the results that are received from all. • In effect, the user is not using just one search engine but a combination of many search engines at once to optimize Web searching. • General: dogpile • Specialized: TRIP, SumSearch.
  26. 26. “turning research into practice”
  27. 27. Prerequisites for successful Literature Searching  Know the EBM Jargon of Terms.
  28. 28. EBM Terminology • Knowledge: Foreground/Background • Types of Literature Articles: Primary (Original)/Secondary (Pre-appraised) • Clinical Outcomes: Patient-oriented vs Disease Oriented Outcomes • Reviews: Systematic/Non-systematic (Narrative) • CAT: Critically Appraised Topic • Clinical Practice Guidelines • Levels of Evidence: Hierarchy Pyramid • Sources of Evidence: Point-of-care etc • Knowledge Translation Resources
  29. 29. Ask clinical question Background /Foreground questions • Background Question • Asks for general knowledge about a disorder. Textbooks are good for answering background questions • Foreground Question Asks for specific knowledge about managing patients with a disorder; consists of three or four components (PICO): Diagnosis, Therapy, Prognosis etc Journal articles are good for answering foreground questions.
  30. 30. Background versus Foreground Information  Case discussion: 27 year old woman with right lower quadrant (RLQ) abdominal pain  Background information available from textbooks  What is the clinical course/complications of the different diagnoses   What typically presents as RLQ pain Specifically, what is typical presentation of appendicitis Foreground information  How good is a CT scan for appendicitis?
  31. 31. Ask clinical question Foreground questions Background question novice expert
  32. 32. Types of Literature  Primary (Original)  Secondary (Pre-appraised)
  33. 33. Types of Literature  Primary (Original)  Research publications e.g. in    Pubmed Embase CINAHL
  34. 34. The Pre-appraised Literature • Pre-appraised = The Secondary Literature • Useful for point-of-care searches • Databases with pre-appraised evidence will give you the highest quality information in the shortest amount of time. • Two types of pre-appraised databases – Those with pre-appraised Synthesis of studies e.g. Guidelines and Systematic Reviews – Those with pre-appraised Individual studies: Critically appraised Topics CATs
  35. 35. Important Outcomes  Patient Oriented Outcomes: PO Evidence outcomes patients actually care about     Death (overall or disease-specific) Heart attacks, strokes, amputations, bed sores, broken hips, renal failure, etc. Ability to perform activities of daily living Versus Disease oriented outcomes: DO Evidence  Biochemical, physiologic, pharmacologic, or laboratory measures
  36. 36. Comparing DOE and POE Example DiseaseOriented Evidence Patient-Oriented Evidence that Matters Comment Anti-arrhythmic Therapy Drug X  PVCs on ECG Drug X increases mortality POE contradicts DOE Type 2 Diabetes Aggressive Tx with insulin or oral agents can keep BS low Aggressive Tx does not reduce mortality or prevent most complications POE contradicts standard teaching Prostate Screening PSA screening detects prostate cancer early Does PSA screening  mortality? DOE exists, but POE is unknown Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60.
  37. 37. What is a Systematic Review? What is a Systematic Review? • Systematic Reviews (SRs) – Use a systematic methodology to identify, critically appraise, and synthesize relevant studies – Individual studies assessed for validity – Differ from traditional review articles (Narrative Reviews) in that conclusions are evidence-based rather than commentary
  38. 38. Comparison Chart Systematic vs. Narrative Review Systematic Review Article Narrow focus, answers foreground questions Systematic scientific approach to finding, evaluating and summarizing the evidence Review Article Broad focus, answers background questions Depends on the author’s inclination Comprehensive search for relevant articles Author gets to pick using any criteria Explicit methods of appraisal and synthesis Methods usually not specified Meta-analysis may be used to combine data Vote count or narrative summary
  39. 39. What is a Meta-analysis? • Meta-analyses – Uses studies from a Systematic Review and applies statistical techniques for combining quantitative data. – A systematic review that uses quantitative methods to summarize the results.
  40. 40. Evidence-based Practice Guidelines • Systematically gather and “grade” evidence on a topic • Developed by professional groups, government agencies, local practices etc
  41. 41. What is a Clinical Practice Guideline?
  42. 42. Level of evidence/Grades of Recommendations Grades of Recommendations Validity/Strength of Inference Oxford Centre of EBM Ia Systematic reviews (meta-analyses) of RCTs Ib Randomized controlled trials Bias II Cohort studies III Case-control-studies IV Case-series V Expert opinion Bias Bias Bias Bias Bias
  43. 43. What is Critical Appraisal?    Critical Appraisal: The process of assessing and interpreting the evidence by systematically considering its validity, results and relevance to the area of work considered. It answers 3 important questions: How well is this study performed? What does it show? Can I use it?
  44. 44. Critically-Appraised Topic (CAT): What is a Critically Appraisal Topic? A standardized one-page summary of the evidence. It consists of a declarative title, clinical bottom line, the clinical question (PICO), search terms, a summary of the study methods, a table summarizing the key results and additional comments (Sackett).
  45. 45. What is the Best Evidence? Hierarchy of Levels of Evidence
  46. 46. Randomized Controlled Clinical Trial (RCT) What is a Randomised Controlled Trial? A group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables/outcomes of interest.
  47. 47. Prerequisites for successful Literature Searching  Know how to formulate your question.
  48. 48. Evidence-based Practice Ask clinical Acquire the questions best evidence Assess 5A’s !! Appraise effectiveness, efficiency of EBM process the evidence Apply evidence to Your patient
  49. 49. Evidence-based Practice Ask clinical questions PICO Ask: Refine ability to convert need for information (e.g., therapy, prevention, diagnosis, prognosis) into an answerable question. PICO format for foreground questions.
  50. 50. Ask clinical question
  51. 51. Ask Clinical Questions: PICO Components of Clinical Questions Patient/ Population Intervention/ Exposure Comparison Outcome does early treatment with a statin compared to placebo decrease cardiovascular mortality? In women with suspected coronary disease what is the accuracy of exercise ECHO compared to exercise ECG for diagnosing significant CAD? In postmenopausal women does hormone replacement therapy compared to no HRT increase the risk of breast cancer? In patients with acute MI
  52. 52. Prerequisites for successful Literature Searching  Know where to go.
  53. 53. Evidence-based Practice Acquire the best evidence Literature Search Acquire: Select “best evidence” resources to answer clinical questions using criteria of: Validity – Can I trust the evidence? Relevance – Does the evidence apply to my patient? Time efficiency – Can I get the evidence fast?
  54. 54. Types of Resources
  55. 55. Characteristics of a Good Resource
  56. 56. “Finding Evidence”: Sources  Primary: PubMed, EmBase, Cinahl, Pyschlit
  57. 57. Primary Resources
  58. 58. Primary Resources
  59. 59. “Finding Evidence”: Sources      Secondary: Systematic Reviews: Cochrane Library, PubMed Guidelines websites: Guidelines Clearinghouse, Guidelines International Network CATS: BestBets, ACP Journal Club Point of Care: Clinical Evidence, EvidencePlus, UpToDate etc
  60. 60. Secondary Resources
  61. 61. Secondary Resources
  62. 62. Secondary Resources
  63. 63. “Finding Evidence”: Sources  Tertiary resources (meta search engines, databases of databases):  TRIP+ (Translating Research Into Practice)  SumSearch
  64. 64. Tertiary Resources
  65. 65. Know what to do when you get there: the site’s technical language/know-how.
  66. 66. Resources For EBM Knowledge Translation EBM Hunting Tools EBM Resources Advanced EBM Skills Point of Care Clinical Resources Updates New Evidence Decision Support Systems Critical Appraisal Tools EvidenceBased Guidelines & Policies EvidenceBased Quality Improvement •DynaMed •Essential Evidence Plus •First Consult •UpToDate •Clinical Evidence •ACP PIERS •Mc Master Plus: STAT REF •BMJ Evidence Updates/Alerts •ACP Journal Club •Open Clinical •Dxplain •Emergency Medicine on the Web •Clinical Decision Making Calculators •EBM toolbox •CATmaker •Evidence based medicine toolkit •EBM Calculator •National Guidelines Clearinghouse • NHS Evidence • ICSI Institute for Clinical Systems Improvements •AHRQ •Institute for Healthcare Improvement •Knowledge Translation Clearinghouse •NICE
  67. 67. Types of Resources 1. 2. 3. 4. 5. 6. 7. 8. Point of Care Clinical Resources/Decision Support Systems Up-Dates & New Evidence Evidence-Based Guidelines, Policies and Protocols Evidence-Based Quality Improvement Critical Appraisal Tools EBM Audiovisual Training Innovations Exchange for New Ideas of Care Portals to All
  68. 68. Resources For EBM Literature Searching 1 2 3 4 • Point of Care Clinical Resources/Decision Support Systems • Up-Dates & New Evidence • Evidence-Based Guidelines, Policies Pathways and Protocols • Evidence-Based Quality Improvement
  69. 69. Resources For EBM Literature Searching 5 6 7 8 • Critical Appraisal Tools • EBM Audiovisual Training • Innovations Exchange for New Ideas of Care • Portals to All
  70. 70. 5S Information Resources: Information in top 4 are used Computerized Decision Support System (CDSS) Systems Evidence based textbooks : UpTo POCRaTs Summaries Date, DynaMed, ACP PIER, BMJ Clinical Evidence Evidence based journals Synopses EBM, EBN, EBMH, ACP J club Systematic Review Syntheses Cochrane reviews Original articles: BMJUpdates, PubMed Clinical Queries Studies 2009 NCKUFM-YCY Haynes, R. (2006, November). Of studies, syntheses, synopses, summaries, and systems: the 5S evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8-A9.
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