Evidence-Based Medicine plays an important part in the medical world today. Although I am not an expert in this area, based on my readings of Cochrane I ‘d like to mention the LOEs etc during our presentation. I think its important to understand the origins of why TCL including the dedicated members of this global organization. This is also helpful to know to better understand more about the process of developing relevant, current systematic reviews and protocols. TCL was developed and the strong influence this powerful resource is having in the field of healthcare today. I also like to note a few of the details that make TCL a valid minimally biased resource to professionals such as trials and metadata analysis, etc. During the live demo you will see how user friendly WIS for users of TCL. We have received positive feedback on how simple it is to navigate so users can focus on finding information and not the platform functionality.
The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. “ Good” doctors use both individual clinical expertise and the best available external evidence , and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable e to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients. Evidence-based medicine (EBM) is an important change in the way physicians practice, teach, and do research. It was initially proposed by Dr. David Sackett and colleagues at McMasters University in Ontario, Canada. Go to cebm.net site to show the LOEs and the chart, tutorials for users as a point of reference on this topic. Sackett realizes that evidence alone is not sufficient for the compassionate, effective care of patients. He stresses that the practice of EBM requires that it be integrated with clinical expertise, which brings the following important elements: expertise in performing the history and physical examination knowledge of the patient, the family, and the community which creates a context for therapeutic decision-making a relationship with the patient informed by his or her beliefs and values practical knowledge of the availability of resources in the community Information Mastery To be useful, medical information should be relevant to everyday practice, correct (valid) and easy to obtain . Slawson and Shaughnessy describe a formula which relates these three factors in a &quot;Usefulness equation&quot;:
epidemology: a branch of medical science that deals with the incidence, distribution, and control of disease in a population 2 : the sum of the factors controlling the presence or absence of a disease or pathogen The Cochrane Collaboration was based on Archie Cochrane’s pioneering work in pregnancy and childbirth. In 1987, the year before he died he referred to a systematic review of randomized controlled trials of care during pregnancy and childbirth as a “real milestone in the history of randomized trials and the evaluation of care”. The model he used in pregnancy and childbirth to access trial data and write systematic reviews was formally incorporated in the Cochrane Collaboration in 1992. Go to
Collaborative Review Groups (51) are made up of people who prepare, maintain and update Cochrane Reviews, and people who support them in this process. Each Group has an 'editorial base' where a small team of people supports the production of Cochrane Reviews. These Groups focus on particular areas of health (for example, Breast Cancer, Infectious Diseases, Multiple Sclerosis, Schizophrenia, Tobacco Addiction). Cochrane Centres(11) (some of which have additional branches) support people in their geographic and linguistic area. Dependent on available resources, some Centres are able to provide training, help with translations, networking, etc. Newcomers are encouraged to contact their local Cochrane Centre for information about The Cochrane Collaboration; this can save a lot of time and effort. Methods Groups (12) are made up of people who develop the methodology of Cochrane Reviews. Networks (11)(some are called ' Fields ') Fields/Networks emerge around areas of interest which extend across a number of health problems. For example, a field coordinator in child health would identify health issues of importance to children and facilitate reviews across the relevant review groups in the interests of this population. The Consumer Network provides information and a forum for networking among consumers (mostly patients), and a liaison point for consumer groups around the world. If you interested in learning more about these entities, The Cochrane Manual contains detailed descriptions of the responsibilities of each of these groups of people ('entities'). Cochrane entities receive their funding from different sources, but agree to follow the policies and practices of The Cochrane Collaboration (also contained in The Cochrane Manual). 11500 collaborators (97% voluntary) >8000 are authors of Cochrane Reviews > 90 countries represented 51 Collaborative Review Groups 11 Fields (or Networks) 12 Cochrane Centres 11 Methods Groups
The Cochrane Library is a collection of databases that contain high-quality, independent evidence to inform healthcare decision-making. It is considered the “gold-standard” as a resource for healthcare professionals worldwide
In this module, I will briefly provide information on the content of each database, as well as definitions used by the collaboration to define A systematic review and protocols as well as the importance of the other databases included in this valued resource.
Trainer note during this slide: It is good to emphasize the six databases-- as most newcomers to Cochrane assume its one large database. You may also wish to note that using Cochrane through Ovid only provides access to three of the six. There is also useful information in the About Us section about the Collaboration. You may wish to show this during your demo module
Answers a specific healthcare question. Aims to identify and include all relevant trials. Uses pre-planned methods and strategies to limit bias and random error. May include META-ANALYSIS : statistical synthesis of the results of included studies. Helps practitioners and patients make decisions about appropriate health care interventions and treatments.
If there are new comers to cochrane, the objective is to explain the importance of what it means to read a systematic review versus other reviews they may find on the web. You can also really note through this slide what is included in a solid Cochrane review – such as the fact they are including published and unpublished studies, and RCTs to develop the full text or abstract information. Systematic reviews differ from other types of review in that they adhere to a strict design in order to make them more comprehensive, thus minimizing the chance of bias, and ensuring their reliability. Rather than reflecting the views of the authors, or being based on a partial selection of the literature, (as is the case with many articles and reviews that are not explicitly systematic), they contain all known references to trials on a particular intervention and a comprehensive summary of the available evidence. The reviews are therefore also valuable sources of information for those receiving care, as well as for decision makers and researchers
Collaborators around the world are hand searching health care journals and conference proceedings. Why? The aims of The Cochrane Collaboration are &quot;preparing, maintaining and disseminating systematic reviews of the effects of health care&quot;. Before one can prepare a systematic review, one has to find the relevant research reports; in the case of The Cochrane Collaboration, this usually means reports of randomized clinical trials. This can be surprisingly difficult. Cochrane review authors rely on several means of searching for relevant reports, including both electronic and manual methods. For complete identification of published reports, there appears to be no alternative to a page-by-page search of the literature. Hundreds of journals have been or are being hand searched by members of The Cochrane Collaboration, some journals by as few as one and others by as many as 32 individual searchers. As of this writing, an estimated 1,000 searchers are contributing to this effort, by searching for and cataloguing trials from more than 2,000 journals. As more trials are identified, it will be possible to prepare, maintain and disseminate increasing numbers of systematic reviews
A statistical technique for assembling the results of several studies in a review into a single numerical estimate: identifies a common effect among a set of studies improves precision of an estimate investigates whether the effect is constant answers controversies arising from conflicting studies or generates new hypotheses
This is an over-implied example of the trial process. We can’t make a solid diagnosis by looking at one trial we need to conduct the trial over a number of times. Number Needed to Treat (NNT) the number of patients who need to be treated to prevent one bad outcome. The NNT is a useful number when you want to compare the costs and adverse effects of a treatment with its benefits.
Odds Ratio describes the odds of an experimental patient suffering an adverse event relative to a control patient. P Value refers to the probability that any particular outcome would have arisen by chance. (The smaller the P value the less likely the data was by chance.) Standard scientific practice, usually deems a P value of less than 1 in 20 (expressed as P=.05) as &quot;statistically significant&quot;. The smaller the P value the higher the significance. A P value of P=.01 ( less than 1 in 100) is considered &quot;statistically highly significant&quot;. Predictive Value of tests: In screening and diagnostic tests, the probability that a person with a positive test is a true positive (i.e., has the disease), is referred to as the positive Predictive Value; whereas, the Negative Predictive Value is the probability that the person with a negative test does not have the disease. Predictive value is related to the sensitivity and specificity of the test. Relative Risk is the risk of developing a disease in the exposed group divided by the risk of developing the disease in the unexposed group. Relative Risk Reduction is the proportional difference between the rates of events in the control group and the intervention group. Relative Risk Reduction is usually a larger number than the Absolute Risk Difference and therefore tends to exaggerate the difference. Sensitivity measures the proportion of patients with the disease who also test positive for the disease.
MeSH includes both an alphabetical and hierarchical listing of related sets that allow you to browse lists for specific terms.
Use ophthalmologist or cardiologist as an example of how they could search basic terms written in a systematic review.
Brief explanation of Boolean Logic if needed. Go back to advanced search and do these, walk thru a review including reference linking.
End by clicking the “Customer Care Training Centre” link to display up to date calendar for other more specific training sessions…
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Please call the following number: <ul><li>Step 1 </li></ul><ul><li>UK/Northern Ireland: 0800 358 2705 freephone </li></ul><ul><li>Republic of Ireland: 1800 944 607 freephone </li></ul><ul><li>Portugal: 800 780 196 </li></ul><ul><li>Denmark: 808 832 64 </li></ul><ul><li>Russia: 810 800 271 83011 </li></ul><ul><li>All other international: +44 20 8609 0205 </li></ul><ul><li>Step 2 </li></ul><ul><li>Then enter the pincode: 365126# </li></ul>The course will begin shortly…
Presentation Agenda <ul><li>Brief introduction of Evidence-Based Medicine theories </li></ul><ul><li>The Cochrane Collaboration – origins, members and aim </li></ul><ul><li>The Cochrane Library Databases – content of each database </li></ul><ul><li>Search Tips: Using MeSH and Advanced Keywords </li></ul><ul><li>Live Demonstration: www.thecochranelibrary.com </li></ul>
Evidence-Based Medicine “ The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” www.cebm.net Centre for Evidence-based Medicine
Cochrane Reviews are now the “gold standard” for systematic reviews in such key publications as The Lancet , New England Journal of Medicine , British Medical Journal , and the Journal of the American Medical Association and routinely appear there as well as in specialised medical journals for various specialty areas.
FOUNDER OF THE COCHRANE COLLABORATION The Cochrane Collaboration is named in honour of Archie Cochrane , a British medical researcher who contributed greatly to the development of epidemiology as a science. He is best know for his influential book, Effectiveness and Efficiency: Random Reflections on Health Services , published in 1972.
THE COCHRANE COLLABORATION Wiley publishes The Cochrane Library for The Cochrane Collaboration <ul><li>Structure - established as an international organisation in 1993, registered as a charity in the UK </li></ul><ul><li>Aim - to help people make well-informed decisions about health care </li></ul><ul><li>How - by preparing and maintaining, and promoting access to, systematic reviews of the effects of healthcare interventions </li></ul><ul><li>Publishing Output – The Cochrane Library </li></ul>
National Provisions to the Cochrane Library Bireme Denmark Australia New Zealand India South Africa UK Ireland +HINARI+ Norway Sweden Finland Poland Various provinces Wyoming Turkey
Who is involved in The Cochrane Collaboration? The members of The Cochrane Collaboration are organised into groups, known as entities , of which there are five different types: Collaborative Review Groups Cochrane Centres Method Groups Networks or ‘Fields’ Cochrane Consumer
WHAT IS THE COCHRANE LIBRARY? The Cochrane Library is the single most reliable source for evidence on the effects of health care.
<ul><li>The Cochrane Database of Systematic Reviews (Cochrane Reviews) </li></ul><ul><li>The Cochrane Database of Reviews of Effects (Other reviews) </li></ul><ul><li>The Cochrane Central Register of Controlled Trials (Clinical trials) </li></ul><ul><li>Health Technology Assessment Database (Technology Assessments) </li></ul><ul><li>NHS Economic Evaluation Database (Economic Evaluations) </li></ul><ul><li>Methodology Register (Methods Studies) </li></ul><ul><li>About The Cochrane Collaboration and the Cochrane Collaborative Review Groups </li></ul>The Cochrane Library is a collection of 6 main databases and 1 additional database that describes Cochrane as an organization. These are:
What is a systematic review? A systematic review identifies an intervention for a specific disease or other problem in health care, and determines whether or not this intervention works 4,152 now online
What is a Protocol? <ul><li>the plan or set of steps to be followed in a study </li></ul><ul><li>should describe the rationale for the review, the objectives, and the methods that will be used to locate, select, and critically appraise studies, and to collect and analyse data from the included studies </li></ul>1,924 now online
What to consider when reading reviews: Do the studies address a sensible clinical question? Do the studies possess high quality designs and methods? Are the results from the studies similar or widely different? Are the conclusions drawn consistent with the method employed? Are all relevant and important outcomes considered? How do the results apply to the care of my patients?
Systematic Reviews and Protocols Process Members include: Trial Search Coordinators Hand-Searchers, Clinicians, Librarians and Statisticians Register title Prepare protocol (3 months to one year) Prepare review (updated quarterly) (one to five years) The Cochrane Library Cochrane Review Group
Meta-Data Analysis <ul><li>a statistical technique for assembling the results of several studies in a review into a single numerical estimate </li></ul>Systematic Review Meta-Data Analysis
10 10 10 10 10 One trial - i.e. 7 /30 people favored one treatment vs. another Trials is conducted several times We will evaluate similar reactions – within each trial to determine an overall estimate *NNT *Number Needed to Treat Number of patients who need to be treated to prevent one bad outcome.
Other Resources: <ul><li>Cochrane Database of Reviews of Effect </li></ul><ul><li>(Other reviews) </li></ul><ul><li>11,000 + records </li></ul><ul><li>Contains critical assessments and and structured abstracts of reviews </li></ul><ul><li>Must meet minimum quality criteria </li></ul><ul><li>Covers topics yet to be covered in CDSR </li></ul><ul><li>For Cochrane reviewers and researchers wanting information on reviews of healthcare effects from sources outside The Cochrane Library </li></ul><ul><li>Cochrane Central Register of Controlled Trials </li></ul><ul><li>(Clinical trials) </li></ul><ul><li>600,000 + records </li></ul><ul><li>Contains a register of studies which may be relevant for inclusion in Cochrane reviews </li></ul><ul><li>World’s largest database of randomized controlled trials </li></ul><ul><li>For Cochrane reviewers needing to identify studies for a Cochrane review and researchers wishing to identify studies in different medical disciplines </li></ul>
<ul><li>Health Technology Assessment Database </li></ul><ul><li>(Technology Assessments) </li></ul><ul><li>7,500 + records </li></ul><ul><li>Contains information on healthcare technology assessments, including details of ongoing projects and completed publications from health technology assessment organisations </li></ul><ul><li>Cochrane Methodology Register </li></ul><ul><li>(Methods Studies) </li></ul><ul><li>12,000 + records </li></ul><ul><li>A bibliography of publications that reports on methods used in the conduct of controlled trials. Including journal articles, books and conference proceedings - these articles are taken from the MEDLINE database and from hand searches . </li></ul>Other Resources:
<ul><li>NHS Economic Evaluation </li></ul><ul><li>Database </li></ul><ul><li>(Economic Evaluations) </li></ul><ul><li>27,000 + records </li></ul><ul><li>Contains structured abstracts of articles describing economic evaluations of health care interventions. </li></ul><ul><li>Articles are identified by searching key medical journals, bibliographic databases and less widely available literature. </li></ul><ul><li>Papers are included if they provide a comparison of treatments and examine both the costs and outcomes of the alternatives. </li></ul>Other Resources:
The Medical Subject Heading (MeSH) search is based on the National Library of Medicine's controlled vocabulary thesaurus of medical subject headings. http://www.nlm.nih.gov/mesh/introduction2004.html What is MeSH?
MeSH Tree Structure Each Descriptor has a tree number that positions the term in the hierarchy. Eye [A01.456.505.420] Eyebrows [A01.456.505.420.338] Eyelids [A01.456.505.420.504] Eyelashes [A01.456.505.420.504.421.] Remember when search MeSH – some terms have MULTIPLE tree numbers because they appear in more than one place in the hierarchy! For example: nose may be under face OR respiratory or sensory
Advanced Search: Using Keywords <ul><li>Boolean logic tips: </li></ul><ul><li>Diabetes AND pregnancy – you want records specifically about diabetes in pregnant women. Both terms must appear in every record. </li></ul><ul><li>Adolescent OR teenager – you want records relating to either adolescents or teenagers. It doesn’t matter which term appears in the record. </li></ul><ul><li>Vaccine NOT MMR – you are interested in vaccines, but want to exclude records about the MMR. Records mentioning the MMR will not appear in your results. </li></ul>
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