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Introduction to health informatics : Clinical questions

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  • Find the highest levels of evidence using PubMed Clinical Queries Find Randomized Controlled Trials in PubMedFind systematic reviews using the Cochrane Library database
  • http://www.hsl.unc.edu/services/tutorials/ebm/studies2.htmCase series and Case reports consist of collections of reports on the treatment of individual patients or a report on a single patient. Because they are reports of cases and use no control groups with which to compare outcomes, they have little statistical validity. Case control studies are studies in which patients who already have a specific condition are compared with people who do not have the condition. The researcher looks back to identify factors or exposures that might be associated with the illness.  They often rely on medical records and patient recall for data collection. These types of studies are often less reliable than randomized controlled trials and cohort studies because showing a statistical relationship does not mean than one factor necessarily caused the other. A case control study starts with patients who already have the outcome and looks backwards to possible exposures.Cohort studies take a large population who are already taking a particular treatment or have an exposure, follow them forward over time, and then compare them for outcomes with a similar group that has not been affected by the treatment or exposure being studied. Cohort studies are observational and not as reliable as randomized controlled studies, since the two groups may differ in ways other than in the variable under study.  A cohort study starts with the exposure and follows patients forward to an outcome.Randomized, controlled clinical trials are carefully planned projects that introduce a treatment or exposure to study its effect on real patients. They include methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control groups (no intervention).  A randomized controlled trial is an experiment and can provide sound evidence of cause and effect.  A RCT randomly assigns the exposures and then follows patients forward to an outcome.Systematic Reviews usually focus on a clinical topic and answer a specific question. An extensive literature search is conducted to identify studies with sound methodology. The studies are reviewed, assessed, and the results summarized according to the predetermined criteria of the review question. - A Meta-analysis will thoroughly examine a number of valid studies on a topic and combine the results using accepted statistical methodology to report the results as if it were one large study.  The Cochrane Collaboration has done a lot of work in the areas of systematic reviews and meta-analysis.A systematic review synthesises the results from all available studies in a particular area and provides a thorough analysis of the results, strengths and weaknesses of the collated studies. A systematic review has several qualities: 1. It addresses a focused, clearly formulated question. 2. It uses systematic and explicit methods: a. to identify, select and critically appraise relevant research b. to collect and analyse data from the studies that are included in the review Systematic reviews may or may not include a meta-analysis used to summarise and analyse the statistical results of included studies. The pyramid serves as a guideline to the hierarchy of study design. You may not always find the highest level of study to answer your question. In the absence of the best evidence, you then need to consider moving down the pyramid.
  • .  Look for secondary sourcesGuidelines: UK National Library for Health, NICE, SIGN; US National Guidelines Clearinghouse; Canadian Medical Association; New Zealand Guidelines Group.CATs: CAT CrawlerEvidence-Based Summaries:Bandolier, Clinical EvidenceStructured Abstracts: EBM Online, ACP Journal ClubSystematic Reviews: Cochrane LibraryTo search several of the databases simultaneously you can use:www.tripdatabase.com
  • How to use DynaMedLevel of Evidence Labeling in DynaMedGrading
  • Screening for bladder cancerSUMMARY AND RECOMMENDATIONSPatients with a history of treated urothelial carcinoma have a high likelihood of developing recurrent disease or a second primary. Surveillance is necessary in this setting to detect disease recurrence. The role of and approaches to surveillance are discussed separately. (See "Treatment of non-muscle-invasive bladder cancer", section on 'Posttreatment management'.Urine biomarkers — A wide range of urinary biomarkers are being evaluated for their utility in surveillance following initial treatment of non-muscle invasive bladder cancer.In the United States several of these urine tests (eg, bladder tumor antigen [BTA] Stat, BTA TRAK, UroVysion, nuclear matrix protein [NMP] 22) are approved for the detection of tumor recurrence. However, none of these tests has been proven to have sufficient diagnostic reliability to eliminate the need for cystoscopy. Major problems with these assays include the lack of sensitivity for small tumors, particularly low-grade lesions, as well as a large number of false positives.The data supporting the use of these assays and their potential role in bladder cancer surveillance are discussed elsewhere. (See "Urine biomarkers for the detection of urothelial (transitional cell) carcinoma of the bladder", section on 'Urine biomarkers'.
  • DARE (Database of Abstracts of Reviews of Effects) is focused primarily on systematic reviews that evaluate the effects of health care interventions and the delivery and organisation of health services.NHS EEDfocuses primarily on the economic evaluation of health care interventions and aims to help decision makers interpret an increasingly complex and technical literature.The focus of the HTA database is on completed and ongoing health technology assessments from around the world. The HTA database is a valuable source for identifying grey literature as much of the information it contains is generally only available directly from individual funding agencies.DARE contains 15,000 abstracts of systematic reviews including over 6,000 quality assessed reviews and details of all Cochrane reviews and protocols.Summaries of all Cochrane reviews and protocols The database is focused on systematic reviews of the effects of health interventions and includes reviews of: interventions that are clearly health related; interventions that have the potential to affect health; adverse effects; diagnostic and prognostic studies; individual patient data (IPD).NHS EED contains 24,000 abstracts of health economics papers including over 7,000 quality assessed economic evaluations. DARE and NHS EED include details of abstracts in the process of being written and these can be 'fast-tracked' on request.HTA brings together details of over 8,000 completed and ongoing health technology assessments from around the world.
  • Chitosanobese OR obesity OR overweight (show then obes*) weight loss= 20 articles+adult = losing 9 articles and some of them are releventUptodate = under Drug therapy of obesity = Chitosan [57] and guar gum are ineffective for weight loss, and their use should be discouraged.DynaMed = Weight loss nonprescription medications and supplements = chitosan may induce some weight loss short-term but effect minimal and unlikely to be of clinical significance (level 2 [mid-level] evidence)ACP PIER =  Obesity = A 4-week randomized clinical trial with chitosan showed no significant weight loss (571). Fecal fat loss was not increased by chitosan (572).Trip database = Chitosan for overweight or obesity
  • CRD = Centre for Reviews & Dissemination, University of York, York, UKDARE contains 15,000 abstracts of systematic reviews including over 6,000 quality assessed reviews and details of all Cochrane reviews and protocols.Summaries of all Cochrane reviews and protocols The database is focused on systematic reviews of the effects of health interventions and includes reviews of: interventions that are clearly health related; interventions that have the potential to affect health; adverse effects; diagnostic and prognostic studies; individual patient data (IPD).NHS EED contains 24,000 abstracts of health economics papers including over 7,000 quality assessed economic evaluations. DARE and NHS EED include details of abstracts in the process of being written and these can be 'fast-tracked' on request.HTA brings together details of over 8,000 completed and ongoing health technology assessments from around the world.
  • ACID SUPPRESSION
  • Chitosanobese OR obesity OR overweight (show then obes*) weight loss= 20 articles+adult = losing 9 articles and some of them are releventUptodate = under Drug therapy of obesity = Chitosan [57] and guar gum are ineffective for weight loss, and their use should be discouraged.DynaMed = Weight loss nonprescription medications and supplements = chitosan may induce some weight loss short-term but effect minimal and unlikely to be of clinical significance (level 2 [mid-level] evidence)ACP PIER =  Obesity = A 4-week randomized clinical trial with chitosan showed no significant weight loss (571). Fecal fat loss was not increased by chitosan (572).Trip database = Chitosan for overweight or obesity
  • ACID SUPPRESSION
  • Monographs include: drug interactions; adverse reactions; cautions and toxicity; therapeutic perspective; specific dosage and administration information; preparations, chemistry, and stability; pharmacology and pharmacokinetics; contraindications; and more.Compendium of Pharmaceuticals and Specialties (e-CPS) - Produced by the Canadian Pharmacists Association, the e-CPS provides health care professionals with web access to the most current Canadian drug information. Please note: online access is by user name and password.
  • http://blogs.trusttheevidence.net/carl-heneghan/autism-and-brain-scan-test-the-real-predictive-value/100811105
  • Transcript

    • 1. INTRODUCTION TO HEALTH INFORMATICS : Strategies for Answering Clinical Questions
      Nazi Torabi
      Research & Instructional Librarian
      Allyn & Betty Taylor Library
      April 14, 2011
      http://www.slideshare.net/ntorabi/
      1
    • 2. Objectives
      Addressing yourclinical information needs within an Evidence Based Medicine (EBM) framework
      To familiarize you with a variety of point-of-care tools
      2
    • 3. 3
    • 4. Evidence Based Medicine (EBM)
      “EBM is integration of best research evidence with clinical expertise and patient values”
      Sackett et al. 2000. Evidence based medicine. How to practice and teach EBM. Second edition. Churchill Livingstone. London
      4
    • 5. Steps in EBM
      Asking clinical questions
      Acquiring the evidence
      Appraising the evidence
      Applying the evidence
      Evaluating the effectiveness of applying the evidence in clinical practice
      5
    • 6. Asking clinical a question (Review)
      Research Question (PICO)
      • Patient or Population
      • 7. Intervention; Prognostic Factor; Exposure
      • 8. Comparison
      • 9. Outcome
      • 10. Type of Question
      • 11. Type of Study
      6
    • 12. Level of Evidence
      7
    • 13. Filtered Information
      Unfiltered Information
      8
    • 14. Acquiring the Evidence
      9
    • 15.
      • Cochrane Database of Systematic Reviews
      • 16. Cochrane Central Register of Controlled Trials (CCTR)
      • 17. ACP Journal Club
      • 18. PubMed (MEDLINE)
      • 19. Trip
      • 20. Up To Date
      • 21. DynaMed
      • 22. DARE
      Filtered Information
      Unfiltered Information
      Trip searches for all
      10
    • 27. DynaMed
      Covers over 1,800 clinical topic summaries
      Point of care tool
      Updated daily
      Recommendations will be labeled as one of the following:
      Grade A recommendation (consistent high-quality evidence)
      Grade B recommendation (inconsistent or limited evidence)
      Grade C recommendation (lacking direct evidence)
      More info : http://support.ebscohost.com/help/index.php?help_id=271
      11
    • 28. UpToDate
      covers over 8500 topics in 17 medical specialties
      Summaries are a combination of synthesized literature reviews and expert knowledge.
      Point of care tool
      Grade 1 recommendation is a strong recommendation to do (or not do) something
      Grade 2 recommendation is a weaker recommendation, where the risks and benefits are more closely balanced or are more uncertain.
      For more info : http://www.uptodate.com/home/about/policies/editorial_policy.html#recommendations
      12
    • 29. ACP PIER
      PIER is a collection of over 400 evidence summaries
      Frequently updated (Monthly Content Updates and Module Additions)
      Consistently structured for rapid access
      Search or browse by organ system
      Integrated drug reference (AHFS DI Essentials)
      13
    • 30. The TRIP Database is free unified search tool of evidence-based sites such as ACP Journal Club, Bandolier, Cochrane, DARE, Health Technology Assessment, and the National Guideline Clearing House. TRIP is produced by the Centre for Research Support in the UK.
      14
    • 31. Centre for Reviews & Dissemination (CRD)
      DARE (Database of Abstracts of Reviews of Effects)
      NHS EED (NHS Economic Evaluation Database)
      HTA Database
      15
    • 32. Scenario 1:
      A 64 year old obese male who has tried many ways to lose weight presents with a newspaper article about ‘fat-blazer’ (chitosan). He asks for your advice.
      Adapted from : http://www.cebm.net/index.aspx?o=2311
      16
    • 33.
      • Formulate a well-built clinical question
      • 34. Search the following resources
      • 35. Share your answer(s) and search strategies with the class
      PubMed
      Scopus
      UpToDate
      Cochrane Library
      CRD = Centre for Reviews & Dissemination
      DynaMed
      ACP PIER
      EMBASE
      Trip database
      CRD = Centre for Reviews & Dissemination
      Group A
      GroupB
      17
    • 36. Your patient is a 50 year old male with non-variceal upper GI bleed and you need to lower his stomach acidity. Should you use PPIs or H2 receptor antagonists?
      Scenario 2:
      Modified from http://ebmlibrarian.wetpaint.com/page/Gastroenterology
      18
    • 37.
      • Formulate a well-built clinical question
      • 38. Search the following resources
      • 39. Share your answer(s) and search strategies with the class
      PubMed
      Scopus
      UpToDate
      Cochrane Library
      CRD = Centre for Reviews & Dissemination
      DynaMed
      ACP PIER
      EMBASE
      Trip database
      CRD = Centre for Reviews & Dissemination
      Group C
      Group D
      19
    • 40. Scenario 1:
      Clinical Question : Is Chitosan consumption an effective intervention for weight loss in obese adult individuals?
      Adapted from : http://www.cebm.net/index.aspx?o=2311
      20
    • 41. Clinical Question: In patients with non-variceal upper GI bleeds, are proton pump inhibitors more effective than H2 receptor antagonists in the reduction of stomach acid?
      Scenario 2:
      21
    • 42. EBM Resources Comparison Chart
      From Duke Program on Teaching Evidence-Based Practice http://www.mclibrary.duke.edu/training/courses/ebmworkshop/ebmchart.pdf
      22
    • 43. For more visit http://www.lib.uwo.ca/programs/generalmedicine/ under Clinical Tools
      23
      Drug Resources
    • 44. Scenario 1
      1 - What type of Iron supplement do you prescribe for a pregnant woman who has been diagnosed for with primary hypercholesterolemia and is taking cholestyramine?
      24
      You need to use more than one resource to find the accurate answer!!
    • 45. 2 - Your patient, suffering from tuberculosis, is asking you whether he can drink alcohol while he is taking Isotamine. What is the right answer?
      3- Do you recommend consumption of alcohol while a patient is on Mylan-Amoxicillin?
      Scenario 2 & 3
      25
    • 46. 4 - You want to prescribe Zoloft for a moderate depressed patient who does not have any psychotic symptoms. What do you need to know about Zoloft?
      Scenario 4
      26
    • 47. Appraising the evidence
      Aug 10, 2010
      http://www.guardian.co.uk/science/2010/aug/10/autism-brain-scan
      Aug 12, 2010
      http://www.guardian.co.uk/science/blog/2010/aug/12/autism-brain-scan-statistics
      27
    • 48. Mobile Devices
      http://www.lib.uwo.ca/programs/clinicaloutreach/guidetohandhelddevices.html
      28
    • 49. Questions
      Need library related assistance?Please don’t hesitate to contact us:
      Nazi Torabi
      519-661-2111 x88992
      ntorabi@uwo.ca
      IM a librarian
      https://www.lib.uwo.ca/chat/
      29