From a presentation to McGill's School of Information Studies course on Health Sciences Information

1. Evidence Based Practice&Health Sciences Librarianship Lorie KlodaMLIS, PhD candidate, School of Information Studies Associate Librarian, Life Science Library October 6, 2010 Health Sciences Information GLIS-671 McGill University http://www.slideshare.net/lkloda

2. Objectives Definition and evolution of EBP EBP process Question framing Levels of evidence Critical appraisal and grading Sources of evidence Systematic reviews Role of the librarian 2

3. Definition & History of EBM Evidence-based medicine (EBM) “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. BMJ, 312, 71-72. (p.71) “…a new paradigm for medical practice is emerging.” Evidence-Based Medicine Working Group (1992). Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA: The Journal of the American Medical Association, 268, 2420-2425. (p. 2420) 3

4. Definition of EBMComponents 4

5. Definition of EBPThe Sicily Statement “Evidence-based practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources.” Dawes, M., Summerskill, W., Glasziou, P., Cartabellotta, A., Martin, J., Hopayian, K. et al. (2005). Sicily statement on evidence-based practice. BMC Medical Education, 5. 5

6. EBP Process 6

7. Question Framingor, Asking Answerable Questions Patient, population, or problem Intervention, prognostic factor, or exposure Comparison Outcomes to measure or be achieved 7 Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. (1995). The well-built clinical question: A key to evidence-based decisions. ACP Journal Club, 123(3), A12-3.

8. 8 PICO Problem/Person Intervention Comparison Outcome (Richardson, Wilson, Nishikawa, & Hayward, 1995) PESICO Person Environment Stakeholders Intervention Comparison Outcome (Schlosser, Koul, & Costello, 2007) PICO + Problem/Person Client’s setting Client’s values Intervention Comparison Outcome (Bennett & Bennett, 2000) Framing Clinical Questions

9. 9 PICO Problem/Person Intervention Comparison Outcome (Richardson, Wilson, Nishikawa, & Hayward, 1995) ECLIPSE Expectation Client group Location Impact Professionals Service (Wildridge & Bell, 2002) COPES Client type & problem What you might do Alternate course of action What you want to accomplish (Gibbs, 2003) Framing Clinical Questions

10. Question FramingExercise 1 As part of your nursing practice, infants and children with fever are often given tepid baths to lower their temperature. A parent asks you whether or not this actually makes a difference in reducing the child’s fever. You decide to look at the literature to substantiate the intervention. 10

11. Levels of EvidenceEvidence Hierarchy 11 (SUNY Downstate Medical Center, Medical Research Library of Brooklyn, n.d.)

12. Question FramingQuestion & Study Types (Quantitative) 12

13. Question FramingQuestion & Study Designs (Qualitative) 13 Gibson, B. E. & Martin, D. K. (2003). Qualitative research and evidence-based physiotherapy practice. Physiotherapy, 89, 350-358.

14. Levels of Evidencefor Question of Therapy 14 Levels of evidence (2001). Centre for Evidence Based Medicine. Retrieved 26 Aug 2008 from http://www.cebm.net/index.aspx?o=1025

15. Question FramingExercise 2 You have recently begun working as a physical therapist in a rehabilitation centre. Your most recent patient is an 8-year-old girl with spastic cerebral palsy. Her parents heard that a weight-bearing physical activity program may be beneficial. You decide to search the literature for evidence to substantiate the claim. 15

16. Question FramingExercise 3 As a nurse in a primary health care practice, you see many adult patients with asthma. The primary health care team wants to discuss strategies to improve care for these patients. They are particularly interested in whether both regular review by a health practitioner and patient education should be continued or whether giving patients written materials is just as effective. You offer to search the literature on the topic and report back at the next team meeting. 16

17. Question FramingExercise 4 You are a public health nurse who has been visiting an elderly man with Alzheimer’s disease who is living at home. His daughter is his primary caregiver. As his condition deteriorates, she is increasingly worried about his safety and finds the situation physically and emotionally draining. The daughter is experiencing anguish and guilt as she realizes that her father will soon need to be placed in a special care unit. She asks you whether others in this situation have similar feelings and what she can expect to fell once he is placed in the special care unit. 17

18. Question FramingExercise 5 Your first new patient in general medicine clinic is a 68 year old male who comes in for a routine physical examination. You find that he is hypertensive and decide to prescribe nifedipine, (a calcium antagonist) to control his high blood pressure. The patient discovers that nifedipine is a calcium channel blocker and remembers that there was something in the news several years ago about this group of drugs causing cancer. He calls you and wants to know if these drugs can cause cancer. 18

19. Question FramingExercise 6 You are working in an urban community hospital. The head of the infectious disease department and the community outreach officer are trying to set up a pilot program to improve the screening and counseling process for identifying and helping AIDS infected people within the community. One of the problems is that the results of the standard test for AIDS, which are very accurate, are not available for up to three weeks. You have read about a new rapid assay test that provides results within ten minutes. You wonder if this test is as accurate. 19

20. Research on Clinical Questions 20 Few physicians' clinical questions followed the recommended PICO structure for EBP Using an EBM-structured form results in more precise searching by librarians. Allowing a free form question good for eliciting details that might enhance retrieval relevance (e.g., context) Huang, X., Lin, J. & Demner-Fushman, D. (2006). Evaluation of PICO as a knowledge representation for clinical questions. In Proceeding of the 2006 Annual Symposium of the American Medical Informatics Association (AMIA 2006), pp. 359-363, Washington, D.C. Booth, A., O'Rourke, A. J. & Ford, N. J. (2000). Structuring the pre-search reference interview: A useful technique for handling clinical questions. Bulletin of the Medical Library Association, 88 (3):239-246.

21. Sources of EvidenceThe 5S Model Haynes, B. (2006). Of studies, syntheses, synopses, summaries, and systems: The "5S" evolution of information services for evidence-based health care decisions. ACP Journal Club, 145,A8-A10. 21

23. JAMA Users’ Guides to the Medical Literature (medicine)

24. PEDro scale (physical & occupational therapy) Determining clinical significance 22

25. Searching & Screening the Literature for Systematic Reviews

26. Systematic Reviews 24 “…reviews of a clearly formulated question that use explicit methods to identify, select, and critically appraise relevant research and to collect and analyse data from the studies that are included in the review.” Cochrane Collaboration

27. From: Wong R. (2003). Systematic reviews and the Cochrane Collaboration. Oncology Rounds, 5(10). [Available from www.oncologyrounds.ca].

28. Knowledge Syntheses 26 Systematic review Meta analysis Scoping review Evidence mapping Mixed methods synthesis Meta-synthesis approaches Realist synthesis approaches Rapid evidence assessment

29. Cochrane Reviews 27 Electronic retrieval of health information by healthcare providers to improve practice and patient care Motivational interviewing for smoking cessation

30. Steps in a Systematic Review Define the clinical question (PICO) Identify all relevant research (published and unpublished) Select studies for inclusion Assess the quality of each study Synthesize the findings (meta-analysis or meta-synthesis, if possible) Interpret the findings and present an unbiased summary 28 McGowan, J. & Sampson, M. (2005). Systematic reviews need systematic searchers. Journal of the Medical Library Association, 93(1), 74-80.

31. Steps in a Comprehensive Literature Search 29 Database /trial registry searches Grey literature search Hand searches Conference proceedings Major journals Bibliographies Citation searches “Related citations” Snowball searches (Reference harvesting) Review papers All included studies Contact researchers Initial searches Supplemental searches

32. 30 “Conducting a comprehensive, objective and reproducible search for studies can be the most time consuming and challenging task in preparing a systematic review.” Higgins, J. P. T. & Green, S. (eds.) (2009). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2. The Cochrane Collaboration. Available from www.cochrane-handbook.org.

33. Selection of Sources 31 Databases Several required (+ clinicial trial registries) Unpublished trials contribute ~20% of the weight in meta-analysis Fries, J. F., & Krishnan, E. (2004). Equipoise, design bias, and randomized controlled trials: The elusive ethics of drug development. Arthritis Research Therapy, 6, R250-R255. Grey literature “unpublished,” fugitive,” “in-house,” “non-commercial” Definition/distinction not important; as long as it’s relevant, it should be included Reduces publication bias Hopewell, S., McDonald, S., Clarke, M. J., & Egger, M. Grey literature in meta-analyses of randomized trials of health care interventions. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: MR000010. doi:10.1002/14651858.MR000010.pub3

34. Search Strategy Development 32 Keywords (natural language) Truncation, synonyms, alternative spelling Subject Headings Explode Limitations Languages, date, publication type Boolean (logical operators), Field searching Title, abstract Hedges (optimal search strategies; filters) Peer review McGowan, J., Sampson, M. & Lefebvre, C. (2010). An evidence based checklist for the peer review of electronic search strategies (PRESS EBC). Evidence Based Library and Information Practice 5 (1),149-154.

35. 33 “Terms within social sciences are often ambiguous, poorly defined and constantly changing. Unfortunately, the use of controlled vocabularies and indexing is not applied across the social sciences databases with the same rigour as in medical databases.” Papaioannou, D., Sutton, A., Carroll, C., Booth, A. & Wong, R. (2010). Literature searching for social science systematic reviews: Consideration of a range of search techniques. Health Information and Libraries Journal, 27(2),114-122.

37. Who developed and conducted the search

38. Supplementary methods: hand searches, citation searches, snowball searches, contacting known researchers

39. Full electronic search strategy for at least one database, such that it can be repeated

40. Use of hedges or any peer reviewed search strategies

41. Additional limitationsMoher. D., Liberati, A., Tetzlaff, J., Altman, D.G., & The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine 6(6), e1000097. doi:10.1371/journal.pmed1000097

42. Health Sciences Librarians & EBP What roles can the health sciences librarian play in teaching and promoting EBP? To fulfill these roles, what skills do we need? 35