part 1 introduction to evidence-based medicine literature searching
TRANSCRIPT
Introduction to EBM Resources
Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS
Consultant Physician & PulmonologistChairman, Knowledge Translation Committee
Department of Medicine KAMCRiyadh
Kingdom of Saudi [email protected]
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
EBP!
The Patient
ClinicalExpertis
e
BestEvidenc
e
3Clinically relevant research, the literature
Practitioner’s knowledge& experience
Patient’s characteristics, preferences & values
Three Pronged Approach
3
Integrates Evidence With Clinical expertise
Experience
Judgment
Patient values and preferences
Quality of life
Costs
Other important factors
Best Available Evidence
Clinical Expertise
Patient Values and Preferences
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, and having found a
likely source of information appraising the
paper for its scientific validity and then
applying the result to your problem.
Evidence-based Practice
Ask clinical Questions
Acquire the best evidence
Appraise the evidence
Applyevidence to your patient
5A’s !!Assess
effectiveness, efficiency of EBM
process
Evidence-based Practice
Ask clinical Questions: PICO
Acquire the best evidence:
Literature Searching
Appraise the evidence:
Critical Appraisal
Applyevidence to your patient:
Knowledge Translation(Implementation)
5A’s !!Assess
effectiveness, efficiency of EBM
process
Self-Education & Training in EBM EBM Resources:
http://guides.mclibrary.duke.edu/content.php?pid=274373&sid=2262393
http://www.med.yale.edu/library/education/guides/feature/finditfast
CEBM Website: http://www.youtube.com/user/cebmed, http://www.cebm.net/index.aspx?o=1965
YouTube: http://www.youtube.com/watch?v=odfo9CQGi0c
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.
Rule 31 – Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
0
500000
1000000
1500000
2000000
2500000
Trials MEDLINE BioMedical
Med
ical
Art
icle
s pe
r Yea
r
5,000?per day
1,400 per day
55 per day
The Decline in Knowledge and Patient Outcomes
Competency in Literature Searching for Professionals Dealing with the daily “challenge” to one’s
knowledge. Life-long learning. Evidence-based practice Valuable employee.
For Whom?
Chairman Nursing ManagerResident
Clinical DirectorQuality
Nurse
Competency in Literature Searching: For Whom? Healthcare Professionals IncludingPolicymakers etc Patients!
Competency in Literature Searching for Patients For successful incorporation of:
1. Values and Preferences 2. Patient-centered Care
The 6 Prerequisites for successful Literature Searching
1 •Know how to use a computer/electronic device.
2 •Know the Internet Jargon of Terms.
3 •Know the EBM Jargon of Terms.
4 •Know how to formulate your question.
5 •Know where to go.
6 •Know what to do when you get there: the site’s technical language/know-how.
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? What is a Database? What is a Search Engine? What is a Meta-search Engine?
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
What is a Database?
• A Database is an organized collection of information records that can be accessed electronically e.g. Medline (Pubmed), Cochrane etc
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
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.
“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-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
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.
Background versus Foreground Information Case discussion: 27 year old woman with right lower
quadrant (RLQ) abdominal pain Background information available from textbooks-
What typically presents as RLQ pain What is the clinical course/complications of the different
diagnoses Specifically, what is typical presentation of appendicitis
Foreground information How good is a CT scan for appendicitis?
Ask clinical question
novice expert
Foreground questions
Background
question
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 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
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
Comparing DOE and POE
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.
ExampleDisease-Oriented Evidence
Patient-Oriented Evidence that
MattersComment
Anti-arrhythmic Therapy
Drug X PVCs on ECG
Drug X increases mortality
POE contradicts DOE
Type 2 Diabetes Aggressive Tx with insulin or oral agentscan keep BS low
Aggressive Tx does not reduce mortality or prevent most complications
POE contradicts standard teaching
ProstateScreening
PSA screening detects prostate cancer early
Does PSA screening mortality?
DOE exists, but POE is unknown
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
What is a Systematic Review?
Comparison ChartSystematic vs. Narrative Review
Systematic Review Article Review Article
Narrow focus, answers foreground questions
Broad focus, answers background questions
Systematic scientific approach to finding, evaluating and summarizing the evidence
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
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.
Evidence-based Practice Guidelines
• Systematically gather and “grade” evidence on a topic
• Developed by professional groups, government agencies, local practices etc
What is a Clinical Practice Guideline?
Level of evidence/Grades of Recommendations
Ia
II
III
IV
V
Oxford Centre of EBM
Systematic reviews (meta-analyses) of RCTs
Cohort studies
Case-control-studies
Case-series
Expert opinion
Grades of Recommendations
Ib Randomized controlled trials
BiasBiasBias
Bias
Bias
Bias
Validity/Strength of Inference
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?
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).
Critically-Appraised Topic (CAT):
What is the Best Evidence? Hierarchy of Levels of Evidence
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.
Randomized Controlled Clinical Trial (RCT)
Prerequisites for successful Literature Searching Know how to formulate your question.
Evidence-based Practice
Ask clinical questions
Acquire the best evidence
Appraise the evidence
Applyevidence to Your patient
5A’s !!Assess
effectiveness, efficiency of EBM
process
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.
Ask clinical question
Ask Clinical Questions: PICO
Patient/Population OutcomeIntervention/
Exposure Comparison
Components of Clinical Questions
In patients withacute MI
In post-menopausal
women
In women withsuspected
coronary disease
does early treat-ment with a statin
what is the accuracy of
exercise ECHO
does hormonereplacement
therapy
compared to placebo
compared to exercise
ECG
compared to noHRT
decrease cardio-vascular mortality?
for diagnosingsignificant
CAD?
increase therisk of
breast cancer?
Prerequisites for successful Literature Searching Know where to go.
Evidence-based Practice
Acquire the best evidence
LiteratureSearch
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?
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: Guidelines Clearinghouse, Guidelines
International Network CATS: BestBets, ACP Journal Club Point of Care: Clinical Evidence, EvidencePlus, UpToDate etc
Secondary Resources
Secondary Resources
Secondary Resources
“Finding Evidence”: Sources Tertiary resources (meta search engines, databases of
databases): TRIP+ (Translating Research Into Practice) SumSearch
Tertiary Resources
Know what to do when you get there: the site’s technical
language/know-how.
Resources For EBM Knowledge Translation
EBM Resources
Point of Care Clinical
Resources
Updates New Evidence
Decision Support Systems
Critical Appraisal
Tools
Evidence-Based QualityImprovement
Evidence-Based
Guidelines & Policies
•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
Advanced EBM SkillsEBM Hunting Tools
Types of Resources
1. Point of Care Clinical Resources/Decision Support Systems
2. Up-Dates & New Evidence3. Evidence-Based Guidelines, Policies and
Protocols4. Evidence-Based Quality Improvement5. Critical Appraisal Tools6. EBM Audiovisual Training7. Innovations Exchange for New Ideas of Care8. Portals to All
Resources For EBM Literature Searching
1 •Point of Care Clinical Resources/Decision Support Systems
2 •Up-Dates & New Evidence
3 •Evidence-Based Guidelines, Policies Pathways and Protocols
4 •Evidence-Based Quality Improvement
Resources For EBM Literature Searching
5 •Critical Appraisal Tools
6 •EBM Audiovisual Training
7 •Innovations Exchange for New Ideas of Care
8 •Portals to All
2009 NCKUFM-YCY
Systematic ReviewCochrane reviews
Evidence based journals EBM, EBN, EBMH, ACP J club
Computerized Decision Support System (CDSS)
5S Information Resources: Information in top 4 are used
Original articles: BMJUpdates, PubMed Clinical Queries
Evidence based textbooks : UpTo Date, DynaMed, ACP PIER, BMJ Clinical Evidence
Studies
Syntheses
Synopses
Summaries
Systems
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.
POCRaTs