Clinical Information Resources/ Evidence Based Practice Sandra A. Martin, M.L.I.S. Health Sciences Resource Coordinator Instructor of Library Services John Vaughan Library Room 305B –

Existing knowledge can prevent… Waste Errors Poor quality clinical care Poor patient experience Adoption of interventions of low value Failure to adopt interventions of high value Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health Service. Quoted on

Harmful practices once supported by expert opinion Source: Adapted from How to read a paper: the basics of evidence-based medicine. 4 th edition. By Trisha Greenhalgh Blackwell Publishing Time periodAccepted practiceShown to be harmful Impact on clinical practice From 500 bcBlood Letting1820Ceased in Thalidomide for morning sickness in early pregnancy 1960Withdrawn when first case report of severe malformations appeared From 1900Bed rest for acute low back pain 1986Still advised by some doctors 1960sBenzodiazepines for mild anxiety 1975“Diazepam” prescribing fell in 1990s due to severe dependence and withdrawal symptoms Late 1990sCox-2 inhibitors to treat arthritis 2004Withdrawn following legal cases in the US

Information Retrieval to conduct Research Comprehensive in scope and time  All levels of resources  Current and Retrospective  Background and Foreground Information 6

Learning Objectives To familiarize students with the information retrieval process for evidence-based research & patient care To enable students to use synthesized/filtered/pre- appraised resources to answer clinical questions To enable students to use the 6S hierarchy of organization of evidence to plan search strategies

“EBM is a process of life-long, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy, and other clinical and health care issues.” Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2. Patient Concerns Life-long Learning Best research evidence EBM What is EBM?

“Evidence-based medicine is the integration of research evidence with clinical expertise and patient values.”best. Patient Concerns Clinical Expertise Best research evidence EBM What is EBM? Sackett, DL, Richardson, WS, Rosenberg, WMC, & Haynes, RB (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

Evolution of EBM in the Literature Term “evidence based medicine” coined by Dr. Gordon Guyatt at McMaster University Term first appeared in the literature in a 1991 editorial in ACP Journal Club Volume 114, Mar-April 1991, pp A-16 Seminal article by the Evidence-Based Medicine Working Group published in JAMA Volume 268, No. 17, 1992, pp

Fundamentally new approach becomes widely recognized JAMA published a series of Users’ Guides to the Medical Literature that served as the first learning tools Courses were developed in residency training and medical school curricula The first handbook, Evidence-Based Medicine: How to practice and teach EBM, by Sackett, et al, was published in Fourth edition published in 2010 EBM process forms basis of evidence based practice in nursing and other health care disciplines as well as psychology and social sciences

Information Retrieval for Evidence Based Patient Care Using research findings versus conducting research Retrieving and evaluating information that has direct application to specific patient care problems Selecting resources that are current, valid and available at point-of-care Developing search strategies that are feasible within time constraints of clinical practice

EBM Process – 5 Steps 1. ASK: Convert need for information into answerable question 2. ACQUIRE: Find best evidence to answer the question 3. APPRAISE: Critically appraise evidence for validity, impact, and applicability 4. APPLY: Integrate evidence with clinical expertise and patient values 5. ASSESS: Evaluate own effectiveness

New Approach Requires New Skills Clinical question formulation Search and retrieval of best evidence Critical appraisal of study methods to determine validity of results

Is All Evidence Created Equal? Small portion of medical literature is immediately useful to answer clinical questions Understanding “wedge or pyramid of evidence” is helpful in finding highest level of evidence High levels of evidence may not exist for all questions due to nature of medical problems and research limitations

As you move up the pyramid the amount of available literature decreases, but it increases in its relevance to the clinical setting. Source: Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

Clinical/Foreground Questions Arise in patient care setting Fill gaps in clinical knowledge regarding  Diagnosis  Therapy/prevention  Prognosis  Etiology

Answers to Clinical/Foreground Questions Require:  precise information about complex issues  trustworthy clinical research data with direct application to patient problems 18

Well Built Questions include Elements of PICO Model P -Patient or population I - Intervention C -Comparison Intervention O - Outcome

Evidence Based Search Strategy 1. Includes search terms from the clinical question 2. Matches best study design for type of question 3. Retrieves answers at highest levels of evidence

Extract search terms from question Therapy/Prevention Question  In patients with primary open angle glaucoma or ocular hypertension [Patient/Population], do topical medications to reduce intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field defect progression [Outcome]?

1. Search Terms Primary open angle glaucoma, POAG Ocular hypertension, OHT Intraocular pressure, IOP Visual fields, VF Limit search results to “therapy” studies

2. Best Study Design for Type of Question Type of QuestionStudy Design Therapy/preventionRandomized controlled trials DiagnosisProspective cohort, blind comparison to a gold standard PrognosisCohort, Case Control, Case Series Etiology/HarmCohort, Case Control, Case Series

3. Highest Level of Evidence – 6S Hierarchy

Integrating the EBM Process into Information Retrieval & Research Convert information needs into focused questions Efficiently track down the best evidence to answer the questions  Consult pre-appraised evidence resources for answers that are directly useful for clinical practice and evidence based research  Critically appraise the evidence found in other clinical information resources for validity and clinical usefulness Apply the results in clinical decision making & research Evaluate usefulness of the evidence

Search First at Top Levels of 6S MEDLINE - major source of “primary” literature  Process of searching, selecting, evaluating original research is time consuming  Requires critical appraisal skills Filtered/Synthesized/Evaluated resources - “secondary” literature  Speed application of evidence at “point-of-care”  Grade strength of treatment recommendations  Rate quality of research evidence

Top of 6S – Point-of-Care Resources Evidence based textbooks  Provide rapid access to concise information to clinicians at the point of care  Not a database of articles from books, journals, or guidelines  Original, current, summaries written by experts  Formal systems used to grade strength of recommendations and quality of evidence Available from Optometry web page  UpToDate  First Consult

Summaries UptoDate –Evidence based summaries of over 10,000 topics in over 22 specialties –8,500 Treatment Recommendations –GRADE System used to score recommendations and strength of evidence –Practice changing updates; Updated continuously –Drug database; Patient education materials –The Gold Standard of summaries

GRADE System UpToDate

Clinical Question Therapy/Prevention  In patients with primary open angle glaucoma or ocular hypertension [Patient/Population], do topical medications to reduce intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field defect progression [Outcome]?

Simple UTD Search Answers Clinical Question in Seconds

Summaries FirstConsult –Search online in Clinical Key –App available through NSU subscription to Clinical Key for iPhone or iPad only –Create a personal account in Clinical Key –Download the app from the Apple app store –Login with your CK username and password –Concise summaries; sections on differential diagnosis; quality of evidence graded –Not updated as rapidly as UTD

Synopsis of Syntheses Database of Abstracts of Reviews of Effects DARE –Search online in OVID –Part of OVID’s evidence based medicine reviews collection –Full text database contains critical assessments of systematic reviews published in various medical journals

Systematic Review Analyzes data from several primary studies to answer a specific clinical question Provides search strategies and resources used to locate studies Includes specific inclusion and exclusion criteria (results in less bias) Meta-Analysis (subclass) statistically summarizes results of several individual studies

Critical Assessment of Systematic Review cited in UTD and FC

Syntheses Cochrane Database of Systematic Reviews (DSR) –Part of the Cochrane Library (1996) –Over 900 completed reviews, 1900 protocols –Among the highest level of evidence upon which to base treatment decisions –Includes Dx since 2008 –Eyes & Vision Research Group Contains over 200 reviews –Full Text Available in Ovid

Synopses of Studies ACP Journal Club –Contains abstracts of studies selected by ACP editors as valid and clinically relevant –Part of OVID’s evidence based medicine reviews collection –Primary care focus

Primary Care Focus

When other S’s do not provide answers, search for original studies

Primary (Original) Studies Articles that report results of original research investigations Conclusions supported by data and reproducible methodology Require time to acquire and appraise Best Sources: Ovid MEDLINE and Clinical Key

“Do it yourself” Appraisal Territory You must appraise quality of the study or find analysis in evidence based summary Limit search results to “Clinical Queries” in Ovid MEDLINE or “Study Type” in Clinical Key Journal Search

Databases MEDLINE –Premiere biomedical database from the NLM (National Library of Medicine) –Covers 1946-present –Indexes >5000 international biomedical journals –Full text available for many articles –Access through Ovid and Clinical Key

Search of Current MEDLINE files yields 49 studies to scan and appraise

Clinical Queries Developed by the EBM Group and National Library of Medicine Filters MEDLINE search results to specific study types and levels of evidence Ovid Tool is based on AAFP SORT System  Level A = Ovid Therapy (specificity) Systematic reviews of randomized controlled trials including meta-analyses Good-quality randomized controlled trials  Level B – Ovid Therapy (sensitivity) Good-quality nonrandomized clinical trials Systematic reviews not in Level A Lower-quality randomized controlled trials not in Level A

CK MEDLINE Yields 89 RCTS in last 5 Years to Scan and Appraise

Take Home Points Focused clinical question (PICO) reveals your search terms and best type of studies Start your search at top of 6S hierarchy and work down (UpToDate, First Consult) Be aware of the filters: levels of evidence, graded recommendations, speed of updating Look at more than one resource in the hierarchy. Findings may differ

Information is Ever Changing