Advanced and Evidence Based Information Retrieval Sandra A. Martin, M.L.I.S. Health Sciences Resource Coordinator Instructor of Library Services John Vaughan Library Room 305B marti004@nsuok.edu – 918-444-3263

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 http://www.nks.nhs.uk/.

Harmful practices once supported by expert opinion Time period Accepted practice Shown to be harmful Impact on clinical practice From 500 bc Blood Letting 1820 Ceased in 1910 1957 Thalidomide for morning sickness in early pregnancy 1960 Withdrawn when first case report of severe malformations appeared From 1900 Bed rest for acute low back pain 1986 Still advised by some doctors 1960s Benzodiazepines for mild anxiety 1975 “Diazepam” prescribing fell in 1990s due to severe dependence and withdrawal symptoms Late 1990s Cox-2 inhibitors to treat arthritis 2004 Withdrawn following legal cases in the US Source: Adapted from How to read a paper: the basics of evidence-based medicine. 4th edition. By Trisha Greenhalgh. 2010 Blackwell Publishing

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

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 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 2420-2425 Click on the “Evidence Based Medicine” tutorial from the Optometry web page to view a brief video of EBM history

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

Evidence Based Search Strategy Derives search terms from the clinical question Matches best study design for type of question Retrieves answers at highest levels of evidence

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

Use PICO model to form a 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 Topical medications, eye drops, ophthalmic solutions Visual fields, VF Limit search results to “therapy” studies

2. Best Study Design for Type of Question Therapy/prevention Randomized controlled trials Diagnosis Prospective cohort, blind comparison to a gold standard Prognosis Cohort, Case Control, Case Series Etiology/Harm

3. Highest Level of Evidence – Begin at top of the 6S Hierarchy

Search First at Top Evidence Levels MEDLINE - major source of “primary” literature, BUT Process of searching, selecting, evaluating original research is time consuming and requires critical appraisal skills Filtered/Synthesized/Evaluated resources - “secondary” literature, e.g., evidence summaries and systematic reviews Speed application of evidence at “point-of-care” Grade strength of treatment recommendations Rate quality of research evidence

Clinical Key “All in one” database with full text access to 1,000 books and 500 journals in every medical and surgical specialty Ophthalmology – Over 60 full text books Access to information at all levels from topic overview to evidence-based data in one search Includes full text journal articles, book chapters, MEDLINE citations, videos, images, drug monographs No complicated search strategies or Boolean connectors Get the App Easier than Google – but with reliable, evidence-based results

Summaries Get the CK app 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 CK app from the app store Login with your CK username and password Concise summaries; sections on differential diagnosis; quality of evidence graded

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 Updated continuously; Includes practice changing updates Drug database; Patient education materials The Gold Standard of evidence summaries

UpToDate GRADE System UpToDate GRADE System Guyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence" and why is it important to clinicians?. BMJ. 2008;336(7651):995-8.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364804/pdf/bmj-336-7651-analysis-00995.pdf

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

Systematic Review Analyzes data from several primary studies to answer a specific clinical question Provides search strategies and resources used to locate studies Uses explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies Statistical methods (meta-analysis) may or may not be used to analyze and summarize results Benefits: Limits bias and increases confidence in conclusions

Syntheses Cochrane Database of Systematic Reviews (DSR) Part of the Cochrane Library (1996) Over 3,000 reviews & protocols (reviews in the making) The Gold Standard of systematic reviews Eyes & Vision Research Group Contains over 200 reviews Full Text Available in Ovid

Overviews and Individual Studies Resources: Clinical Key (Includes MEDLINE) Ovid MEDLINE (tools for “precise” search strategies) Science Direct – Best for scientific and technical topics, e.g., pharmaceutics, contact lenses, refraction (does not include MEDLINE) Visionet – vision therapy related topics eBooks and library print book collection

MEDLINE Covers 1946-present U. S. National Library of Medicine’s premier database. Contains over 20 million citations to journal articles in medicine, nursing, allied health, and basic sciences as they relate to health care Covers 1946-present Clinical Key includes “user friendly” interface. Natural language processing of keywords eliminates complicated searches Use Clinical Key or Ovid MEDLINE for links to full text in our subscribed journals

Science Direct Peer reviewed journal articles and book chapters published by Elsevier in both subscription and open access resources Includes full text of Clinical Key journals published before 2007 Does not include MEDLINE Does include full text of journals not found in MEDLINE searches Good for scientific & technical journals

Visionet – no full text Citations to articles in Optometry journals not found in MEDLINE Especially useful for articles on vision therapy, visual training, vision screening, low vision, practice management, etc. Contact Sandra for help

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 (Clinical Key, First Consult, UpToDate, Cochrane) Be aware of the filters: levels of evidence, graded recommendations, speed of updating Look at more than one resource in the hierarchy. Information is ever changing; findings may differ!

Not all topics fit the 6S Model High levels of evidence may not exist for all questions

If you need Help, contact Sandra, marti004@nsuok.edu