Clinical Information Resources OPT 5191 Intro to Clinic II 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/.

Learning Objectives At the end of the presentation, you will: be familiar with the information retrieval process for evidence-based patient care be able to conduct efficient online searches of books and articles to answer background questions be able to use the PICO model to develop clinical questions be able to access and use synthesized, evaluated evidence to answer clinical questions be able to conduct efficient online searches of MEDLINE using clinical filters be able to quickly locate full text articles and books in the NSU libraries online collection

Sandra Provides…. Instruction Research Assistance Consulting for individuals and small groups Database Searches Help in Locating Full Text Articles Online – Mobile - Print Customized Information Services Assistance with any health-related information need

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

Getting Started Match information resource to your information need Ask questions to clarify your knowledge gap

Background Questions Ask background questions when you need general knowledge Two parts: A question root: who, what, why, where, or how An aspect of health care: disorder, test, treatment, etc. Example: What are the risk factors for open angle glaucoma?

Answers to Background Questions Usually found in books and articles that provide overviews of broad topics Examples: MD Consult Books@Ovid Science Direct Access Medicine Ovid MEDLINE “Basic Search”

Foreground Questions Specific knowledge questions that affect clinical decisions Usually compare two or more concepts – drugs, treatments, tests, prognosis of two groups, harms or benefits of two approaches Example: Does lowering intraocular pressure medically or surgically in patients with open angle glaucoma delay visual field loss?

Asking and Answering Foreground Questions Requires New Skills Clinical question formulation Search and retrieval of best evidence Critical appraisal of study methods

Integration of Clinical Research into Patient Care Process

What is EBM? “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” Patient Concerns Clinical Expertise Best research evidence EBM 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. This definition of what EBM is and isn’t has gained wide acceptance and made it easier for us to get our points across. 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.

Evolution of EBM in the Literature 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

EBM Process – 5 Steps ASSESS: Recognize and prioritize important patient problems ASK: Construct clinical questions that facilitate an efficient search ACQUIRE: Track down the best evidence to answer the questions APPRAISE: Systematically evaluate best available evidence for validity, importance, and usefulness APPLY: Interpret the applicability of evidence to specific problems, given patient preferences and values

Step 1 ASSESS the clinical problem Begin with the patient encounter Select question that Is most important to the patient’s well being Fills gaps in your clinical knowledge Is feasible to answer in the time available

Step 2 ASK focused clinical questions Four common types of clinical questions: Therapy/prevention Diagnosis Etiology Prognosis

Well Built Clinical Questions Deal with patient management issues Contain elements of PICO Model Patient/Population Intervention Comparison Intervention (if useful) Outcome Facilitate an efficient search

Example – Therapy/Prevention Question In patients with open angle glaucoma, does topical pharmacological treatment compared to no treatment prevent progression of visual field defects?

Step 3 ACQUIRE: Track down the evidence to answer the question Use the 4S approach to select the most likely resource Start with the highest level resource available

4S Hierarchy

4S Examples Evidence Based Summaries: Dynamed, FIRSTConsult, ACP PIER, UptoDate ACP Journal Club Cochrane and other Systematic Reviews MEDLINE Searches limited to Clinical Queries SOURCE: Haynes, R. B. (2001). Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence. Evidence-Based Medicine, 6 (2), 36-38. Retrieved 2-07-07 from http://ebm.bmj.com/cgi/reprint/6/2/36

Critically Appraised Content

Ongoing Development of Evidence Based Summaries None are integrated with individual patient EMRs Can be run through same computers as EMRs Some have direct link from within the EMR via the “Info Button”

Evidence Based Retrieval Finds the answer that is supported by valid studies appropriate to the type of question and that is available in a timely manner. Requires search terms plus best study design for question plus highest level of evidence

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.

Therapy/Prevention Question In patients with open angle glaucoma, does lowering intraocular pressure versus no treatment delay visual field loss? Find the answer that is supported by valid studies appropriate to the type of question and that is available in a timely manner.

Extract search terms from question Therapy/Prevention Question in PICO In patients with open angle glaucoma [Patient/Population], does lowering intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field loss [Outcome]?

Possible Search Terms Open angle glaucoma, poag, intraocular pressure, iop, visual field loss

Find 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

Levels of Evidence in Ovid based on AAFP Criteria Level A = “Specificity” in Ovid Clinical Queries Systematic reviews of randomized controlled trials including meta-analyses Good-quality randomized controlled trials Level B = “Sensitivity” in Ovid Clinical Queries Good-quality nonrandomized clinical trials Systematic reviews not in Level A Lower-quality randomized controlled trials not in Level A Other types of study: case control studies, clinical cohort studies, cross sectional studies, retrospective studies, and uncontrolled studies Level C Evidence-based consensus statements and expert guidelines

Find critically appraised content under “Evidence Based Medicine”

Systems/Summaries DynaMed Summaries for more than 3,000 topics Monitors >500 medical journals and systematic review databases Updated daily Each article evaluated for clinical relevance and scientific validity Includes “graded evidence”

Evidence-based answer found in 1 minute, 39 seconds Glaucoma Summary Evidence-based answer found in 1 minute, 39 seconds

DynaMed 1:39

Systems/Summaries ACP PIER Over 400 evidence-based summaries for primary care published by the American College of Physicians Recommendations based on citations from medical literature and ranked by experts at McMaster University Updated monthly Reference citations rated by type and quality of study

Systems/Summaries UptoDate Evidence based summaries of over 9,500 topics in over 20 specialties Ophthalmology not one of the specialties Good for information on systemic conditions Available through individual subscription. Online access plus Mobile app for iPhone and iPad. Cost: $199 per year in training; $499 per year in practice

Available in the Optometry Clinic at Hastings Hospital Available in the Optometry Clinic at Hastings Hospital. Use Resource tab and scroll down to the UptoDate link Sample summary at http://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus

Systems/Summaries FirstConsult Available through NSU subscription to MD Consult for iPhone or iPad only Create a personal account in MD Consult Download the app from the Apple app store Login with your username and password Summaries are detailed and include sections on Differential Diagnosis Eyes and Vision topics well covered

Evidence Based Journal Abstracts ACP Journal Club consists of two journals, ACP Journal Club, a publication of the American College of Physicians, and Evidence-Based Medicine, a joint publication of the American College of Physicians and the British Medical Journal Group includes studies which ACP's editors have selected as methodologically sound and clinically relevant

Syntheses Cochrane Database of Systematic Reviews (DSR) Part of the Cochrane Library (1996) 916 completed reviews, 1905 protocols Among the highest level of evidence upon which to base treatment decisions Includes Dx since 2008 Eyes & Vision Research Group Contains over 165 reviews

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 Access full text of Cochrane reviews in OVID

Review found in 15 seconds Cochrane DSR Review found in 15 seconds

Copyright: The Cochrane Library, Copyright 2009, The Cochrane Collaboration

Levels of Evidence Grade the quality of evidence based on the design of the clinical study Variety of hierarchies in use

DynaMed

GRADE Grading of Recommendations Assessment, Development and Evaluation High: High confidence that the evidence supports this finding. Further research is unlikely to change our confidence in the relationship between this clinical action and the reported patient outcome(s) Moderate: Moderate confidence that the evidence supports this finding. Further research may change our confidence in the relationship between this clinical action and the reported patient outcome(s) Low: Low confidence that the evidence supports this finding. Further research is likely to change our confidence in the relationship between this clinical action and the reported patient outcome(s) Very Low (Insufficient): Very low confidence that the evidence supports this finding. There is either no evidence available, or what is available does not allow evaluation of the relationship between this clinical action and the reported patient outcome(s) FirstConsult in transition from SORT to GRADE. See JAMA 300(15) October 2008,”Progress in Evidence-Based Medicine”, for details on GRADE

Appraise the Filter (pre-appraised content) Criteria Speed of updating Scope and number of summaries Summaries with graded evidence Authors’ credentials, affiliations listed Developing and using a rubric for evaluating evidence-based medicine point-of-care tools. Journal of the Medical Library Association, Volume 99, No. 3, July 2011 Speed of updating online evidence based point of care summaries: prospective cohort analysis. BMJ 2011;343:doi:10.1136/bmj.d5856 (Published 23 September 2011)

Appraisal Required by User

Step 4 Appraise best available evidence from original studies If the other “S’s” don’t provide the answer, search for original studies Use “clinical queries” limit in Ovid MEDLINE to speed retrieval Least efficient (in terms of time) to answer clinical questions

Primary (Original) Studies Articles that report results of original research investigations Conclusions supported by data and reproducible methodology Require time to acquire and appraise Good Source: MEDLINE (OVID)

MEDLINE Premier biomedical database from the National Library of Medicine (NLM) Covers 1946-present Full text available from subscribed NSU journals plus Ovid Deposit Account journals available only for NSUOCO Ovid interface includes tools to quickly filter search results to specific study types and levels of evidence Access from http://library.nsuok.edu/collegeop/index.html

To Use Clinical Queries Tool, enter search terms and then click on “Additional Limits”.

Ovid MEDLINE Clinical Queries Tool

Levels of Evidence in Ovid based on AAFP SORT Level A = “Specificity” in Ovid Clinical Queries Systematic reviews of randomized controlled trials including meta-analyses Good-quality randomized controlled trials Level B = “Sensitivity” in Ovid Clinical Queries Good-quality nonrandomized clinical trials Systematic reviews not in Level A Lower-quality randomized controlled trials not in Level A Other types of study: case control studies, clinical cohort studies, cross sectional studies, retrospective studies, and uncontrolled studies Level C Evidence-based consensus statements and expert guidelines

Step 5 APPLY the evidence to patient care problems Practice the EBM process in daily patient encounters Access databases and tools from http://library.nsuok.edu/collegeop/index.html UptoDate available at Hastings Hospital Use Resource tab and scroll down to UptoDate link

Take Home Points Focused clinical question (PICO) reveals your search terms Start your search at top of 4S hierarchy and work down Be aware of the filter, i.e., levels of evidence, speed of updating Look at more than one resource in the hierarchy. Findings may differ. Practice makes perfect