Evidence Based Medicine Resources Payam Kabiri, MD. PhD. Clinical Epidemiologist Tehran University of Medical Sciences

Finding resources for practicing EBM The widespread practice of Evidence Based Medicine requires that we get the right information to the right person at the right time. Current systems frequently fail: important information is missing, presented inappropriately, distorted in reporting, never gathered, hard to search, and hard to find.

Objectives You will: Formulate a clinical question Identify and utilize EBM online resources to answer your questions EBM Databases & Resources Guidelines Apply rules for levels of evidence to make clinical decisions

Usefulness of medical information Information Mastery Creating a culture of inquiry Usefulness of medical information Relevance x Validity = work

Medical Sources Types A primary source is firsthand testimony or direct evidence concerning a topic under investigation not interpreted. Primary resources are generally articles that appear in peer-reviewed journals and are found primarily by searching Medline. Secondary sources describe or analyze the primary sources. are summaries and analyses of the evidence derived from and based on primary sources. A secondary source is a work that appraises, interprets or analyzes. Secondary resources available as Clinical Evidence, ACP Journal Club, and Cochrane Library, EBMR. Tertiary resources list, compile, digest or index primary or secondary sources.  Examples of tertiary resources include UpToDate, DynaMed, TripDatabase.

EBM Resources Systematic Literature Searches Cochrane Library (OVID) Clinical Evidence Systematic Literature Surveillance ACP Journal Club (OVID) DARE DynaMed Medical InfoRetriever EMB Search Engine TRIP Database Today we are going to learn how to use these resources. Clinical Evidence: Currently we don’t subscribe to this. I have recommended we do. Clinical Evidence summarizes the current state of knowledge and uncertainty about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature. It is neither a textbook of medicine nor a set of guidelines. It describes the best available evidence from systematic reviews and RCTs, and if there is no good evidence it says so. Clinical Evidence aims to help people make informed decisions about which treatments to use. It can also show where more research is needed. For clinicians and patients we wish to highlight treatments that work and for which the benefits outweigh the harms, especially those treatments that may currently be underused. We also wish to highlight treatments that do not work or for which the harms outweigh the benefits. For the research community our intention is to highlight gaps in the evidence — where there are currently no good RCTs or no RCTs that look groups of people or at important patient outcomes The Database of Abstracts of Reviews of Effects DARE includes structured abstracts of systematic reviews from around the world, which have been critically appraised by reviewers at the NHS Centre for Reviews and Dissemination at the University of York, England. DARE also contains references to other reviews which may be useful for background information. We subscribe to this through OVID. 4/22/2017 EBM Resources

Guidelines What is a guideline? Guidelines may be Explicit evidence-based Evidence-based Research-based (highly referenced) Opinion-based “expert consensus” Definition of Clinical Practice Guideline The National Guideline Clearinghouse™ (NGC™) employs the definition of clinical practice guideline developed by the Institute of Medicine (IOM). Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. [Institute of Medicine. (1990). Clinical Practice Guidelines: Directions for a New Program, M.J. Field and K.N. Lohr (eds.) Washington, DC: National Academy Press. page 38]. Criteria for Inclusion of Clinical Practice Guidelines in NGC All of the criteria below must be met for a clinical practice guideline to be included in NGC. The clinical practice guideline contains systematically developed statements that include recommendations, strategies, or information that assists physicians and/or other health care practitioners and patients make decisions about appropriate health care for specific clinical circumstances. The clinical practice guideline was produced under the auspices of medical specialty associations; relevant professional societies, public or private organizations, government agencies at the Federal, State, or local level; or health care organizations or plans. A clinical practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organizations does not meet the inclusion criteria for NGC. Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development. A guideline is not excluded from NGC if corroborating documentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline's recommendations. The guideline is English language, current, and the most recent version produced. Documented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the last five years. 4/22/2017 EBM Resources

Levels of Evidence Level 1: Randomized Clinical Trials Level 2: Head to Head Trial or Systematic Review of Cohort Studies Level 3: Case-Control Studies Level 4: Case-series Level 5: Expert Opinion

Levels of Evidence Type of Study Level of Evidence 1a 1b 2a 2b 3a 3b 4 Systematic reviews of randomized clinical trials (RCTs) 1b Individual RCTs 2a Systematic reviews of cohort studies 2b Individual cohort studies and low-quality RCTs 3a Systematic reviews of case-controlled studies 3b Individual case-controlled studies 4 Case series and poor-quality cohort and case-control studies 5 Expert opinion based on clinical experience Levels of Evidence To help clinicians critically review the external evidence they locate, Sackett et al. developed a hierarchical model to categorize most studies. It is important to note that these levels of evidence are not a rigid set of rules, but serve only as a set of guidelines for the critical appraisal of the literature. According to Sackett (BMJ 1996;312:71-2), the randomized trial (especially the systematic review of randomized trials) has become the “gold standard” for judging whether or not a particular treatment is beneficial. The practice of evidence-based medicine is not restricted to randomized trials. Studies from other levels may be better meet you needs for information or may be better in terms of quality. For example, although the cohort study design ranked lower than that of the randomized controlled trial, it may be the highest level of evidence (excluding systematic reviews) for other aspects of patient care (e.g., validity of diagnostic tests, assessing prognosis) or when randomized controlled clinical trials cannot be performed due to ethical concerns (e.g., study of harmful interventions or exposures). Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

Guidelines Resources www.guideline.gov (AHRQ) www.mdconsult.com (MD Consult) www.nice.org.uk/Guidance/ (NICE) www.sign.ac.uk/guidelines (SIGN clinical guidelines) www.g-i-n.net (Guidelines International Network (G-I-N)

Cochrane Database Included in OVID subscription Limitations limited to English only addresses questions amenable to randomized trials most of medicine has not been studied enough to allow for conclusions Cochrane Review Groups Cochrane Acute Respiratory Infections Group Cochrane Airways Group Cochrane Anaesthesia Group Cochrane Back Group Cochrane Breast Cancer Group Cochrane Colorectal Cancer Group Cochrane Consumers & Communication Group Cochrane Cystic Fibrosis and Genetic Disorders Group Cochrane Dementia and Cognitive Improvement Group Cochrane Depression, Anxiety and Neurosis Group Cochrane Developmental, Psychosocial and Learning Problems Group Cochrane Drugs and Alcohol Group Cochrane Ear, Nose and Throat Disorders Group Cochrane Effective Practice and Organisation of Care Group Cochrane Epilepsy Group Cochrane Eyes and Vision Group Cochrane Fertility Regulation Group Cochrane Gynaecological Cancer Group Cochrane Haematological Malignancies Group Cochrane Heart Group Cochrane Hepato-Biliary Group Cochrane HIV/AIDS Group Cochrane Hypertension Group Cochrane Incontinence Group Cochrane Infectious Diseases Group Cochrane Inflammatory Bowel Disease Group Cochrane Injuries Group Cochrane Lung Cancer Group Cochrane Menstrual Disorders and Subfertility Group Cochrane Metabolic and Endocrine Disorders Group Cochrane Methodology Review Group Cochrane Movement Disorders Group Cochrane Multiple Sclerosis Group Cochrane Musculoskeletal Group Cochrane Musculoskeletal Injuries Group Cochrane Neonatal Group Cochrane Neuromuscular Disease Group Cochrane Oral Health Group Cochrane Pain, Palliative Care and Supportive Care Group Cochrane Peripheral Vascular Diseases Group Cochrane Pregnancy and Childbirth Group Cochrane Prostatic Diseases and Urologic Cancers Group Cochrane Renal Group Cochrane Schizophrenia Group Cochrane Sexually Transmitted Diseases Group Cochrane Skin Group Cochrane Stroke Group Cochrane Tobacco Addiction Group Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Cochrane Wounds Group 4/22/2017 EBM Resources

Cochrane Databases The Cochrane Library is a collection of 6 main databases and 1 additional databases that describe Cochrane as an organization. These are: The Cochrane Database of Systematic Reviews (CDSR) The Cochrane Database of Reviews of Effects (DARE) The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Database of Methodology Reviews (CDMR) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (NHS EED) THE COCHRANE METHODOLOGY REGISTER (CMR) About The Cochrane Collaboration and the Cochrane Collaborative Review Groups The Cochrane Library is a collection of 6 main databases and 2 additional databases that describe Cochrane as an organization. These are: The Cochrane Database of Systematic Reviews (CDSR) The Cochrane Database of Reviews of Effects (DARE) The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Database of Methodology Reviews (CDMR) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (NHS EED) About the Cochrane Collaboration List of Review Groups

The Cochrane Library 2007, Issue 4 Database Total Records The Cochrane Database of Systematic Reviews (Cochrane Reviews) 5053 Database of Abstracts of Reviews of Effects (DARE) 6761 The Cochrane Central Register of Controlled Trials (CENTRAL) 522,340 The Cochrane Database of Methodology Reviews (Methodology Reviews) 20 The Cochrane Methodology Register (Methodology Register) 10,008 Health Technology Assessment Database (HTA) 7078 NHS Economic Evaluation Database (NHS EED) 22,731 About The Cochrane Collaboration and the Cochrane Collaborative Review Groups (About) 92

ACP Journal Club About 100 journals systematically surveyed Highest-validity articles abstracted Structured abstracts to guide critical appraisal Clinical commentary Included in our OVID subscription 4/22/2017 EBM Resources

UpToDate & you know UpToDate …. ! 4/22/2017 EBM Resources

DynaMed Designed as entry point to information Textbooks and Medline not efficient Intuitive clinical organization Brief summarized information presented Links and references if more details needed ICD-9 codes and links to patient information handouts 4/22/2017 EBM Resources

E-Books MD Consult Free Books 4 Doctors Gigapedia http://www.mdconsult.com Free Books 4 Doctors http://www.freebooks4doctors.com/ Gigapedia http://gigapedia.com/

EBM Calculators Statistics for Diagnostic, Prospective, Case Control & Randomized studies Can graph pre- and post test probability with likelihood ratio for Diagnostic Studies. Can save results and view at another time EBM Calculator – Centre for EBM – University Health Network

EBM Online Calculators Some Examplses: http://www.graphpad.com/quickcalcs/NNT1.cfm http://www.ebem.org/nntcalculator.html http://www.cebm.net/index.aspx?o=1160

Selected Electronic Health Information Resources Internet Address ACP Journal Club www.acpjc.org Cochrane Library www.update-software.com UpToDate www.uptodate.com PubMED www.pubmed.com eMedicine www.emedicine.com Clinical practice guidelines www.guidelines.gov MD Consult www.mdconsult.com EBMR Reviews (OVID) www.ovid.com/site/catalog Selected Electronic Health Information Resources

Bandolier http://www.medicine.ox.ac.uk/bandolier/ A monthly newsletter about evidence-based health care; top source for such information on the net.

Evidence-Based Medicine http://www.evidence-basedmedicine.com Bi-monthly journal which summarises important recent articles from major clinical fields (family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, public health, surgery). (Note: Best Evidence is the cumulated contents of ACP Journal Club (since 1991) and Evidence-Based Medicine (since 1995) in an annual CD.

BestBETS http://www.bestbets.org Provides rapid evidence-based answers to reallife clinical questions in emergency medicine, using a systematic approach to reviewing the literature. BETs take into account the shortcomings of much current evidence, allowing physicians to make the best of what there is. Developed in the Emergency Department of Manchester Royal Infirmary, UK.

Clinical Evidence http://www.clinicalevidence.com Clinical Evidence is an updated directory of evidence on the effects of clinical interventions. It summarises the current state of knowledge, ignorance, and uncertainty about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature. It covers 20 specialties and includes 134 conditions. Updated/expanded coverage every six months in print and CD.

TRIP Database http://www.tripdatabase.com Searches several different evidence-based resources including PubMed, Bandolier, and the ATTRACT question-answering service. Only allows title searches, but does allow AND, OR, NOT

How to Search? Use the components of the PICO to direct your search • (Population OR synonym1 OR synonym2…) AND • (Intervention OR synonym1 OR synonym2…) AND • (Comparator OR synonym1 OR synonym2…) AND • (Outcome OR synonym1 OR synonym2…)

EBM “Systems” vs Traditional Textbook Model Author is an “authority” Author selects, reports on own One-year production line from manuscript to bookstand Three-year production schedule

Updating in EBM Systems Authors are provided with new studies and reviews that are: Assessed for validity Rated by clinicians for relevance Rated by clinicians for newsworthiness Within a month of original publication

Computerized Decision Evidence-based textbook Support System (CDSS) Evidence-based textbook Systems Evidence-based Journals Synopses Cochrane reviews Syntheses Original published Articles like Medline Studies

بزنید ! Email اگر میل داشتید payam.kabiri@gmail.com