Occupational Therapy 5903 Sandra A. Martin, M.L.I.S. Instructor of Library Services Health Sciences Resource Coordinator John Vaughan Library Room 305B –

Knowledge is the Enemy of Disease Sir Muir Gray Existing Knowledge Can Prevent – Waste & Errors – Poor Patient Experience – Adoption of low value interventions – Failure to adopt high value interventions

PART II - Information Retrieval for Evidence Based Practice 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

Learning Objectives At the end of the presentation, you will be able to: Define evidence-based practice (EBP) Understand the Five Steps to practice EBP Use the 4S hierarchy to conduct an efficient search for the best evidence Access online pre-appraised resources Locate print and online tools to assist in critical appraisal of individual studies

“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” 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 Clinical Expertise Best research evidence EBM What is EBM?

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

EBP 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

Integration of EBM into medical school curricula patient-doctor courses

Information Retrieval to Answer Clinical Questions Requires New Skills Clinical question formulation Search and retrieval of best evidence Critical appraisal of study methods

Key developments that streamlined the practice of EBM Advances in ease of accessing and understanding information Development of preprocessed (preappraised) tools Improvements in search interfaces to MEDLINE Collaboration between EBM Working Group and National Library of Medicine in development of hedges, “clinical queries” tool, that filters search results to specific study types and levels of evidence Dissemination of systematic reviews of primary studies and growth of the Cochrane Collaboration

Background v Foreground Knowledge Both types of knowledge needed Varies over time Depends on experience with condition Point A: Student – limited experience Point B: Resident – growing clinical experience Point C: Attending – extensive experience Note: Diagonal line shows “we’re never too green to learn foreground knowledge, nor too experienced to outlive the need for background knowledge” Source: Evidence-based medicine: how to practice and teach it. 4 th edition. By Straus, et. al. Churchill Livingstone Elsevier

Answerable Questions Arise in patient care setting and are:  Important to the patient’s well being  Fill gaps in your clinical knowledge  Feasible to answer in time available

Clinical Questions Four Common Types  Therapy/prevention  Diagnosis  Etiology  Prognosis

Background Questions What are methods of reducing fatigue in patients with multiple sclerosis? What are newer approaches to rehabilitation therapy for stroke patients that are based on motor learning?

Foreground Questions Is vestibular rehabilitation effective in reducing fatigue and improving balance?

PICO Model P -Patient or population I - Intervention C -Comparison Intervention O - Outcome

Clinical Question – Therapy/Intervention P -Patient or population In patients with multiple sclerosis, I - Intervention is vestibular rehabilitation effective C -Comparison Intervention compared to exercise O - Outcome in reducing fatigue and improving balance?

Possible Search Terms Multiple sclerosis, vestibular rehabilitation, exercise, fatigue, balance

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

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.

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

American Academy of Family Physicians SORT –Level A Systematic reviews of randomized controlled trials including meta- analyses Good-quality randomized controlled trials –Level B 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

DynaMed and FirstConsult

4S Hierarchy

Highest Level of Evidence - Critically Appraised Content Evidence Based Summaries First Consult, DynaMed, Joanna Briggs Institute Joanna Briggs, Mosby’s Nursing Consult, OT Seeker, PEDro, ACP Journal Club, DARE Joanna Briggs, Cochrane Database of Systematic Reviews MEDLINE, CINAHL Plus w/Full Text (Use Limits to narrow search to highest evidence levels) 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), Retrieved from

New Tools Target High-Quality Studies Increase ease of accessing and understanding information Preprocessed (preappraised) tools - practical resources that facilitate ready access to high-quality research Pre-appraised – tools that have undergone a filtering process to include only those studies that are regularly updated and of higher quality

Critically Appraised (Evidence- Based) Summaries FirstConsult DynaMed Joanna Briggs Institute

Summaries FirstConsult Includes summaries of systematic reviews of primary research, high-quality research papers from MEDLINE and evidence-based practice guidelines Included studies are evaluated for clinical relevance and scientific validity Recommendations labeled with Levels of Evidence Detailed narrative format and lengthy overviews

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 Recommendations labeled with Levels of Evidence

Joanna Briggs Institute (JBI) an international, not-for-profit research organization at the University of Adelaide collaborates internationally with over 70 entities to promote synthesis and transfer of evidence contributes to improving health care outcomes by supporting evidence-based practice Includes documents primarily related to Nursing but allied health content is growing

JBI Database Evidence Summaries – literature reviews that summarize existing literature on common health care problems Evidence-Based Recommended Practices – procedures that recommend practice on clinical topics Best Practice Information Sheets – guidelines produced for practicing health care professionals Consumer Information Sheets – summaries designed for patients, clients, and care providers Updated weekly, access through Ovid

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

JBI Database Systematic Reviews – comprehensive reviews of international research literature – mostly Nursing but increasing number of protocols for SRs in allied health Updated weekly, access through Ovid

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 and JBI reviews in OVID

Review found in 15 seconds Cochrane DSR

Appraisal Required by User

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 Sources: Ovid MEDLINE and CINAHL Plus w/Full Text

When to search for original studies If the other “S’s” don’t provide the answer, search for original studies “Do it yourself” appraisal territory You must appraise quality of the study or find analysis in evidence based summary Quality of the journal does not always guarantee quality of individual studies Limit to “Clinical Queries” in Ovid MEDLINE and CINAHL

Databases MEDLINE  Premier biomedical database from the NLM (National Library of Medicine)  Covers 1946-present  Indexes >5,000 international biomedical journals  Careful journal screening and selection process  Full text available for many articles  Access through Ovid

Databases - CINAHL Plus w/Full Text CINAHL stands for Cumulative Index to Nursing and Allied Health Literature Indexes 770 journals in nursing and allied health Use “CINAHL Headings” to search topics for best results, e.g., search “pediatric occupational therapy” for occupational therapy with children Full text available for many articles Important to use limits, peer reviewed, academic journals, research article, etc., to eliminate trade magazines and other non-scholarly material

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 Apply in clinical settings and continually assess your progress

Life-Long Learning Selecting and searching online databases is challenging Information is ever changing Contact Sandra ( preferred)

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Occupational Therapy 5903 Sandra A. Martin, M.L.I.S. Instructor of Library Services Health Sciences Resource Coordinator John Vaughan Library Room 305B –