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 –

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

Learning Objectives To familiarize students with the information retrieval process for evidence-based patient care To enable students to access and use synthesized, evidence-based resources to answer clinical questions To enable students to conduct efficient online searches of databases, e-Journals, and e-Books to answer clinical questions

Sandra Provides…. Instruction Research Assistance Consulting for individuals and small groups Database Searches Help in Locating Full Text Articles  Online – Mobile - Print RUSH delivery of Interlibrary loan requests Assistance with any health-related information need 5

Helpful Tools Optometry Web Page  Optometry Databases, e-journals, e-books, and other tools available 24/7  Supports specific research, teaching, and patient care needs of NSUOCO faculty, students, and residents  Start Here to find resources for all vision science and medical topics Guide to Library Resources and Services  Lists current online databases, e-Journals, and e-Books 6

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Remote Access Enter NT-NSU user id and password to access the library’s electronic resources Contact Tom Tinnell if you have problems with your user id or password Contact Sandra to report other technical problems or for search assistance 8

Interlibrary Loan (ILL) Requests requests to Articles  Include full citation of article in your  Provide your contact information  Indicate your status as an Optometry student  ILL will the article link Books  Include full citation of book in your  Set up an online ILL profile when you pick up the book Questions  ILL: Contact Donna Graham – x3243 –  RUSH Delivery: Contact Sandra –

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

Integration of Clinical Research into Patient Care Process

Clinical Questions Four common types:  Therapy/prevention  Diagnosis  Etiology  Prognosis

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

Answerable Questions Select Questions That:  Are most important to the patient’s well being  Fill gaps in your clinical knowledge  Are feasible to answer in the time available

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: problem, test, treatment, etc. Example:  What are the risk factors for open angle glaucoma?  What are eye and vision care issues of patients with special needs? 16

Answers to Background Questions Require general knowledge of disease and therapeutic processes Resources:  Books – online and print collections  Narrative review articles  Examples: Clinical Key, Science Direct, Access Medicine 17

Review Articles Background articles that provide an overview of current research Integrate recent advances with accepted practice Summarize – not original works May mix opinions/bias of the authors with evidence

Foreground Questions Compare two or more concepts – drugs, treatments, tests, prognosis of two groups, harms or benefits of two approaches Examples:  Does lowering intraocular pressure medically or surgically in patients with open angle glaucoma delay visual field loss?  In patients with open angle glaucoma, does topical pharmacological treatment compared to no treatment delay progression of visual field defects? 19

Answers to Foreground Questions Provide precise information about complex issues Sources should contain current, original clinical research data Resources  Evidence Based Summaries  Systematic Reviews  Clinical Key  MEDLINE – Clinical Queries 20

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

“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?

EBM Process – 5 Steps 1. ASSESS - Begin with the patient encounter 2. ASK - clinical questions that address important patient problems 3. ACQUIRE - the best evidence to answer the questions (Use 4S Approach) 4. APPRAISE - Evaluate the evidence for validity, importance, and usefulness 5. APPLY - Does the evidence “fit” your patient’s specific problems and needs? Practice the EBM process in daily patient encounters

4S Hierarchy

4S Examples  Evidence Based Summaries: Dynamed, Clinical Key (FIRSTConsult), UptoDate  ACP Journal Club Cochrane and other Systematic Reviews (Clinical Key, MEDLINE)  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), Retrieved from

Critically Appraised Content

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 Retrieval Find 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

Therapy/Prevention Question 1. In patients with open angle glaucoma, does lowering intraocular pressure versus no treatment delay visual field loss? 2. 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]?

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

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. Begin Search at Top Level of Evidence

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

Levels of Evidence – AAFP Criteria –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

New Resource – Clinical Key Full text access to 1,000 books and 500 journals in every medical and surgical specialty Ophthalmology – Over 60 full text books Includes 12 Content Types Access to information at all levels from topic overview to evidence-based data in one search Smart search engine matches first few letters of search word/words to relevant clinical content No complicated search strategies or Boolean connectors Easier than Google – but with reliable, evidence-based results 37

Clinical Key includes all 4S levels plus books and overviews

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”

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

DynaMed 1:39

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. Use Resource tab and scroll down to the UptoDate link  Sample summary at diabetes-mellitus diabetes-mellitus

Systems/Summaries FirstConsult –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 Clinical Key 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 that 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

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

Appraisal Required by User

Step 4 If the other “S’s” don’t provide the answer, search for original studies Search MEDLINE in Clinical Key or Ovid. Use “clinical queries” limit in Ovid to match study type to clinical question 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) with Clinical Queries Limit

MEDLINE Premier biomedical database from the National Library of Medicine (NLM) Covers 1946-present Full text available for most Ophthalmology/Optometry Ovid journals Ovid interface includes tools to quickly filter search results to specific study types and levels of evidence Access only from PubMed will not provide links to NSU full text

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

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

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Click on the Optometry Librarian’s Page link from the Optometry web page Phone: ext or Location: Library Room 305B Available for individual or small group consultation Send with “OPT Clinical” in the subject line - Receive a response within 24 hours 60