Clinical Information Resources Sandra A. Martin, M.L.I.S. Health Sciences Resource Coordinator Instructor of Library Services John Vaughan Library Room 305B –

Learning Objectives To familiarize residents with the information retrieval process for evidence-based patient care To enable residents to use synthesized/filtered/pre- appraised resources to answer clinical questions To enable residents to use the 6S hierarchy of organization of evidence to plan search strategies

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

Clinical Applications of EBM Convert information needs into focused questions. Efficiently track down the best evidence to answer the questions.  Consult pre-appraised evidence resources for answers that are directly useful for clinical practice decisions, or  Critically appraise the evidence found in other clinical information resources for validity and clinical usefulness Apply the results in clinical decision making. Evaluate usefulness of the evidence in clinical application.

Answers to Clinical Questions Require:  precise information about complex issues  trustworthy clinical research data with direct application to patient problems Fill gaps in clinical knowledge pertinent to:  Therapy/prevention  Diagnosis  Prognosis  Etiology 5

Search Strategy for EBM Retrieval 1. Derive search terms from clinical question 2. Match best study design to type of question 3. Begin search at highest level of evidence 7

Extract search terms from 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 Visual fields, VF Limit search results to “therapy” studies

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. Highest Level of Evidence – 6S Hierarchy

Search First at Top Levels of 6S MEDLINE - major source of “primary” literature  Process of searching, selecting, evaluating original research is time consuming  Requires critical appraisal skills Filtered/Synthesized/Evaluated resources - “secondary” literature  Speed application of evidence at “point-of-care”  Grade strength of treatment recommendations  Rate quality of research evidence

Top of 6S – Point-of-Care Resources Evidence based textbooks  Provide rapid access to concise information to clinicians at the point of care  Not a database of articles from books, journals, or guidelines  Original, current, summaries written by experts  Formal systems used to grade strength of recommendations and quality of evidence Available from Optometry web page  UpToDate  First Consult

Summaries UptoDate –Evidence based summaries of over 9,500 topics in over 22 specialties –8,500 Treatment Recommendations –GRADE System used to score recommendations and strength of evidence –Practice changing updates; Updated continuously –Drug database; Patient education materials –The Gold Standard of summaries

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

Summaries 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 app from the Apple app store –Login with your CK username and password –Concise summaries; sections on differential diagnosis; quality of evidence graded –Not updated as rapidly as UTD

Synopsis of Syntheses Database of Abstracts of Reviews of Effects DARE –Search online in OVID –Part of OVID’s evidence based medicine reviews collection –Full text database contains critical assessments of systematic reviews published in various medical journals

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

Critical Assessment of Systematic Review cited in UTD and FC

Syntheses Cochrane Database of Systematic Reviews (DSR) –Part of the Cochrane Library (1996) –Over 900 completed reviews, 1900 protocols –Among the highest level of evidence upon which to base treatment decisions –Includes Dx since 2008 –Eyes & Vision Research Group Contains over 200 reviews –Full Text Available in Ovid

Synopses of Studies ACP Journal Club –Contains abstracts of studies selected by ACP editors as valid and clinically relevant –Part of OVID’s evidence based medicine reviews collection –Primary care focus

Primary Care Focus

When other S’s do not provide answers, search for original studies

Primary (Original) Studies Articles that report results of original research investigations Conclusions supported by data and reproducible methodology Require time to acquire and appraise Best Sources: Ovid MEDLINE and Clinical Key

“Do it yourself” Appraisal Territory You must appraise quality of the study or find analysis in evidence based summary Limit search results to “Clinical Queries” in Ovid MEDLINE or “Study Type” in Clinical Key Journal Search

Databases MEDLINE –Premiere biomedical database from the NLM (National Library of Medicine) –Covers 1946-present –Indexes >5000 international biomedical journals –Full text available for many articles –Access through Ovid and Clinical Key

Search of Current MEDLINE files yields 49 studies to scan and appraise

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

CK MEDLINE Yields 89 RCTS in last 5 Years to Scan and Appraise

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 (UpToDate, First Consult) Be aware of the filters: levels of evidence, graded recommendations, speed of updating Look at more than one resource in the hierarchy. Findings may differ Apply in clinical settings; assess your progress

Information is Ever Changing