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

3. 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

4. Harmful practices once supported by expert opinion
Time period
Accepted practice
Shown to be harmful
Impact on clinical practice
From 500 bc
Blood Letting
1820
Ceased in 1910
1957
Thalidomide for morning sickness in early pregnancy
1960
Withdrawn when first case report of severe malformations appeared
From 1900
Bed rest for acute low back pain
1986
Still advised by some doctors
1960s
Benzodiazepines for mild anxiety
1975
“Diazepam” prescribing fell in 1990s due to severe dependence and withdrawal symptoms
Late 1990s
Cox-2 inhibitors to treat arthritis
2004
Withdrawn following legal cases in the US
Source: Adapted from How to read a paper: the basics of evidence-based medicine. 4th edition. By Trisha Greenhalgh Blackwell Publishing

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

6. What is EBM? Patient Concerns Life-long EBM
“EBM is a process of life-long, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy, and other clinical and health care issues.”
Patient
Concerns
Life-long
Learning
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.

7. What is EBM?
“Evidence-based medicine is the integration of research evidence with clinical expertise and patient values.”best
Patient
Concerns
Clinical
Expertise
Best research
evidence
EBM
Sackett, DL, Richardson, WS, Rosenberg, WMC, & Haynes, RB (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone. .

8. Evolution of EBM in the Literature
Term “evidence based medicine” coined by Dr. Gordon Guyatt at McMaster University
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
Click on the “Evidence Based Medicine” tutorial from the Optometry web page to view a brief video of EBM history

9. Fundamentally new approach becomes widely recognized
JAMA published a series of Users’ Guides to the Medical Literature that served as the first learning tools
The first handbook, Evidence-Based Medicine: How to practice and teach EBM, by Sackett, et al, was published in Fourth edition published in 2010
Courses were developed in residency training and medical school curricula beginning in the mid-1990s
EBM process has become basic in medicine, nursing, speech pathology, occupational therapy, other health care disciplines including psychology and the social sciences

10. Integration of EBM into medical school curricula patient-doctor courses

11. EBM Process – 5 Steps
ASK: Convert need for information into answerable question
ACQUIRE: Find best evidence to answer the question
APPRAISE: Critically appraise evidence for validity, impact, and applicability
APPLY: Integrate evidence with clinical expertise and patient values
ASSESS: Evaluate own effectiveness

12. New Approach Requires New Skills
Clinical question formulation
Search and retrieval of best evidence
Critical appraisal of study methods to determine validity of results

13. 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

14. 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

15. 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.

16. Clinical/Foreground Questions
Arise in patient care setting
Fill gaps in clinical knowledge regarding
Diagnosis
Therapy/prevention
Prognosis
Etiology

17. Answers to Clinical/Foreground Questions
Require:
precise information about complex issues
trustworthy clinical research data with direct application to patient problems

18. Well Built Questions include Elements of PICO Model
P - Patient or population
I - Intervention
C - Comparison Intervention
O - Outcome

20. Evidence Based Search Strategy
Includes search terms from the clinical question
Matches best study design for type of question
Retrieves answers at highest levels of evidence

21. Use PICO model to form a 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]?

22. 1. Search Terms Primary open angle glaucoma, POAG
Ocular hypertension, OHT
Intraocular pressure, IOP
Topical medications, eyedrops, ophthalmic solutions
Visual fields, VF
Limit search results to “therapy” studies

23. 2. 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

24. 3. Highest Level of Evidence – 6S Hierarchy

26. Search First at Top Levels of 6S
MEDLINE - major source of “primary” literature
Process of searching, selecting, evaluating original research is time consuming and 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

27. Point-of-Care Resources
Evidence based summaries
Provide rapid access to concise information for 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

28. Summaries
UptoDate
Evidence based summaries of over 10,000 topics in over 22 specialties
8,500 Treatment Recommendations
GRADE System used to score recommendations and strength of evidence
Updated continuously; Includes practice changing updates
Drug database; Patient education materials
The Gold Standard of evidence summaries

29. UpToDate GRADE System UpToDate GRADE System Guyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence" and why is it important to clinicians?. BMJ. 2008;336(7651):995-8. 

30. 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]?

31. Simple UTD Search Answers Clinical Question in Seconds

32. 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

34. 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

35. Systematic Review
Analyzes data from several primary studies to answer a specific clinical question
Provides search strategies and resources used to locate studies
Uses explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies
Statistical methods (meta-analysis) may or may not be used to analyze and summarize results
Benefits: Limits bias and increases confidence in conclusions

37. Critical Assessment of Systematic Review cited in UTD and FC

38. Syntheses Cochrane Database of Systematic Reviews (DSR)
Part of the Cochrane Library (1996)
Over 3,000 reviews & protocols (reviews in the making)
The Gold Standard of systematic reviews
Eyes & Vision Research Group
Contains over 200 reviews
Full Text Available in Ovid

41. 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

43. Primary Care Focus

44. Not all topics fit the 6S Model
High levels of evidence may not exist for all questions

45. Overviews and Individual Studies
Resources:
Clinical Key (Includes MEDLINE)
Ovid MEDLINE (tools for “precise” search strategies)
Science Direct – Best for scientific and technical topics, e.g., pharmaceutics, contact lenses, refraction (does not include MEDLINE)
eBooks and library print book collection
Visionet – vision therapy related topics

46. Clinical Key
“All in one” database with full text access to 1,000 books and 500 journals in every medical and surgical specialty
Ophthalmology – Over 60 full text books
12 Content Types including MEDLINE, images & videos
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

47. MEDLINE Covers 1946-present
U. S. National Library of Medicine’s premier database. Contains over 20 million citations to journal articles in medicine, nursing, allied health, and basic sciences as they relate to health care
Covers 1946-present
Ovid and Clinical Key include “user friendly” interface. Natural language processing of keywords eliminate complicated searches
Must use Ovid or Clinical Key MEDLINE for links to full text in our subscribed journals!!

48. Science Direct
Elsevier’s database of peer reviewed journal articles (published by Elsevier) in both subscription and open access journals
NSU subscribes to journals in life sciences, health sciences, and some physical sciences
Does not include MEDLINE
Best for scientific and technical journals
Use “Advanced Search” to limit results to available full text

49. Visionet – produced by SCO
Citations to articles in Optometry journals not found in MEDLINE
Especially useful for articles on vision therapy, visual training, vision screening, low vision, practice management, etc.
No full text
Contact Sandra for help

50. 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

51. Information is Ever Changing

52. If you need Help, contact Sandra, marti004@nsuok.edu