Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6) This module explains why HINARI users might want to start by searching evidence-based.

Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6)
This module explains why HINARI users might want to start by searching evidence-based resources and highlights HINARI, as well as, freely available resources that support evidence-based practice. 01 March 2018

Table of Contents – Part A
Evidence & EBM definitions 5 step EBM process Hinari Resources (partial) Cochrane Library Joanna Briggs Institute Resources introduce you to Evidence-based Practice and related HINARI resources 01 March 2018

Patient Values/Local Conditions
What is EBP? Best Evidence Clinical Expertise Patient Values/Local Conditions The integration of best evidence* from current research, patient preferences and values, and clinical expertise to clinical questions in a timely fashion (Sackett, 2000). EBP "Evidence-Based Practice requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources." Sicily statement on evidence-based practice. BMC Medical Education, 2005 Jan 5;5(1):1 *Best available evidence is: consistent research evidence with high quality and quantity 01 March 2018

Why EBP? Improve care To bridge the gap between research & practice
“Kill as few patients as possible” (O. London) new treatment fewer side effects cheaper or less invasive resistance to existing therapies, etc. Keep knowledge and skills current (continuing education) To save time to find the best information 01 March 2018

What are some Barriers for EBP?
Time, effort & skills needed Access to evidence Overuse, underuse, misuse of evidence Poor decision making Environment not supportive of EBP Intimidation by senior clinicians 01 March 2018

How does EBP help? A patient comes to a clinic with a fresh dog bite. It looks clean and the nurse and patient wonder if prophylactic antibiotics are necessary. The nurse searches PubMed and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%. For every 100 people with dog bites, treatment with antibiotics will save 7 from infection Treating 14 (NNT) people with dog bites will prevent 1 infection You explain these numbers to the patient along with possible consequences and patient decides not to take antibiotics. On a follow up visit you find out that he did not get infected. Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007. 01 March 2018

The 5 Step EBP Process Ask Access Appraise Apply Assess
ASK: Formulate an answerable clinical question ACCESS: Track down the best Evidence 3. APPRAISE: Appraise the evidence for its validity and usefulness 4. APPLY: Integrate the results with your clinical expertise and your patient values/local conditions ASSESS: Evaluate the effectiveness of the process There are 5 main steps to the EBP process: ask, access, appraise, apply, and assess. Today we will only be looking at steps 1 and 2 in more detail, and briefly touching upon steps 3-5. (Info on Validity -

Step 1: ASK (questions, PICO)
a focused (answerable) clinical question Ask Background Questions Foreground Questions General questions - disorder What is the disorder? What causes it? How does it manifest? Treatment options? Information Resources books guidelines (best practice) narrative reviews general overview of a topic treatment of heart disease Specific questions - patient INTERVENTION/PREVENTION ETIOLOGY, RISK DIAGNOSIS PROGNOSIS Information Resources journal articles synopses of articles systematic reviews answer specific questions best medication to reduce blood pressure Starting with Step 1: Ask: There are two components that you will need to understand to master Step 1: 1) types of questions, and 2) the PICO format. Starting with types of questions: Background questions are general clinical questions about a topic. These are the kind of questions you ask when you are trying to learn about a topic that is new to you i.e. what is the disorder; what causes it; how does it manifest; what are some treatment options. These questions can be answered by using "background" resources such as books, which contain that generally agreed upon knowledge about a topic. Guidelines can be useful if you are trying to understand what is the current best practice for this topic. And narrative reviews in journals are a good source because they give a general overview of a topic i.e. Treatment of heart disease. Foreground questions ask specific questions about a specific patient. Focused, answerable clinical questions about a patient are the backbone of EBP. This is because the kind of question you ask, will determine where you go to look for information to answer that question. You will see this when we start looking at the different resources later today. Intervention/therapy questions tend to be the most common type of question asked, but there are other types of focused, clinical foreground questions we might be asking: -We might have etiology or risk questions – i.e. what causes the disease? Where does it come from? -Diagnosis questions – Diagnostic questions deal with determining whether a person has the problem, and they can also be about the kind of test you use to determine this. -Prognosis questions – who is likely to get this disease or disorder, and how likely are the chances that they will get it? Question can vary slightly by discipline, but these are the basic foreground clinical questions. Answers to foreground questions can be found in primary sources, original research articles published in journals, and secondary sources synopses (or summaries) of individual studies, as well as systematic reviews of the topic. Where narrative reviews give an overview of a broad topic, Systematic Reviews look to answer very specific questions i.e. What is more effective in reducing blood pressure in heart transplant patients, norvasc or normodyne (labetalol)? Stop for questions. So to summarize background questions are questions you ask to learn about a new topic. Foreground questions are specifically about a patient, the kind of clinical questions we are talking about when we talk about EBP and go through these 5 steps. &

P = Patient, population or problem I = Intervention
Step 1: ASK PICO Format Ask P = Patient, population or problem I = Intervention C = Comparison intervention (optional) O = Outcome Many times when you are in clinic your patients will provide you with information in a very indirect, or sometimes disorganized way. We use the PICO format to help us sort through all of the information you obtain during the clinical visit, to then write a focused, foreground clinical question. Using this format, your question will be broken down into four parts: P = Patient, population or problem (Who are the patients or populations? What is the disease?) I = Intervention (What do you want to do with this patient (e.g. treat, diagnose, observe)? C = Comparison intervention – (What is the alternative to the intervention (e.g. placebo, different drug, nothing? - sometimes you do not have a C) O = Outcome (What are the relevant outcomes (e.g. morbidity, mortality, death, complications)? If any of you have done research this PICO format should look familiar to you since it is made up of the same concepts that are typically addressed when setting up research studies.

Why should I use PICO? define problem - clarify it in your own mind
identify concepts/terms for searching ask patient centered questions: treatment of Pneumococcal Pneumonia SHOULD be different for: Terminal Cancer Patient Young, mother of 2 children Using PICO will not only help you to organize your thinking, it is also a very useful tool for organizing your literature search. Breaking down the question into these 4 specific components will help you to keep your question focused on the patient and specific problem/s, as well as the outcomes and issues that matter to your patient. For example, treatment of pneumonia would differ for a terminally ill cancer patient in comparison to a young healthy mother.

Example: Intervention Questions
A 54 year old male patient was diagnosed with intermediate grade prostate cancer and wants to know whether to get a radical prostatectomy or radiation treatment. He is concerned about the risk of impotence. Identify the 4 PICO components O.k. let’s take a moment to look at how this works: Here is the practice scenario we will be working with today: A 54 year old male patient was diagnosed with intermediate grade prostate cancer and wants to know whether to get a radical prostatectomy or radiation treatment. He is concerned about the risks of impotence. As a group let’s identify the 4 PICO components. Have them call out answer for each part of PICO, then reveal the answer in PPT. PICO P - 54 year old male / prostate cancer I – radical prostatectomy C- radiation treatment O- impotence 02 February 2018

Formulate the Clinical Question
PICO P (patient) - 54 year old male / prostate cancer I (intervention) - radical prostatectomy C (comparison intervention) - radiation treatment O (outcome) - reduce risk of impotence Focused clinical question In 54 year old male patients with intermediate grade prostate cancer, is radical prostatectomy more effective compared to radiation treatment in reducing the risk of impotence? Have them call out answer for each part of PICO, then reveal the answer in PPT. PICO P - 54 year old male / prostate cancer I – radical prostatectomy C- radiation treatment O- impotence Once you have identified your 4 components, you can then write a focused clinical question: Focused clinical question In 54 year old male patients with intermediate grade prostate cancer, is radical prostatectomy more effective compared to radiation treatment in reducing the risk of impotence? 02 February 2018

Formulate the Clinical Question
PICO P (patient) - 30 year old male with a fresh dog bite I (intervention) – prophylactic antibiotics C (comparison intervention) – clean and bandage; no antibiotics O (outcome) - reduce risk of infection Focused clinical question In 30 year old male patients with a fresh dog bite, is prophylactic antibiotics more effective then cleaning & bandaging the would in reducing the risk of infection? Deconstruct your PICO Keywords: dog OR animal* bite* antibiotics infection* Limiter: Adult, age 18 – 45 English Only 01 March 2018

Templates for EBP Questions
For a therapy: In adult patients w/total hip replacements (P), what is the effect of PCA pain Medication (I) on postoperative pain(O) compared with prn IM pain Medication(C)? For etiology: Are adult males (P) who have a vasectomy (I) at an increased (Increased/decreased) risk for/of testicular cancer (O) compared with adult males (P) with/without no vasectomy (C)? Diagnosis or diagnostic test: Are (is) mammogram(I) more accurate in diagnosing breast cancer (P) compared with clinical breast exam (C) for earlier diagnosis of breast cancer (O)? Prevention: For women under the age of 60 (P) does the use of low-dose aspirin (I) reduce the future risk of stroke (O) compared with none (C)? Prognosis: Does smoking education (I) influence young people not to smoke (O) in patients who have high risk of smoking (P)? Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins. This question template can be useful in helping you to structure the different types of focused clinical foreground questions. 02 February 2018

EBP Step 2: ACCESS (studies, hierarchies) Track Down the Best Evidence
Start “hunting” from the best resource: match your question to the best medical information resource for this question. O.k. we’ve covered the first part of Step 1 – which is “asking a focused question”. Now that you know about 1) the different Types of questions: background (general), foreground (specific), and 2) the PICO format, you are ready to start accessing the literature. With so much literature out there, you want to make sure that you start “hunting” from the best resource. In order to do this, you will need to match your question to the best medical information resource for this question.

Hierarchy of Evidence Research Studies
synthesis experimental If you recall we said that to answer foreground clinical questions we should look at journal articles. You guys already know that journal articles come from research studies. There are many types of articles because there are many types of research studies. So in order to understand why one type of article is considered to be stronger evidence than another type, we need to take a moment to look at the key research studies that generate the evidence-based literature. This pyramid is a hierarchy of evidence for the different types of medical research studies. Literature that comes directly from a study is called primary literature, so this is going to be any literature that comes from either observational or experimental studies. Synthesis: At the top we have studies that synthesize (combine) the primary literature. These are called secondary sources/literature. Looking at Observational studies: Case reports/series: these are reports on the treatment of individual patients / the evidence in these reports is not considered very strong because it is difficult to generalize or to apply the findings to a larger population /. However, literature from these reports is great when there is a rare or emerging disease. Case control / cohort: Move up the hierarchy to case control and cohort studies, we have a smaller number of studies / but these studies start to compare groups / they also have more controls in place to reduce bias (error or subjectivity). Experimental: Here at the top, RCTs are considered to be stronger evidence because controls are built into the study in order to reduce bias i.e. random sample allocation; blinding; also look at larger #s. Because there is less bias, the findings are more valid, reliable, and generalizable. Finally, at the top we have Systematic Reviews and Meta analysis. These are considered to be the gold standard / the strongest evidence in EBP. Let’s take a look as to why. observational primary literature – comes directly from a study secondary literature – combines findings from primary literature

Systematic Reviews: synthesize (combine) the findings of all high quality RCTs that studied the same question; i.e. What is more effective in reducing blood pressure in heart transplant patients, norvasc or normodyne (labetalol)? When a team conducts a SR they have to have strict inclusion criteria. This means they only include the findings from RCTs that have good methods and controls, and look at similar populations. In EBP a systematic review is considered to be the best resource to answer a foreground clinical question, because the strict inclusion criteria helps to reduce bias, and the synthesis of findings gives a broader perspective of what works. Meta Analysis: If you find a meta-analysis this is even a bit stronger than a SR, since they have used statistical tools to combine the data in a systematic review.

Hierarchy of Evidence - Medical Literature access at the level that will give you the best evidence
Track Down Filtered & Critically Appraised Expert Opinion and Not Filtered This pyramid is a Hierarchy of Evidence for all of the medical literature. Again, you can see that not all articles or information resources are considered to be equal. Information resources at the bottom of the pyramid will have the least clinical relevance, and those at the top will have the most. At the bottom we have background information, here you will find medical text books, and as we discussed, they are good for answering background questions, but are not the best resources for your patient specific, foreground questions. Next we have all of the unfiltered information. This is the type of information you would find in PubMed. This is where we find all of the primary literature from our research studies. Of course there is a large number of literature at this level, so it is harder to find what you are looking for, and the burden of determining the validity and relevance of the findings is up to you, the user. At the top of our pyramid, we have filtered and critically appraised resources. This is the literature that has been identified (summarized and synthesized) as the best for answering clinical questions. Again, a well designed systematic review is going to be the best evidence to begin answering your question. You can find SRs in specialized databases, such as Cochrane - only includes high quality SRs. How many of you have used Cochrane before? We are only going to look at PubMed today, since Cochrane studies are also included there. If you cannot find a systematic review or meta-analysis, you will want to track down the hierarchy to the next best resource. What this is, is going to depend on the type of clinical question you are asking. Background info. Most clinically relevant (at the top) Least clinically relevant (at the bottom)

Types of EBM resources: Pre-appraised literature vs
Types of EBM resources: Pre-appraised literature vs. Non-appraised literature* Pre-appraised literature uses an explicit review process – by experts - to find and appraise evidence; to provide clinicians with the best evidence, often at the point of care (evidence summaries, journals that summarize research, clinical practice guidelines) September 2016 Non-appraised or primary sources (individual research articles) answer very specific questions and provide the most recent data. One must be able to search efficiently and critically appraise the information. 23 September 2016 *Regardless of category, sources must be appraised by the user 01 March 2018

Filtered (appraised) sources: Cochrane Library, Joanna Briggs…
Select sources to find primary studies: Filtered (pre-appraised) or Not-filtered (not appraised)? Not-filtered (not-appraised) sources: Medline (PubMed), Scopus, Google/Scholar... Filtered (appraised) sources: Cochrane Library, Joanna Briggs… Create comprehensive searches Conduct systematic reviews Conduct synonym searching using thesauri Set up and distribute alerts Limit to populations & publication types ‘Not all clinicians will need or want to do lit searches and clinical appraisal’ Save Time Ask the experts Use quality research only Use at the point of care 01 March 2018

Hierarchy of Evidence – Question Type
Therapy/Prevention What should I do about this problem? RCT>cohort > case control > case series Diagnosis Does this person have the problem? cross-sectional study with blind comparison to a gold standard Etiology/Harm What causes the problem? RCT > cohort > case control > case series Prognosis/Prediction Who will get the problem? RCT >cohort study > case control > case series Frequency and Rate How common is the problem? cohort study > cross-sectional study You can see that the study types vary a little bit by question type, but for most of them the next best resource will be the literature from: RCTs, cohort, case control, case series. Stop for questions A well designed systematic review of RCTS (randomized controlled trials) is best as it is least biased therefore more valid. After that, start with the least biased study type for the question.

‘Dog Bite’ Example: Nurse Search
The nurse searches PubMed and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%. For every 100 people with dog bites, treatment with antibiotics will save 7 from infection Treating 14 (NNT) people with dog bites will prevent 1 infection 01 March 2018

EBP Step 3:Appraise (validity, impact):
Appraisal principles (primary and secondary research) Does PICO of the study match my PICO question? validity internal validity – methods How well was the study done? Is it biased? external validity generalizability impact Does it matter to your patient? GATE Appraisal Form: University of Oxford’s Center of EBM: Evaluating the Evidence section in the EBM tutorial at: CHECK THESE LINKS – add that robosis from webinar??? Step 2 was Accessing the Literature Step 3 is Appraising the Literature First you want to ask yourself- Does the PICO of the study match my PICO question? Then, no matter where you find your evidence, you always want to appraise it yourself to determine if the results of the findings are valid and useful. Starting with validity: internal validity analyzes the methods of the study How well was the study done? Is it biased? external validity looks at how generalizable the results are, here you want to think about details such as how large of a study was it? With impact you want to consider, are the findings relevant? Do they make a difference to your patient? Tools for evaluating studies can be found in the links listed in the slide.

EBP Step 4: APPLY (patient, setting):
EBP Step 4: APPLY (patient, setting): Integrate the results with your clinical expertise and your patient values Apply Patient Is my patient similar enough that the results of the study apply? Will the potential benefits outweigh the potential harms of treatment ? What does my patient think? What are his cultural beliefs? Setting Is the intervention feasible in my settings? What alternatives are available? Step 4 APPLY: In this step of the process you want to combine the knowledge from the research studies with your own clinical expertise, to determine if the findings from the research are relevant to the specific details of your patient – both their condition and personal values, and the clinical setting: Patient Is my patient similar enough that the results of the study apply? Will the potential benefits outweigh the potential harms of treatment? What does my patient think? What are their cultural beliefs? Setting Is the intervention feasible in my settings? What alternatives are available?

‘Dog Bite’ Example: Application/Recommendation/Decision
You explain these numbers to the patient along with possible consequences Probability of infection, based on age, health, etc, is low. But leaves the decision to the patient. Patient decides not to take antibiotics. 01 March 2018

Assess EBP Step 5: ASSESS (patient, yourself) Evaluate the effectiveness of the process. Am I asking questions? Am I writing down my information needs? How is my searching going? Am I becoming more efficient? What is my success rate in the EBM steps? Am I periodically syncing (checking) my skills and knowledge with new developments? Teach others EBP skills Keep a record of your questions ASSESS Evaluate the effectiveness of the process. You want to evaluate how your patient is doing, but you also want to evaluate yourself - your ability to apply the EBP process. In order to improve your skills and abilities over time you should ask yourself questions such as: How am I doing? Am I asking questions? Am I writing down my information needs? How is my searching going? Am I becoming more efficient? What is my success rate in the EBM steps? Am I periodically syncing (checking) my skills and knowledge with new developments? Teach others EBP skills Keep a record of your questions

‘Dog Bite’ Example: Follow Up
On a follow up visit you find out that he did not get infected. Keep records 01 March 2018

To learn more about EBM, go to the online tutorial Introduction to Evidence-Based Medicine. Developed by Duke University Medical Center Library and Health Sciences Library/University of North Carolina/Chapel Hill. If you are interested in learning more about EBP (also called EBM) I’ve included links to two comprehensive online tutorials here. This one was created by Duke University.

SUNY Downstate also provides a comprehensive online tutorial about EBM.
Case Series / Reports This one is from SUNY Downstate Medical Cente r in New York. It has these wonderful detailed slides about the different kinds of studies.

Hinari Resources Cochrane Library – filtered
Joanna Briggs Institute Resources - filtered Remind to ALWAYS log in through HINARI!!!! 01 March 2018

The Cochrane Library by The Cochrane Collaboration
Independent non-for-profit international collaboration Reviews are among the studies of highest scientific evidence Minimum Bias: Evidence is included/excluded on the basis of explicit quality criteria; A panel of experts reviews the evidence, peer-reviewed, dynamic (updated regularly) Reviews involve exhaustive searches for all RCT, both published and unpublished, on a particular topic Abstracts searchable for free on the Internet; Some of Cochrane Library resources searchable in PubMed 1995- 14 March 2018

The Cochrane Library Content
Cochrane Database of Systematic Reviews (CDSR) Cochrane Reviews & Protocols primarily on interventions Database of Abstracts of Reviews of Effects (DARE) Structured abstracts on other reviews also on diagnosis, prevention, rehabilitation, screening (not available in CDSR or Medline) Cochrane Central Register of Controlled Trials (CENTRAL) The largest single source of RCTs from all over the world (from Medline, Embase, conference proceedings, and more) Cochrane Methodology Register (CMR) - Methods Studies Health Technology Assessment Database (HTA) – Technology Assessments NHS Economic Evaluation Database (NHSEED)- Economic Evaluations 14 March 2018

From the Hinari Content page, open the Reference sources list to access Cochrane Library and other EBM resources. 14 March 2018

From the Reference Sources menu, we now will click on the Cochrane Library link. The Cochrane Library contains high-quality, independent evidence including reliable evidence from Cochrane and other systematic reviews and clinical trials. It is published by John Wiley. The first resource we are going to look at is of course the Cochrane Library. 14 March 2018

The initial page of this site has a title, abstract or keyword option Search engine. You also have various options in Cochrane Reviews to Browse by Topic and Browse by Review Group Open the Browse by CDSR Notice the More Resources List. 14 March 2018

Searching the Cochrane Library
Select Search manager Search for PICO terms one at a time Combine synonyms with OR Combine different terms with AND You retrieved 20 results Scroll down to view results Select Search manager Search for PICO terms one at a time Combine synonyms with OR Combine different terms with AND You retrieved 20 results Scroll down to view results 14 March 2018

Displaying Results in the Cochrane Library
All results CDSR (default) DARE CENTRAL Search all Cochrane databases at once Results from CDSR display as default Notice results from DARE, CENTRAL, etc. Systematic reviews are available Click on 1st one to view If not satisfied view reviews from DARE or Randomized Control Trials from CENTRAL 14 March 2018

Viewing Results in the Cochrane Library
Note that you can download the PDF. 14 March 2018

Review Key Information
14 March 2018

Review Abstract to see if your PICO matches review’s criteria
14 March 2018

View Main Results and Conclusions
14 March 2018

Plain Language Summary for Your Patient
14 March 2018

Viewing Randomized Control Trials from CENTRAL
14 March 2018

From the Cochrane Reviews drop down menu open Browse by Topic.
14 March 2018

From the extensive Browse by Topic list, you have another option for locating subject- specific material. 14 March 2018

JBI Database of Systematic Reviews and Implementation Reports (JBI)
JBI resources are primarily found through the Ovid platform, however, when it is feasible, some of the Protocols will be published through PROSPERO which is Open Access. Besides Systematic Reviews, JBI publishes: Best Practice Information Sheets Consumer Information Sheets Evidence Summaries Recommended Practices Systematic Review Protocols Systematic Reviews and Technical Reports 14 March 2018

Two Methods for Searching JBI: The first is article searching
No advanced Search Best bet when you have an article title/volume/issue Retrieval Path Click on J from the Journals Collection Find the JBI Database of Systematic Reviews and Implementation Reports Note: There are two options. Choose the year range that is appropriate for your citation. 14 March 2018

JBI Database of Systematic Reviews and Implementation Reports: Article Searching
Note the Article searching options. 14 March 2018

Article Searching through JBI Database
Advanced Search Search the journal issue list Using Date, Volume, issue and page number The Advanced Search is a simple title, author, etc search. Keyword/subject search; generally used when you have no citation available; this method searches 2003 to present; from volume 1/issue 1 14 March 2018

Open the Joanna Briggs Institute EBP Database from the Browse databases list -another option for locating subject- specific material. 14 March 2018

Check All Resources and click on OK.
14 March 2018

To search for just JBI materials, perform a Multi-Field Search.
Type JBI in the search box, and in the drop down menu select Journal Words. Enter specific search – Blood donation with All Fields – in the box below. Open Search History above to see more details. 14 March 2018

Field limiters available in the OVID Database for JBI:
Abstract – to ensure you are coming up with the best search possible, search for keyword; should only be used for main phrase terms; note: you will lose any material without an abstract Title - this is very specific and searchers should be very careful to only search the most specific term using this method Text Word – the text word limiter searches both Abstract and Title 14 March 2018

Example Search – JBI & infectious diseases and Africa
The results for this search are 26 that will be opened by clicking on Display Results. 14 March 2018

Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6) This module explains why HINARI users might want to start by searching evidence-based.

Similar presentations

Presentation on theme: "Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6) This module explains why HINARI users might want to start by searching evidence-based."— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6) This module explains why HINARI users might want to start by searching evidence-based.

Similar presentations

Presentation on theme: "Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6) This module explains why HINARI users might want to start by searching evidence-based."— Presentation transcript:

Similar presentations

About project

Feedback