1. Evidence-based Practice for HINARI Users (Advanced Course Module 6 Part A)
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.
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2. Table of Contents Evidence & EBM definitions 5 step EBM process
HINARI Resources
Cochrane Library
Evidence-based Medicine Guidelines
Essential Evidence Plus
EBM Journals
PubMed/Clinical Queries
PubMed Filters
Evidence Aid
Other (Internet) Resources
introduce you to Evidence-based Practice and related HINARI resources
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3. Tacit evidence (views and realities of doctors and patients)
What is Evidence?
Context-free scientific evidence (medical effectiveness or biomedical research)
Context sensitive scientific evidence (putting evidence into a particular operational setting)
Tacit evidence (views and realities of doctors and patients)
Evidence concerns facts intended for use to support a conclusion
A fact is something known by experience or observation
Evidence is used to support a conclusion; it is not the conclusion itself
Evidence
The first is context-free evidence, which is what works in general, or knowledge about the overall “potential” of something.
This is typically medical-effectiveness or biomedical research (e.g., male circumcision can be a strong preventative measure to HIV- acquisition In men).
The second is context-sensitive evidence, which puts evidence into a particular operational setting (e.g., male circumcision in LMICs may fail as an intervention owing to health system weakness and underlying poverty issues).
The third and often most troublesome category is tacit evidence. Roughly defined as any kind of evidence “that establishes a fact or gives reason for believing in something,” it is typically a product of expert opinion (which can be biased) and first-hand experience (which may be anomalous or misinterpreted).
Source: Lomas J et al. Conceptualizing and combining evidence for health system guidance. Canadian Health Services Research Foundation, 2005.
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4. 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
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5. 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
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6. 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
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7. 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.
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8. 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
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9. 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
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10. Pyramid of Evidence Source: JBI Levels of Evidence
To find this best available, current, valid and relevant evidence we will need to consult the research. This is my favorite pyramid, and there are many out there. Some consider RCT’s to be at the top of the pyramid. Many pyramids are beginning to include Systematic Reviews at the top of the pyramid.
Source: JBI Levels of Evidence
Developed by the Joanna Briggs Institute of Evidence and Grades of Recommendation Working Party, 2013.
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11. What is a systematic review?
“…a scientific investigation that focuses on a specific question and uses explicit, pre- specified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies.”
Source: “Finding What Works in Health Care”, Institute of Medicine,
Available from
In general, a systematic review aims to decrease bias and increase reproducibility and transparency.
They provide guidance for practice and policy- making, and identify gaps in knowledge and a need for research.
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12. traditional literature review
Systematic review vs.
traditional literature review
Review stage
Narrative review
Systematic review
Review question
Question is broad and terms are not well-defined
Question is specific; terms and protocol are defined in advance
Study selection
Convenience sampling and biased selection
Exhaustive searches with pre-defined criteria applied for selection by more than one reviewer
Quality assessment
None
Selected studies assessed for risk of bias and study quality
Synthesis
Qualitative and narrative; vote-counting may be used
Sometimes quantitative, including meta-analysis with risk of bias considered
For more information about Systematic Reviews, see Hinari_Advanced_Course_Module_6_Appendix
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13. 20 May 2018

14. Well designed Systematic Reviews¹ can be a great place to start since they contain commentary about validity.
¹A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question. Cook DJ, Mulrow CD, Haynes RB. Annals of Internal Medicine March 1, 1997; 126 (5) 376.
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15. EBM resources: searching priorities
Priority 1: Cochrane Library, Joanna Briggs - pre-appraised sources but may not discuss the topic or could be out of date
Priority 2: Clinical Queries – non pre-appraised source; search tool that focuses on ‘clinical study categories’ and ‘systematic reviews’ and could lead to up-to-date information; tool to quickly identify ebm literature
Priority 3: PubMed with appropriate filters (meta-analysis, systematic reviews, randomized controlled trials) – also non pre-appraised sources but another way of searching whole database
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16. The 5 Step EBP Process
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
Ask
Access
Appraise
Apply
Assess
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17. 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
narrative reviews
general overview of a topic
Specific questions - patient
INTERVENTION/PREVENTION
ETIOLOGY, RISK
DIAGNOSIS
PROGNOSIS
Information Resources
journal articles
synopses of articles
systematic reviews
answer specific questions
Good questions are the backbone of EBM practicing. It is important to use all parts of the question if possible when you are building the question.
Patient specific, real patient related outcomes
Morbidity: The proportion of patients with a particular disease during a given year per given unit of population
Mortality: All deaths reported in a given population. Statistical Term
Phenomena – Can relate to any category questions (diagnosis, treatment…) only involves a population (P) or an outcome (O) the outcome is a broad category (ideas, beliefs, concerns) e.g, For mothers of children with a fever what are the principle concerns?
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18. Step 1: ASK
PICO Format
Ask
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 - treat, diagnose, observe)?
C = Comparison intervention (What is the alternative to the intervention - placebo, different drug, nothing?)
O = Outcome (What are the relevant outcomes - morbidity, mortality, death, complications)?
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?)
O = Outcome (What are the relevant outcomes (e.g. morbidity, mortality, death, complications)?
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19. 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
elderly, severely demented patient
terminal cancer Patient
young, mother of 2 children
Developing the question requires:
Some background knowledge of the condition
Understanding of the patient and what are the outcomes and beliefs that matter to this patient
Death? Disability? Quality of life? Cost? Improvement of symptoms?
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20. 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.
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21. 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 death from prostate cancer and also risks of impotence and incontinence.
Identify the 4 PICO components
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22. Formulate the Clinical Question
PICO P (patient) - 54 year old male with intermediate grade prostate cancer
I (intervention) - radical prostatectomy
C (comparison intervention) - radiation treatment
O (outcome) - reduce risk of mortality, impotence, and incontinence
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 mortality, impotence, and incontinence?
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23. 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
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24. Etiology and Risk Questions What causes a disease or health condition?
The reverse of intervention questions-they deal with harmful outcomes of an activity or exposure (public health issues)
Develop a clinical question for the case:
S. is a smoker and just found out that she is 3 months pregnant. She quit smoking immediately. But she is worried if her developing baby was harmed and if the baby is at risk for having developmental problems. She is asking you if smoking during the first trimester can harm her baby?
e.g. if eating certain foods increases the risk of heart disease; or smoking increases the risk of cancer)
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25. Etiology or Risk Questions
P-babies of mothers who smoke
I- smoking in first trimester
C-nothing
O-increase risk of developmental problems
Question: Are babies of mothers who smoke during their first trimester at an increased risk of developmental disabilities?
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26. 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.
Filtered (pre-appraised) vs. Not-filtered (not appraised)
Why not get info only from textbooks and review articles? Information can be dated/old, not based on most recent evidence. Biased.
These resources help with background knowledge (learn about disease) not foreground (answer the specific clinical question for this patient)
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27. ‘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
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28. 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?
University of Oxford’s Center of EBM:
Evaluating the Evidence section in the EBM tutorial at:
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29. Apply
EBP Step 4: APPLY (patient, setting) Integrate the results with your clinical expertise and your patient values
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?
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30. ‘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.
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31. 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
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32. ‘Dog Bite’ Example: Follow Up
On a follow up visit you find out that he did not get infected.
Keep records
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33. HINARI Resources Cochrane Library – filtered
Joanna Briggs Institute - filtered
PubMed – unfiltered
Clinical Queries
Filters
HINARI EBM Journals
Remind to ALWAYS log in through HINARI!!!!
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34. 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-
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35. 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
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36. From the HINARI Content page, open the Reference sources list to access Cochrane Library and other EBM resources.
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37. 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.
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38. 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.
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39. 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
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40. 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
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41. Viewing Results in the Cochrane Library
Note that you can download the PDF.
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42. Review Key Information
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43. Review Abstract to see if your PICO matches review’s criteria
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44. View Main Results and Conclusions
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45. Plain Language Summary for Your Patient
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46. Viewing Randomized Control Trials from CENTRAL
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47. From the Cochrane Reviews drop down menu open Browse by Topic.
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48. From the extensive Browse by Topic list, you have another option for locating subject- specific material.
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