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 Part A: Evidence & EBM definitions
5 step EBM process
HINARI Resources
Cochrane Library
Essential Evidence Plus
EBM Journals
Part B: 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. 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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9. Systematic Review: a review in which specified and appropriate methods have been used to identify, appraise, and summarize studies addressing a defined question. (It can, but need not, involve meta-analysis).
Meta-analysis: A statistical technique that summarizes the results of several studies in a single weighted estimate, in which more weight is given to results of studies with more events and sometimes to studies of higher quality.
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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10. 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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11. Definitions of other Study Types
Randomized Controlled Trial: a trial in which participants are randomly assigned to two or more groups: at least one (the experimental group) receiving an intervention that is being tested and another (the comparison or control group) receiving an alternative treatment or placebo. This design allows assessment of the relative effects of interventions.
Controlled Clinical Trial: a trial in which participants are assigned to two or more different treatment groups. In Clinical Evidence, we use the term to refer to controlled trials in which treatment is assigned by a method other than random allocation. When the method of allocation is by random selection, the study is referred to as a randomized controlled trial (RCT). Non-randomized controlled trials are more likely to suffer from bias than RCTs.
Cohort Study: a non-experimental study design that follows a group of people (a cohort), and then looks at how events differ among people within the group. A study that examines a cohort, which differs in respect to exposure to some suspected risk factor (e.g. smoking), is useful for trying to ascertain whether exposure is likely to cause specified events (e.g. lung cancer). Prospective cohort studies (which track participants forward in time) are more reliable than retrospective cohort studies.
Case control study: a study design that examines a group of people who have experienced an event (usually an adverse event) and a group of people who have not experienced the same event, and looks at how exposure to suspect (usually noxious) agents differed between the two groups. This type of study design is most useful for trying to ascertain the cause of rare events, such as rare cancers.
Case Series: analysis of series of people with the disease (there is no comparison group in case series). (From BMJ Glossary of EBM Terms:
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12. Hierarchy of Evidence & Search Approaches
Ask the Experts
Start with filtered sources
Cochrane Database of
Systematic Reviews
EBM Guidelines Essential Evidence Plus
PubMed
CINAHL
CENTRAL
Textbooks
See for Yourself
Start with unfiltered sources
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.
Evidence can be filtered (appraised) by experts but should always be evaluated by users!
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13. 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.
*Regardless of category, sources must be appraised by the user
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14. 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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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. Step1. ASK
Answer Background Questions First- What/How Questions Help you learn more about the scope of the topic and the possible alternatives in order to address the real problem.
E.g. What is hypertension? How do treatment A works?)
Formulate focused clinical questions using PICO* - Address the real problem. *You may not always have all 4 elements in one question. P
Patient: Who is the patient and what's the disease? I
Intervention: What do you want to do with this patient: treat, diagnose? C
Comparison: What alternatives are available, other drugs, placebo? O
Outcome: What are the outcomes-morbidity, mortality, complications?
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18. Next-Classify the Type of Question
What is the treatment/preventive treatment? Question of INTERVENTION/PREVENTION
What causes the problem? Question of ETIOLOGY, RISK,HARM
Does this person have the problem? Question of DIAGNOSIS
Who (and how likely) will get the problem? Question of PROGNOSIS
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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19. 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)?
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)?
For etiology/harm: 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)?
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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20. Exercise: Formulating Intervention Questions
Identify the 4 PICO components and formulate the clinical question in the following case:
A 54 year old male patient was diagnosed with intermediate grade prostate cancer. He 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.
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21. Formulate Intervention Questions
P - 54 year old male with intermediate grade prostate cancer
I - radical prostatectomy
C - radiation treatment
O - reduce risk of mortality, impotence, and incontinence
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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22. Exercise: 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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23. Formulate Etiology/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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24. Next-Decide on the best type of study for question For each type of question there is a hierarchy of evidence
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/Risk What causes the problem?
RCT > cohort > case control > case series
Prognosis/Prediction Who will get the problem?
RCT >cohort study > case control > case series
NOTE: A well designed systematic review of RCTs may be best as it is least biased therefore more valid.
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25. Exercise: A Case on Postpartum Hemorrhage
Ask the clinical question, identify type of question and best study design
A. is a 35 year old woman, mother of 4, is pregnant with her 5th child. She has a history of postpartum bleeding. She lives in a remote village with no convenient transportation and clinic nearby. A. is very worried and is wondering how likely is that this may happen to her again. She had heard about the drug Misoprostol and wants to find out if it is safe to take to prevent severe postpartum bleeding.
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26. Exercise: A Case on Postpartum Hemorrhage
In 35 year old pregnant women is Misoprostol effective in preventing severe postpartum bleeding and reducing mortality ?
This is a Question of Prevention
Best study design is RCT
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27. EBP Step 2: ACCESS the evidence
Track down the best available evidence
Start from the best resource for your question
Develop effective EBP search strategies
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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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. 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?
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30. Am I writing down my information needs?
EBP Step 5: ASSESS (patient, yourself) Evaluate the effectiveness of the process.
Assess
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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31. 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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32. The Cochrane Library The Cochrane Collaboration
Cochrane Library Content
Navigating and searching the Cochrane Library
Alternative access to content
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33. The Cochrane Collaboration
Independent non-for-profit international collaboration (36,000 contributors from 107 countries, 40 regional centers, 52 review groups)
Produces Systematic Reviews - internationally recognized as the highest standard in evidence-based health care because they contain the 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
Reviews are primarily on intervention, rehabilitation, prevention, or diagnoses
Active Consumer Network
Abstracts and plain language summaries searchable for free
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34. Content of The Cochrane Library
Cochrane Database of Systematic Reviews (CDSR)
7600 reviews & 2400 protocols
Central Register of Controlled Trials (CENTRAL)
Over 1.1 million articles
Cochrane Clinical Answers
1,600 clinical answers available
Systematic Reviews from Epistemonikos
200,000 systematic reviews
Editorials & Special Collections
Links to other systematic reviews and podcasts
Content Changes: Retired Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluations Database (EED) & Health Technology Assessment (HAA)
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35. Cochrane Database of Systematic Reviews (CDSR)
Each SR addresses a clearly formulated question, e.g. Can antibiotics help in alleviating the symptoms of a sore throat? 
All the existing primary research on a topic that meets certain pre-determined criteria is searched for and collated, and then carefully assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment.
Contains the highest level of evidence available on treatment, intervention, prevention, rehabilitation
Cochrane Reviews are updated with new evidence over time
Cochrane review groups website: cochrane.org/contact/review-groups
Full text of SR available through Cochrane Library
Plain Language summaries for each SR to help people understand the evidence
Example of SR form CDSR (next 3 slides)
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36. Example of a Cochrane Systematic Review:
Structured Abstract
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37. 30 December 2018

38. Central Register of Controlled Trials (CENTRAL)
The worlds largest database of Randomized Controlled Trials (RCTs) and Controlled Clinical Trials (CCT)
Note: Other type of studies (cohort, case control etc.) are not included
Article records are selected for inclusion from
Bibliographic databases (PubMed and Embase)
Review Group’s Specialized Register
Cochrane Review Groups maintains a collection of trials on the groups area of expertise
Hand searching of other published literature
100,000 records from ClinicalTrials.gov
No full text available from CENTRAL
Search HINARI journals for full text of articles
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39. Where the article came from-Pubmed or Embase
In Central, you can see:
Where the article came from-Pubmed or Embase
How Cochrane used the article from CENTRAL in a SR
Link to the SR where article was used (after clicking on tab How Cochrane used this article)
View the Cochrane’s independently collected PICO analysis and risk of bias for the trial
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40. Cochrane Clinical Answers (CCA)
Evidence – based answers at the point of care
Based on the high quality evidence from CDSR
Highlight the most clinically relevant outcomes from CDSR
Brief clinical summary, yet one can see the evidence on which it is based at the same time
“Take home” message format
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41. Example of Cochrane Clinical Answer
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42. Epistemonikos The words largest source of Systematic Reviews (SR)
Uses comprehensive and systematic approach to identify SR
Powered by Artificial Intelligence
Curated and annotated by experts
More about Epistemonikos’ methods:
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43. Examples of a Systematic review from Epistemonikos
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44. From the HINARI Content page, open the Reference sources list to access Cochrane Library and other EBM resources.
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45. 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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46. Now opened is the Cochrane Library site
Now opened is the Cochrane Library site. Click on Browse (by topic or by review group) or Advanced Search or Title Abstract Keyword.
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47. Select Search to create basic and advanced searches with search builder. Enter PICO terms one at a time in Title Abstract Keyword field. Combine Terms with AND. Click on Run Search or Send to Search manager – to perform more complex searching.
Select Search to create easy searches with search builder
Search your PICO terms one at a time (drug, disease/syndrome)
Combine terms with AND
Click Run Search/or Send to Search manager to perform more complex searching (add synonyms or MESH)
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48. The search for Misoprostol retrieves 5 Cochrane Systematic Reviews and 74 Trials (CENTRAL).
You retrieved 5 Cochrane SR and 74 Trials (CENTRAL)
Notice notes for type of review and date of publication
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49. Search with Medical Subject Headings (MESH)
Click on Medical terms (MESH) tab to search articles indexed with MESH (Medline articles only). Type term postpartum hemorrhage to find out what is the MESH term for your concept. The database retrieves exact term and partial matches. Scroll down and click on postpartum hemorrhage.
The MESH Tree shows hierarchy of terms. Explode selected trees and click Select. Add MESH to Search Manager to search
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50. Search using Search Manager
Select Search Manager to do more complex searches. Search PICO terms one at a time
You can add MESH directly by clicking on MESH tab next to search string. Combine terms with OR first then with AND. You retrieved 359 results
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51. Displaying Results in the Cochrane Library
Access all Content with a single search
Cochrane reviews are displayed by default.
Filter results if needed on left (e.g. status of review-filters by events that have affected the review; Update status, etc.
Click on other tabs to view Protocols (CDSR), Trials (CENTRAL), Editorials, Special Collections, Clinical answers, More (Epistemonikos reviews)
From the HINARI Content page, open the Reference sources list to access Cochrane Library and other EBM resources. Access all Content with a single search
Cochrane reviews are displayed by default.
Filter results if needed on left (e.g. status of review-filters by events that have affected the review; Update status, etc.
Click on other tabs to view Protocols (CDSR), Trials (CENTRAL), Editorials, Special Collections, Clinical answers, More (Epistemonikos reviews)
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52. Displayed are the results of the four Cochrane Protocols tab.
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53. Displayed are the results of the first 4 results from the Trials tab.
From the HINARI Content page, open the Reference sources list to access Cochrane Library and other EBM resources.
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54. Viewing a Systematic Review
View HTML or PDF
Click on View Article Information for article metrics, history of versions, sources of support, etc. -external validity.
Click on Appendices to find out rick of bias and overall risk of bias of studies generated by the Cochrane reviewers
Click on Translation notes to find out more of data analysis and characteristic of studies
From the HINARI Content page, open the Reference sources list to access Cochrane Library and other EBM resources.
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55. Cochrane Podcasts 5 min audio on latest Cochrane evidence
View entire catalog of podcasts on the Cochrane’s website or subscribe via iTunes
Download iTunes and search for ‘Cochrane Podcasts
Scroll to the bottom of the Cochrane Library website or the Cochrane website and click the menu called ‘Publications’
Cochrane Summaries are available via the Cochrane website. If the Summary has a podcast, a link to listen to that podcast will be provided
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56. Cochrane Journal Club Monthly email service launched in June 2017.
Subscribers receive 30 day free access to a Cochrane Review.
Every Journal Club includes a Clinical case
The Journal Club resources provide everything you need to present a relevant and interesting paper at your next journal club, or simply to explore a review in more depth on your own.
60+journal clubs in archive
Sign up here:
Read a Cochrane review from the Journal Club
Download Clinical Case and Discussion Questions for Journal Club
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57. From the Cochrane Reviews drop down menu open Browse by Topic.
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58. From the extensive Browse by Topic list, you have another option for locating subject- specific material.
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