1. Evidence-based Practice for HINARI Users (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.

2. Table of Contents EBM definition 5 step EBM process HINARI Resources
Cochrane Library
Evidence-based Medicine Guidelines
Essential Evidence Plus
EBM Journals
PubMed/Clinical Queries
PubMed Health
Other Resources
introduce you to Evidence-based Practice and related HINARI resources

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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?

9. 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)?

10. 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?

11. 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

12. Formulate the Clinical Question
PICO P - 54 year old male with intermediate grade prostate cancer
I - radical prostatectomy
C- radiation treatment
O- 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?

13. 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)

14. 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?

15. Templates for EBP Questions
For a therapy: In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C)?
For etiology: Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C)?
Diagnosis or diagnostic test: Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?
Prevention: For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?
Prognosis: Does __________ (I) influence ________ (O) in patients who have _______ (P)?
Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

16. 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.
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)

17. Hierarchy of Evidence Research Studies
synthesis
experimental
observational

18. 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.

19. 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
If you cannot find a systematic review (SR) to answer your question, then you must find the articles that are generated from the specific studies. Studies are the bridge between the question and the literature. Question / study is conducted / findings are written up in the literature. For each type of question there is a hierarchy of evidence, based on the types of studies. There are many types of studies, but I’m only going to speak briefly about the main studies that you need for EBP. Discuss study types.
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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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.

20. 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:

21. 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?

22. 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

23. HINARI Resources Cochrane Library – filtered PubMed – unfiltered
Clinical Queries
Filters
PubMed Health
HINARI EBM Journals
Remind to ALWAYS log in through HINARI!!!!

24. Cochrane Database of Systematic Reviews
The Cochrane Library (John Wiley)
high-quality, filtered, critically appraised Systematic Reviews from all over the world
minimum bias: evidence is included/excluded on the basis of explicit quality criteria
abstracts searchable for free on the Internet; complete database is available via HINARI

25. 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.

26. The initial page of this site has a title, abstract or keyword option Search engine. You also can Browse Cochrane Database by broad subject heading . The initial page also highlights New and Updated Cochrane Reviews. We will go to the Advanced Search.
Also from the initial page, there is a link to the Cochrane Journal Club.
Take a minute to review the main page of the Cochrane Library. Note in the upper right you can browse Cochrane Reviews and there are other sources as well, such as individual clinical trials. There is a search box and field options for searching. One can also click on Advanced Search to construct a search by filling in boxes and making selections.

27. Here we see the Advanced Search box and search for items that discuss both diarrhea AND children. Note the ability to put a wildcard * at the end of child to search for child, children.
We have opened the Advanced Search option where you can specify search fields and have the ability to combine terms using AND/OR/NOT operators.
In this text Advanced Search, we have combined diarrhea child* using the Search All Text option with the wildcard (*) used to locate the terms child and children.
Note that you also can complete a MeSH Search, look at your Search History or Saved Searches.

28. The Advanced Search results for diarrhea child
The Advanced Search results for diarrhea child* has retrieved 451 records from the Cochrane Database of Systematic Reviews. You have the option to Export All Results (save).
Note: if the results of your search are too many, you can narrow it by limiting the keyword search to Title instead of Search All Text.
Note that we retrieved more than 400 Systematic Reviews and it might be smart to further restrict the search with more terms, realizing that you might miss some good articles. For our purposes, though, let’s look at the record about oral zinc (note that variations of the spelling of diarrhoea are accounted for).

29. The screen displays the Abstract of the first systematic review listed in the search - Oral zinc for treating diarrhoea in children.
To access the full-text review, click on the Full PDF hypertext link in the left column. Other options are Summary and Standard.
Also note the hypertext links to specific sections of the systematic review.
This is the information about who did the systematic review and when it was last updated. If we click on Summary, we’ll see the following .

30. We have displayed the Abstract of the systematic review that includes the Background, Objectives, Search strategy, Selection criteria, Data collection and analysis and Main Results.
Summary gives a good overview of purpose, methodology, results, conclusions and a plane language summary (next slide).

31. The final section of the Abstract is titled Plain language summary
The final section of the Abstract is titled Plain language summary. This section is useful for disseminating the results to groups of health workers and patients.
Also note the Main results and author’s conclusions (the ‘bottom line’) as these sections discuss the review’s results and how they should be used.

32. We have displayed the PDF Full version of the Oral zinc for treating diarrhoea in children systematic review. Other options include Summary and Standard files.
Note: The url that contains gw.who.int/whalecom... shows that we have logged in to HINARI properly and will have access to the full-text version of this review.

33. From the Advanced Search page of the Cochrane Library, we have clicked on the Cochrane Reviews: By Topic hyperlink. This has displayed the Topics for Cochrane Reviews. From this extensive list, you have another option for locating subject- specific material.
Note that there are other search lists including an A-Z list, Updated Reviews and New Reviews.

34. For more training material, you can click on The Cochrane Library Help hyperlink. We have opened the Search Manual. Another option is a listing of Web Updates.

35. From the Reference Sources list, we have opened the initial page of EBM Guidelines Evidence-Based Medicine. Also published by John Wiley, this resource is a collection of clinical guidelines for primary care combined with evidence-based research.
You can Search by keyword or Browse database contents by EBM Guidelines, Evidence summaries, Pictures, Audio samples, Videos and Programs.

36. We have completed a keyword search for Influenza
We have completed a keyword search for Influenza. The results page includes summaries of the key issues including Related resources and References and links to important websites. PRIMARY and SECONDARY HITS
Also included are links to the Evidence summaries.

37. We have displayed the 2nd Evidence summary
We have displayed the 2nd Evidence summary. Each link contains a brief review of the study and notes the reference(s).

38. From the Reference Sources list, we have opened the initial page of Essential Evidence Plus. Also published by John Wiley, it includes access to Cochrane Library and also a series of databases and tools to access the EBM material.
By keyword, you can Search all or some of the databases.

39. We have opened the EBMG evidence summaries database that, via broad subject categories, has access to 4440 articles.

40. We have opened the initial page of EBMG evidence summaries listing for Infectious disease. Material is listed by either a summary view or expanded view that includes a sentence describing each entry.

41. We have opened Decision Support Tools that has 406 tools and calculators that assist in clinical decision making.

42. HINARI Evidence-Based Journals (other journals may have EBM articles)
We have browsed the ‘E’ in the HINARI Find journals by title list and it notes several journals for evidence-based practice.
Depending on publishers’ offer to countries, some of these journals may not be accessible.