1. Clinical Information Resources OPT 5191 Intro to Clinic II
Sandra A. Martin, M.L.I.S.
Health Sciences Resource Coordinator
Instructor of Library Services
John Vaughan Library Room 305B –

3. Existing knowledge can prevent…
Waste
Errors
Poor quality clinical care
Poor patient experience
Adoption of interventions of low value
Failure to adopt interventions of high value
Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health Service. Quoted on

4. Learning Objectives At the end of the presentation, you will:
be familiar with the information retrieval process for evidence-based patient care
be able to conduct efficient online searches of books and articles to answer background questions
be able to use the PICO model to develop clinical questions
be able to access and use synthesized, evaluated evidence to answer clinical questions
be able to conduct efficient online searches of MEDLINE using clinical filters
be able to quickly locate full text articles and books in the NSU libraries online collection

5. Sandra Provides…. Instruction Research Assistance
Consulting for individuals and small groups
Database Searches
Help in Locating Full Text Articles
Online – Mobile - Print
Customized Information Services
Assistance with any health-related information need

6. Information Retrieval for Evidence Based Patient Care
Using research findings versus conducting research
Retrieving and evaluating information that has direct application to specific patient care problems
Selecting resources that are current, valid, and available at point of care
Developing search strategies that are feasible within time constraints of clinical practice

7. Getting Started Match information resource to your information need
Ask questions to clarify your knowledge gap

8. Background Questions
Ask background questions when you need general knowledge
Two parts:
A question root: who, what, why, where, or how
An aspect of health care: disorder, test, treatment, etc.
Example:
What are the risk factors for open angle glaucoma?

9. Answers to Background Questions
Usually found in books and articles that provide overviews of broad topics
Examples:
MD Consult
Science Direct
Access Medicine
Ovid MEDLINE “Basic Search”

10. Foreground Questions
Specific knowledge questions that affect clinical decisions
Usually compare two or more concepts – drugs, treatments, tests, prognosis of two groups, harms or benefits of two approaches
Example:
Does lowering intraocular pressure medically or surgically in patients with open angle glaucoma delay visual field loss?

11. Asking and Answering Foreground Questions Requires New Skills
Clinical question formulation
Search and retrieval of best evidence
Critical appraisal of study methods

12. Integration of Clinical Research into Patient Care Process

13. What is EBM?
“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values”
Patient
Concerns
Clinical
Expertise
Best research
evidence
EBM
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2.
This definition of what EBM is and isn’t has gained wide acceptance and made it easier for us to get our points across.
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2.

14. Evolution of EBM in the Literature
Term first appeared in the literature in a 1991 editorial in ACP Journal Club Volume 114, Mar-April 1991, pp A-16
Seminal article by the Evidence-Based Medicine Working Group published in JAMA Volume 268, No. 17, 1992, pp

15. EBM Process – 5 Steps
ASSESS: Recognize and prioritize important patient problems
ASK: Construct clinical questions that facilitate an efficient search
ACQUIRE: Track down the best evidence to answer the questions
APPRAISE: Systematically evaluate best available evidence for validity, importance, and usefulness
APPLY: Interpret the applicability of evidence to specific problems, given patient preferences and values

16. Step 1 ASSESS the clinical problem Begin with the patient encounter
Select question that
Is most important to the patient’s well being
Fills gaps in your clinical knowledge
Is feasible to answer in the time available

17. Step 2 ASK focused clinical questions
Four common types of clinical questions:
Therapy/prevention
Diagnosis
Etiology
Prognosis

18. Well Built Clinical Questions
Deal with patient management issues
Contain elements of PICO Model
Patient/Population
Intervention
Comparison Intervention (if useful)
Outcome
Facilitate an efficient search

19. Example – Therapy/Prevention Question
In patients with open angle glaucoma, does topical pharmacological treatment compared to no treatment prevent progression of visual field defects?

20. Step 3 ACQUIRE: Track down the evidence to answer the question
Use the 4S approach to select the most likely resource
Start with the highest level resource available

21. 4S Hierarchy

22. 4S Examples
Evidence Based Summaries: Dynamed, FIRSTConsult, ACP PIER, UptoDate
ACP Journal Club
Cochrane and other Systematic Reviews
MEDLINE Searches limited to Clinical Queries
SOURCE: Haynes, R. B. (2001). Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence. Evidence-Based Medicine, 6 (2), Retrieved from

23. Critically Appraised Content

24. Ongoing Development of Evidence Based Summaries
None are integrated with individual patient EMRs
Can be run through same computers as EMRs
Some have direct link from within the EMR via the “Info Button”

25. Evidence Based Retrieval
Finds the answer that is supported by valid studies appropriate to the type of question and that is available in a timely manner.
Requires search terms plus best study design for question plus highest level of evidence

26. Is All Evidence Created Equal?
Small portion of medical literature is immediately useful to answer clinical questions
Understanding “wedge or pyramid of evidence” is helpful in finding highest level of evidence
High levels of evidence may not exist for all questions due to nature of medical problems and research limitations

27. As you move up the pyramid the amount of available literature decreases, but it increases in its relevance to the clinical setting.
Source:  Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

28. Therapy/Prevention Question
In patients with open angle glaucoma, does lowering intraocular pressure versus no treatment delay visual field loss?
Find the answer that is supported by valid studies appropriate to the type of question and that is available in a timely manner.

29. Extract search terms from question
Therapy/Prevention Question in PICO
In patients with open angle glaucoma [Patient/Population], does lowering intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field loss [Outcome]?

30. Possible Search Terms
Open angle glaucoma, poag, intraocular pressure, iop, visual field loss

31. Find Best Study Design for Type of Question
Therapy/prevention
Randomized controlled trials
Diagnosis
Prospective cohort, blind comparison to a gold standard
Prognosis
Cohort, Case Control, Case Series
Etiology/Harm

32. Levels of Evidence in Ovid based on AAFP Criteria
Level A = “Specificity” in Ovid Clinical Queries
Systematic reviews of randomized controlled trials including meta-analyses
Good-quality randomized controlled trials
Level B = “Sensitivity” in Ovid Clinical Queries
Good-quality nonrandomized clinical trials
Systematic reviews not in Level A
Lower-quality randomized controlled trials not in Level A
Other types of study: case control studies, clinical cohort studies, cross sectional studies, retrospective studies, and uncontrolled studies
Level C
Evidence-based consensus statements and expert guidelines

33. Find critically appraised content under “Evidence Based Medicine”

34. Systems/Summaries DynaMed Summaries for more than 3,000 topics
Monitors >500 medical journals and systematic review databases
Updated daily
Each article evaluated for clinical relevance and scientific validity
Includes “graded evidence”

35. Evidence-based answer found in 1 minute, 39 seconds
Glaucoma Summary
Evidence-based answer found in 1 minute, 39 seconds

36. DynaMed
1:39

37. Systems/Summaries ACP PIER
Over 400 evidence-based summaries for primary care published by the American College of Physicians
Recommendations based on citations from medical literature and ranked by experts at McMaster University
Updated monthly
Reference citations rated by type and quality of study

38. Systems/Summaries UptoDate
Evidence based summaries of over 9,500 topics in over 20 specialties
Ophthalmology not one of the specialties
Good for information on systemic conditions
Available through individual subscription. Online access plus Mobile app for iPhone and iPad. Cost: $199 per year in training; $499 per year in practice

39. Available in the Optometry Clinic at Hastings Hospital
Available in the Optometry Clinic at Hastings Hospital. Use Resource tab and scroll down to the UptoDate link
Sample summary at

40. Systems/Summaries FirstConsult
Available through NSU subscription to MD Consult for iPhone or iPad only
Create a personal account in MD Consult
Download the app from the Apple app store
Login with your username and password
Summaries are detailed and include sections on Differential Diagnosis
Eyes and Vision topics well covered

41. Evidence Based Journal Abstracts
ACP Journal Club
consists of two journals, ACP Journal Club, a publication of the American College of Physicians, and Evidence-Based Medicine, a joint publication of the American College of Physicians and the British Medical Journal Group
includes studies which ACP's editors have selected as methodologically sound and clinically relevant

42. Syntheses Cochrane Database of Systematic Reviews (DSR)
Part of the Cochrane Library (1996)
916 completed reviews, 1905 protocols
Among the highest level of evidence upon which to base treatment decisions
Includes Dx since 2008
Eyes & Vision Research Group
Contains over 165 reviews

43. Systematic Review
Analyzes data from several primary studies to answer a specific clinical question
Provides search strategies and resources used to locate studies
Includes specific inclusion and exclusion criteria (results in less bias)
Meta-Analysis (subclass) statistically summarizes results of several individual studies
Access full text of Cochrane reviews in OVID

44. Review found in 15 seconds
Cochrane DSR
Review found in 15 seconds

45. Copyright: The Cochrane Library, Copyright 2009, The Cochrane Collaboration

46. Levels of Evidence
Grade the quality of evidence based on the design of the clinical study
Variety of hierarchies in use

47. DynaMed

48. GRADE Grading of Recommendations Assessment, Development and Evaluation
High: High confidence that the evidence supports this finding. Further research is unlikely to change our confidence in the relationship between this clinical action and the reported patient outcome(s)
Moderate: Moderate confidence that the evidence supports this finding. Further research may change our confidence in the relationship between this clinical action and the reported patient outcome(s)
Low: Low confidence that the evidence supports this finding. Further research is likely to change our confidence in the relationship between this clinical action and the reported patient outcome(s)
Very Low (Insufficient): Very low confidence that the evidence supports this finding. There is either no evidence available, or what is available does not allow evaluation of the relationship between this clinical action and the reported patient outcome(s)
FirstConsult in transition from SORT to GRADE. See JAMA 300(15) October 2008,”Progress in Evidence-Based Medicine”, for details on GRADE

49. Appraise the Filter (pre-appraised content)
Criteria
Speed of updating
Scope and number of summaries
Summaries with graded evidence
Authors’ credentials, affiliations listed
Developing and using a rubric for evaluating evidence-based medicine point-of-care tools. Journal of the Medical Library Association, Volume 99, No. 3, July 2011
Speed of updating online evidence based point of care summaries: prospective cohort analysis. BMJ 2011;343:doi: /bmj.d5856 (Published 23 September 2011)

50. Appraisal Required by User

51. Step 4 Appraise best available evidence from original studies
If the other “S’s” don’t provide the answer, search for original studies
Use “clinical queries” limit in Ovid MEDLINE to speed retrieval
Least efficient (in terms of time) to answer clinical questions

52. Primary (Original) Studies
Articles that report results of original research investigations
Conclusions supported by data and reproducible methodology
Require time to acquire and appraise
Good Source: MEDLINE (OVID)

53. MEDLINE
Premier biomedical database from the National Library of Medicine (NLM)
Covers 1946-present
Full text available from subscribed NSU journals plus Ovid Deposit Account journals available only for NSUOCO
Ovid interface includes tools to quickly filter search results to specific study types and levels of evidence
Access from

54. To Use Clinical Queries Tool, enter search terms and then click on “Additional Limits”.

55. Ovid MEDLINE Clinical Queries Tool

57. Levels of Evidence in Ovid based on AAFP SORT
Level A = “Specificity” in Ovid Clinical Queries
Systematic reviews of randomized controlled trials including meta-analyses
Good-quality randomized controlled trials
Level B = “Sensitivity” in Ovid Clinical Queries
Good-quality nonrandomized clinical trials
Systematic reviews not in Level A
Lower-quality randomized controlled trials not in Level A
Other types of study: case control studies, clinical cohort studies, cross sectional studies, retrospective studies, and uncontrolled studies
Level C
Evidence-based consensus statements and expert guidelines

58. Step 5 APPLY the evidence to patient care problems
Practice the EBM process in daily patient encounters
Access databases and tools from
UptoDate available at Hastings Hospital
Use Resource tab and scroll down to UptoDate link

59. Take Home Points
Focused clinical question (PICO) reveals your search terms
Start your search at top of 4S hierarchy and work down
Be aware of the filter, i.e., levels of evidence, speed of updating
Look at more than one resource in the hierarchy. Findings may differ.
Practice makes perfect