1. Evidence Based Medicine Resources
Payam Kabiri, MD. PhD. Clinical Epidemiologist Tehran University of Medical Sciences

2. Finding resources for practicing EBM
The widespread practice of Evidence Based Medicine requires that we get the right information to the right person at the right time.
Current systems frequently fail: important information is missing, presented inappropriately, distorted in reporting, never gathered, hard to search, and hard to find.

3. Objectives You will: Formulate a clinical question
Identify and utilize EBM online resources to answer your questions
EBM Databases & Resources
Guidelines
Apply rules for levels of evidence to make clinical decisions

4. Usefulness of medical information
Information Mastery
Creating a culture of inquiry
Usefulness of medical information
Relevance x Validity =
work

5. Medical Sources Types
A primary source is firsthand testimony or direct evidence concerning a topic under investigation not interpreted. Primary resources are generally articles that appear in peer-reviewed journals and are found primarily by searching Medline.
Secondary sources describe or analyze the primary sources. are summaries and analyses of the evidence derived from and based on primary sources. A secondary source is a work that appraises, interprets or analyzes. Secondary resources available as Clinical Evidence, ACP Journal Club, and Cochrane Library, EBMR.
Tertiary resources list, compile, digest or index primary or secondary sources.  Examples of tertiary resources include UpToDate, DynaMed, TripDatabase.

6. EBM Resources Systematic Literature Searches
Cochrane Library (OVID)
Clinical Evidence
Systematic Literature Surveillance
ACP Journal Club (OVID)
DARE
DynaMed
Medical InfoRetriever
EMB Search Engine
TRIP Database
Today we are going to learn how to use these resources.
Clinical Evidence: Currently we don’t subscribe to this. I have recommended we do. Clinical Evidence summarizes the current state of knowledge and uncertainty about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature. It is neither a textbook of medicine nor a set of guidelines. It describes the best available evidence from systematic reviews and RCTs, and if there is no good evidence it says so.
Clinical Evidence aims to help people make informed decisions about which treatments to use. It can also show where more research is needed. For clinicians and patients we wish to highlight treatments that work and for which the benefits outweigh the harms, especially those treatments that may currently be underused. We also wish to highlight treatments that do not work or for which the harms outweigh the benefits. For the research community our intention is to highlight gaps in the evidence — where there are currently no good RCTs or no RCTs that look groups of people or at important patient outcomes
The Database of Abstracts of Reviews of Effects DARE includes structured abstracts of systematic reviews from around the world, which have been critically appraised by reviewers at the NHS Centre for Reviews and Dissemination at the University of York, England. DARE also contains references to other reviews which may be useful for background information. We subscribe to this through OVID.
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EBM Resources

7. Guidelines What is a guideline? Guidelines may be
Explicit evidence-based
Evidence-based
Research-based (highly referenced)
Opinion-based
“expert consensus”
Definition of Clinical Practice Guideline
The National Guideline Clearinghouse™ (NGC™) employs the definition of clinical practice guideline developed by the Institute of Medicine (IOM).
Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. [Institute of Medicine. (1990). Clinical Practice Guidelines: Directions for a New Program, M.J. Field and K.N. Lohr (eds.) Washington, DC: National Academy Press. page 38].
Criteria for Inclusion of Clinical Practice Guidelines in NGC
All of the criteria below must be met for a clinical practice guideline to be included in NGC.
The clinical practice guideline contains systematically developed statements that include recommendations, strategies, or information that assists physicians and/or other health care practitioners and patients make decisions about appropriate health care for specific clinical circumstances.
The clinical practice guideline was produced under the auspices of medical specialty associations; relevant professional societies, public or private organizations, government agencies at the Federal, State, or local level; or health care organizations or plans. A clinical practice guideline developed and issued by an individual not officially sponsored or supported by one of the above types of organizations does not meet the inclusion criteria for NGC.
Corroborating documentation can be produced and verified that a systematic literature search and review of existing scientific evidence published in peer reviewed journals was performed during the guideline development. A guideline is not excluded from NGC if corroborating documentation can be produced and verified detailing specific gaps in scientific evidence for some of the guideline's recommendations.
The guideline is English language, current, and the most recent version produced. Documented evidence can be produced or verified that the guideline was developed, reviewed, or revised within the last five years.
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EBM Resources

8. Levels of Evidence Level 1: Randomized Clinical Trials
Level 2: Head to Head Trial or Systematic Review of Cohort Studies
Level 3: Case-Control Studies
Level 4: Case-series
Level 5: Expert Opinion

9. Levels of Evidence Type of Study Level of Evidence 1a 1b 2a 2b 3a 3b 4
Systematic reviews of randomized clinical trials (RCTs) 1b
Individual RCTs 2a
Systematic reviews of cohort studies 2b
Individual cohort studies and low-quality RCTs 3a
Systematic reviews of case-controlled studies 3b
Individual case-controlled studies 4
Case series and poor-quality cohort and case-control studies 5
Expert opinion based on clinical experience
Levels of Evidence
To help clinicians critically review the external evidence they locate, Sackett et al. developed a hierarchical model to categorize most studies. It is important to note that these levels of evidence are not a rigid set of rules, but serve only as a set of guidelines for the critical appraisal of the literature.
According to Sackett (BMJ 1996;312:71-2), the randomized trial (especially the systematic review of randomized trials) has become the “gold standard” for judging whether or not a particular treatment is beneficial.
The practice of evidence-based medicine is not restricted to randomized trials. Studies from other levels may be better meet you needs for information or may be better in terms of quality. For example, although the cohort study design ranked lower than that of the randomized controlled trial, it may be the highest level of evidence (excluding systematic reviews) for other aspects of patient care (e.g., validity of diagnostic tests, assessing prognosis) or when randomized controlled clinical trials cannot be performed due to ethical concerns (e.g., study of harmful interventions or exposures).
Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

10. Guidelines Resources www.guideline.gov (AHRQ)
(MD Consult)
(NICE)
(SIGN clinical guidelines)
(Guidelines International Network (G-I-N)

11. Cochrane Database Included in OVID subscription Limitations
limited to English
only addresses questions amenable to randomized trials
most of medicine has not been studied enough to allow for conclusions
Cochrane Review Groups
Cochrane Acute Respiratory Infections Group Cochrane Airways Group Cochrane Anaesthesia Group Cochrane Back Group Cochrane Breast Cancer Group Cochrane Colorectal Cancer Group Cochrane Consumers & Communication Group Cochrane Cystic Fibrosis and Genetic Disorders Group Cochrane Dementia and Cognitive Improvement Group Cochrane Depression, Anxiety and Neurosis Group Cochrane Developmental, Psychosocial and Learning Problems Group Cochrane Drugs and Alcohol Group Cochrane Ear, Nose and Throat Disorders Group Cochrane Effective Practice and Organisation of Care Group Cochrane Epilepsy Group Cochrane Eyes and Vision Group Cochrane Fertility Regulation Group Cochrane Gynaecological Cancer Group Cochrane Haematological Malignancies Group Cochrane Heart Group Cochrane Hepato-Biliary Group Cochrane HIV/AIDS Group Cochrane Hypertension Group Cochrane Incontinence Group Cochrane Infectious Diseases Group Cochrane Inflammatory Bowel Disease Group Cochrane Injuries Group Cochrane Lung Cancer Group Cochrane Menstrual Disorders and Subfertility Group Cochrane Metabolic and Endocrine Disorders Group Cochrane Methodology Review Group Cochrane Movement Disorders Group Cochrane Multiple Sclerosis Group Cochrane Musculoskeletal Group Cochrane Musculoskeletal Injuries Group Cochrane Neonatal Group Cochrane Neuromuscular Disease Group Cochrane Oral Health Group Cochrane Pain, Palliative Care and Supportive Care Group Cochrane Peripheral Vascular Diseases Group Cochrane Pregnancy and Childbirth Group Cochrane Prostatic Diseases and Urologic Cancers Group Cochrane Renal Group Cochrane Schizophrenia Group Cochrane Sexually Transmitted Diseases Group Cochrane Skin Group Cochrane Stroke Group Cochrane Tobacco Addiction Group Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Cochrane Wounds Group
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EBM Resources

12. Cochrane Databases
The Cochrane Library is a collection of 6 main databases and 1 additional databases that describe Cochrane as an organization. These are:
The Cochrane Database of Systematic Reviews (CDSR)
The Cochrane Database of Reviews of Effects (DARE)
The Cochrane Central Register of Controlled Trials (CENTRAL)
The Cochrane Database of Methodology Reviews (CDMR)
Health Technology Assessment Database (HTA)
NHS Economic Evaluation Database (NHS EED)
THE COCHRANE METHODOLOGY REGISTER (CMR)
About The Cochrane Collaboration and the Cochrane Collaborative Review Groups
The Cochrane Library is a collection of 6 main databases and 2 additional databases that describe Cochrane as an organization. These are:
The Cochrane Database of Systematic Reviews (CDSR)
The Cochrane Database of Reviews of Effects (DARE)
The Cochrane Central Register of Controlled Trials (CENTRAL)
The Cochrane Database of Methodology Reviews (CDMR)
Health Technology Assessment Database (HTA)
NHS Economic Evaluation Database (NHS EED)
About the Cochrane Collaboration
List of Review Groups

13. The Cochrane Library 2007, Issue 4
Database
Total Records
The Cochrane Database of Systematic Reviews (Cochrane Reviews)
5053
Database of Abstracts of Reviews of Effects (DARE)
6761
The Cochrane Central Register of Controlled Trials (CENTRAL)
522,340
The Cochrane Database of Methodology Reviews (Methodology Reviews) 20
The Cochrane Methodology Register (Methodology Register)
10,008
Health Technology Assessment Database (HTA)
7078
NHS Economic Evaluation Database (NHS EED)
22,731
About The Cochrane Collaboration and the Cochrane Collaborative Review Groups (About) 92

14. ACP Journal Club About 100 journals systematically surveyed
Highest-validity articles abstracted
Structured abstracts to guide critical appraisal
Clinical commentary
Included in our OVID subscription
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EBM Resources

15. UpToDate
& you know UpToDate …. !
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EBM Resources

16. DynaMed Designed as entry point to information
Textbooks and Medline not efficient
Intuitive clinical organization
Brief summarized information presented
Links and references if more details needed
ICD-9 codes and links to patient information handouts
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EBM Resources

17. E-Books MD Consult Free Books 4 Doctors Gigapedia
Free Books 4 Doctors
Gigapedia

18. EBM Calculators
Statistics for Diagnostic, Prospective, Case Control & Randomized studies
Can graph pre- and post test probability with likelihood ratio for Diagnostic Studies.
Can save results and view at another time EBM Calculator – Centre for EBM – University Health Network

19. EBM Online Calculators
Some Examplses:

20. Selected Electronic Health Information Resources
Internet Address
ACP Journal Club
Cochrane Library
UpToDate
PubMED
eMedicine
Clinical practice guidelines
MD Consult
EBMR Reviews (OVID)
Selected Electronic Health Information Resources

21. Bandolier http://www.medicine.ox.ac.uk/bandolier/
A monthly newsletter about evidence-based health care; top source for such information on the net.

22. Evidence-Based Medicine http://www.evidence-basedmedicine.com
Bi-monthly journal which summarises important recent articles from major clinical fields (family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, public health, surgery). (Note: Best Evidence is the cumulated contents of ACP Journal Club (since 1991) and Evidence-Based Medicine (since 1995) in an annual CD.

23. BestBETS http://www.bestbets.org
Provides rapid evidence-based answers to reallife clinical questions in emergency medicine, using a systematic approach to reviewing the literature. BETs take into account the shortcomings of much current evidence, allowing physicians to make the best of what there is. Developed in the Emergency Department of Manchester Royal Infirmary, UK.

24. Clinical Evidence http://www.clinicalevidence.com
Clinical Evidence is an updated directory of evidence on the effects of clinical interventions. It summarises the current state of knowledge, ignorance, and uncertainty about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature. It covers 20 specialties and includes 134 conditions. Updated/expanded coverage every six months in print and CD.

25. TRIP Database http://www.tripdatabase.com
Searches several different evidence-based resources including PubMed, Bandolier, and the ATTRACT question-answering service. Only allows title searches, but does allow AND, OR, NOT

26. How to Search?
Use the components of the PICO to direct your search • (Population OR synonym1 OR synonym2…) AND • (Intervention OR synonym1 OR synonym2…) AND • (Comparator OR synonym1 OR synonym2…) AND • (Outcome OR synonym1 OR synonym2…)

27. EBM “Systems” vs Traditional Textbook Model
Author is an “authority”
Author selects, reports on own
One-year production line from manuscript to bookstand
Three-year production schedule

28. Updating in EBM Systems
Authors are provided with new studies and reviews that are:
Assessed for validity
Rated by clinicians for relevance
Rated by clinicians for newsworthiness
Within a month of original publication

29. Computerized Decision Evidence-based textbook
Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based Journals
Synopses
Cochrane reviews
Syntheses
Original published
Articles like Medline
Studies

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