EVIDENCE-BASED MEDICINE-DATABASES€¦ · EVIDENCE-BASED PRACTICE "Evidence-Based Practice requires...
Transcript of EVIDENCE-BASED MEDICINE-DATABASES€¦ · EVIDENCE-BASED PRACTICE "Evidence-Based Practice requires...
EVIDENCE-BASED MEDICINE-DATABASES
MARYAM OKHOVATI
ASSOCIATE PROF.
MEDICAL LIBRARY & INFORMATION SCIENCE
KERMAN UNIVERSITY OF MEDICAL SCIENCES
OUTLINE
A brief introduction to Evidence
Based Medicine
Databases
- Cochrane
- UpToDate
- ClinicalKey
-OVID
-PubMed
-Clinical Queries
-AskMedline
-TRIP
ARCHIE COCHRANE
In 1979, Archie Cochrane wrote “it
is surely a criticism of our
profession that we have not
organized a critical summary, by
specialty or subspecialty, adapted
periodically of all relevant
randomized controlled trials”
WHERE DOES EBM COME FROM?
1980’s: McMasters University in Ontario, Canada
Dr. David Sackett and colleagues proposed Evidence Based
Medicine (EBM) as a new way of teaching, learning and
practicing medicine.
“…The conscientious, explicit, and judicious use of current
best evidence in making decisions about the care of
individual patients.”
(Sackett DL, et al. Evidence-based medicine: what it is and it isn’t. BMJ 1996;312:71-2.)
IN THE PRACTICE OF EVIDENCE BASED MEDICINE …
it is the physician’s duty to find the best and most
current information and apply it judiciously for the
benefit of the patient.
EVIDENCE-BASED PRACTICE
"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).
GOOD CLINICAL PRACTICE
Knowledge from best external evidence based on clinical
research
Judgement from experience.
Understanding of patient's beliefs & preferences.
WHY EBM? To improve care
To bridge the gap between research & practice
“Kill as few patients as possible” (O. London)
A new treatment might have fewer side effects.
A new treatment could be cheaper or less invasive
A new treatment may be necessary in case people develop resistance to existing therapies, etc.
To keep knowledge and skills current (continuing education)
To save time to find the best information
BENEFITS OF EBM
Minimize the errors in patient care
Reduces the cost of treatment to the patient
Optimizes the quality of patient care
Skills learnt in practicing EBM are the very same ones needed for
being a lifelong, self-directed learner
Habit of accessing literature on a daily basis is the best guarantor of
ensuring advancement of knowledge and keeping abreast of
scientific progress
PATIENT
PHYSICIANINFORMATION
Question
or Problem
THREE MAJOR
COMPONENTS of
EBM
Medical Decision
PATIENT
Values, Concerns Preferences,
Expectations
Life predicament
PHYSICIAN
Training & Experience
Current Expertise
Continued learning
Demand for proof
INFORMATION
Clinically relevant
Proven by research
Best up-to-date
evidence
EBM
THE ADDED DETAILS
THE FIVE BASIC STEPS OF EBM
1. Clinical Question: Patient-focused, problem-oriented
2. Find Best Evidence: Literary Search
3. Critical Appraisal: Evaluate evidence for quality and
usefulness
4. Apply the Evidence: Implement useful findings in clinical
practice
5. Evaluate: The information, intervention, & EBM process
EVIDENCE BASED MEDICINE
Identify a clinical problem
Ask a relevant, focused question
Acquire the necessary
resources to answer the
question
Appraise the evidence obtained
Apply to patient care
Evaluate
ASK
ACQUIREAPPRAISE
APPLY
patient
Answ
era
ble
quest
ions
Resources
Evi
dence
ASK/ BACKGROUND QUESTIONS
Background Questions
Information can be found in textbooks and review articles
General questions about conditions, illnesses, syndromes
and patterns of disease, pathophysiology
ASK/ FOREGROUND QUESTIONS
Foreground Questions
Information found in evidence-based extraction
service, guidelines, or systematic reviews
Questions about issues of care, i.e diagnostic tests or
therapies, needed for clinical decision-making
BACKGROUND and FOREGROUND QUESTIONS
FOREGROUND QUESTIONS
BACKGROUND QUESTIONS
NEW POSSIBILITIES
INDEFINITE ANSWERS
“Where do we want to go,
and how else might
we get there?”
EXPERTGRADSTUDENT
“Where are we now?
And which way are we headed?”
BASIC & CONCRETE
BACKGROUND VS. FOREGROUND
1. What causes gastroenteritis? / Background
2. Is oral rehydration as effective as IV rehydration? /Foreground
3. What are the symptoms of otitis media?/ Background
4. Can I effectively treat otitis media with a shorter course of
antibiotics?/ Foreground
5. Can this febrile infant be safely treated as an outpatient?/
Foreground
ASK/ FORMULATE THE CLINICAL QUESTION
PICO
Patient or Population
Intervention
Comparison Group
Outcome of Interest
PICO
In pediatrics patients with dental fear does playing music reduce anxiety?
Population: Pediatrics patients with dental fear
Intervention: playing music
Comparison: treatment as usual
Outcome: reduce anxiety
ASK/ FORMULATE THE CLINICAL QUESTION
1. Is oral rehydration in the emergency room more
cost-effective than IV rehydration?
• Patient/Population – Not identified. Examples: infants,
infants with vomiting.
• Intervention – Oral rehydration.
• Comparison – IV rehydration.
• Outcome – Cost-effectiveness.
ASK/ FORMULATE THE CLINICAL QUESTION
2. Will atrovent help prevent hospitalization of my 2
year old patient with an acute asthma exacerbation?
Patient/Population – Child w/ acute asthma
Intervention – Atrovent
Comparison - Not identified. Examples: standard
therapy, albuterol alone.
Outcome – Prevent hospitalization.
ASK/ FORMULATE THE CLINICAL QUESTION
3. Is 10 days of antibiotic therapy better than 5 days of
antibiotic therapy for treating an infant with acute
otitis media?
Patient/Population – Infant with AOM
Intervention – 10 days of antibiotic therapy
Comparison – 5 days of antibiotic therapy
Outcome – Not identified. Examples: Resolution of
symptoms, recurrence risk, persistent effusion.
ASK CLINICAL QUESTIONS
ACQUIRE
Select initial search terms (Population, Intervention)
Narrow search (Comparison, Outcome), using limiters
(Date of publication, Type of study, Language, Human, Specific
age,…)
Use MeSH terms
Decide on the best type of study for questionFor each type of question there is a hierarchy of evidence
Therapy/PreventionWhat should I do about this problem?
RCT>cohort > case control > case series
DiagnosisDoes this person have the problem?
cross-sectional study with blind comparison to a gold
standard
Etiology/HarmWhat causes the problem?
RCT > cohort > case control > case series
Prognosis/PredictionWho will get the problem?
RCT >cohort study > case control > case series
Frequency and Rate
How common is the problem?
cohort study > cross-sectional study
HIERARCHY OF EVIDENCE
Tra
ck D
ow
n
Filtered & Critically Appraised
Expert Opinion and Not Filtered
Background info.
ACQUIRE/ EVIDENCE-BASED SOURCES
MedlinePlus
Clinical Queries
Askmedline
UptoDate
ClinicalKey
Cochrane
Pubmed
OVID
Trip Database
MEDLINEPLUS
MEDLINEPLUS
CLINICAL QUERIES
ASKMEDLINE
TRIP DATABASE
UPTODATE
UPTODATE
a comprehensive clinical decision support resource used by professionals
around the world to diagnose and treat specific health issues.
includes more than 7700 peer-reviewed topics; fully-referenced, and illustrated
topic reviews.
more than 6,900 physician authors, editors, and peer reviewers use their deep
clinical domain expertise to critically evaluate available medical literature to
produce original content in a succinct, searchable format that can be quickly
and easily accessed at the point of care. Medline abstracts and a complete
drug information database.
An updated version of UpToDate is released every four months.
UPTODATE
UPTODATE
Content
By specialty
Patient information
Drug interactions
Calculators
Pathway
Lan interpretations
UPTODATE
UPTODATE/SEARCH
UPTODATE/SEARCH/FILTERS
UPTODATE/RESULTS
UPTODATE/GRADE
UPTODATE/GRADE TYPES
UPTODATE/DRUG INTERACTIONS
UPTODATE/DRUG INTERACTIONS/RISK RATING
UPTODATE/DRUG INTERACTIONS/RISK RATING TYPES
UPTODATE/FEATURES
UPTODATE/CALCULATORS
UPTODATE/PATIENT EDUCATION
UPTODATE/TOPICS BY SPECIALTY
UPTODATE/PRACTICE CHANGING UPDATES
UPTODATE PATHWAYS
UPTODATE/LABINTERPRETATIONS
CLINICALKEY
CLINICALKEY
a clinical search engine that supports clinical decisions by
making it easier to find and apply relevant knowledge.
ClinicalKey drives better care by delivering fast, concise
answers when every second counts, and deep access to
evidence whenever, wherever you need it.
CLINICALKEY/SEARCH BROWSE
Search
browse
CLINICALKEY
CLINICALKEY CAN NARROW RESULTS BY SOURCE TYPE, STUDY
TYPE, SPECIALTY AND DATE
CLINICALKEY CAN NARROW RESULTS BY SOURCE TYPE, STUDY
TYPE, SPECIALTY AND DATE
COCHRANE COLLABOARTION
Cochrane Database of Systematic Reviews / CDSR / Cochrane DSR Full-
text of completed systematic reviews carried out by the Cochrane
Collaboration, plus protocols for reviews currently in preparation. Reviews
are updated in the light of new evidence and the date of the latest update is
given. Database of Abstracts of Reviews of Effects (formerly Database of
Abstracts of Reviews of Effectiveness) Especially written structured
abstracts of quality-assessed systematic reviews published elsewhere in the
medical literature. Cochrane Central Register of Controlled Trials / CCTR /
CENTRAL References to randomised control trials (RCTs) identified
through hand searching of journals and databases.
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
Reviews involve exhaustive searches for all RCT, both published
and unpublished, on a particular topic
1995-
THE COCHRANE LIBRARY ( THE COCHRANE COLLABORATION)
COCHRANE/SEARCH RULES
1. Expand your search using the truncation symbol * e.g. depress* finds depression or
depressive, depressed etc. The truncation symbol can be used at the beginning and the end
of your term.
2. * is also a wildcard to signify letter(s) within a word e.g. p*ediatric finds paediatric or
pediatric. Note that singular and plural alternatives are automatically searched.
3. A question mark ? can be used to search for a single character.
4. To search phrases, put terms in quotes.
5. Combine and separate your search terms using the Boolean Operators AND or OR or
NOT.
6. If combining phrases in the same line, enclose combination threads in parentheses.
COCHRANE/ SEARCH FOR YOUR TERM(S) USING
MeSH terms
Natural language
SEARCHING FOR YOUR TERM USING NATURAL LANGUAGE
Advanced Search, Type your first term into the search box. Select Title,
Abstract or Keywords from the drop-down menu on the left. If you wish to
add another term, click on the + sign, situated to the left of the drop down
menu, and another search box and drop down menu of Boolean operators will
appear. Click on Go.
OR
Enter the keywords one by one & click on Add to Search Manager after each
word. Navigate backwards and forwards between the Search tab & the Search
Manager until all your terms are present in the Search Manager, then combine
them in the Search Manager. This option is useful if you intend to combine
terms in Natural Language with your MeSH terms in your search strategy.
COCHRANE
SEARCHING FOR THE TERM USING THE MEDICAL SUBJECT
HEADINGS (MESH DESCRIPTOR)
click on Advanced Search. Click on the Medical Terms (MeSH) search tab.
Enter your first term into the Enter MeSH term box, and select any
appropriate subheadings/ qualifiers from the drop-down menu in the Select
MeSH qualifiers box. Click on Look Up. When you search for a term using
the MeSH Thesaurus button, the database will search for all of the MeSH
descriptors that contain your term. By selecting the MeSH descriptor through
the thesaurus, the database will retrieve results containing the MeSH
descriptor and related narrower terms
the MeSH descriptor: Myocardial Infarction Anterior Wall
Myocardial Infarction; Inferior Wall Myocardial Infarction; Myocardial
Stunning; Shock, Cardiogenic etc.).
SEARCHING FOR THE TERM USING THE MEDICAL SUBJECT
HEADINGS (MESH DESCRIPTOR)
The next screen (see caption above) displays a definition of your search term,
and Thesaurus matches, including synonyms of your search term, on the left.
The central column shows you where your term sits in the MeSH tree, and
enables you to explode one or more MeSH trees. 3. If you wish to search for
the descriptor only, select the Single MeSH term (unexploded) option. If you
wish to search for the descriptor and its narrower terms, select the Tree
Number * box (es), and Explode either the selected trees or all the trees. 4. The
box on the right shows you how many results in total there are for that specific
search. Click on Add to Search Manager. 5. Repeat this procedure until you
have entered all your search terms and are ready to combine your searches in
the Search Manager tab
COMBINING SEARCH TERMS
OVID/SEARCH
OVID
1.Basic search
2.Advanced search
3.Multi-filed search
4.Find citations
OVID/BASIC SEARCH
OVID/RESULTS PAGE
OVID/SEARCH RESULTS
OVID/SEARCH/FIND CITATIONS
OVID/SEARCH FIELDS
OVID/ADVANCED SEARCH
OVID/MULTIFIELD SEARCH
PUBMED
OTHER DATABASES/ TRIP
TRIP
Turning Research Into Practice
From 1997
How the TRIP algorithms work?
- Text score
- Publication score
- Date
TRIP
LIMITATIONS OF EVIDENCE-BASED MEDICINE
“Evidence-based medicine in practice defines the likelihood of something happening. It is never 100%. It is not absolute truth. Evidence never tells you what to do.The same evidence applied in one case may not apply in another. The circumstances of the individual may be different, r the circumstances may be the same but patients may refuse one treatment in favor of another. What evidence-based medicine does is inform one about what their best options are—but it doesn’t make the decision.”
Brian Haynes MD, McMaster University at the Canadian Medical Association September 30, 2003
CONCLUSION
NATIONAL GUIDELINE CLEARINGHOUSE
CLINICAL PRACTICE GUIDELINES
CPG Infobase
Canadian Medical Association (Cancer Care Ontario)
NICE Clinical Guidelines
National Institute for Health and Clinical Evidence, UK
Evidence-Based Guidelines (Programs in Evidence-Based Care)
Best Practice Guidelines: Registered Nurses Association of Ontario (RNAO)
Guidelines (Through Clinical Key)
OTHER RESOURCES
BMJ best practice
BMJ clinical evidence
EvidenceAlert
Cinahl
EVIDENCE BASED ABSTRACT JOURNALS
Evidence-Based Medicine
ACP Journal Club
Evidence-Based Mental Health
Cancer Treatment Reviews
Evidence-Based Nursing
APPRAISE
Critical appraisal is the process of carefully and systematically
assessing the outcome of scientific research (evidence) to
judge its trustworthiness, value and relevance in a particular
context. Critical appraisal looks at the way a study is
conducted and examines factors such as internal validity,
generalizability and relevance.
APPRAISE
1. 1. Is the evidence from a known, reputable source?
2. 2. Has the evidence been evaluated in any way? If so, how and by whom?
3. 3. How up-to-date is the evidence?
4. 1. How was the outcome measured?
5. 2. Is that a reliable way to measure?
6. 3. How large was the effect size?
7. 4. What implications does the study have for your practice? Is it relevant?
8. 5. Can the results be applied to your organization?
APPRAISE
Validity
Can I trust this information?
Clinical Importance
If true, will the use of this information make an important
difference?
Applicability
Can I use the information in this instance?
APPRAISEKey Criteria:
blindness of randomisation
blindness of intervention
completeness of follow up
blinding of outcome measurement
For individual trials, mean differences (and 95% confidence intervals)
were reported for continuous variables
For categorical outcomes the relative risk and risk difference (and
95% confidence intervals) were reported
APPRAISE
Critical appraisal tools …
- CASP
APPLY THE EVIDENCE
Consider the patient preferences
EVALUATE THE PROCESS
THANKS FOR YOUR ATTENTION