Transcript 1. Clinical Information Resources/Evidence Based

Clinical Information Resources/
Evidence Based Practice
Sandra A. Martin, M.L.I.S.
Health Sciences Resource Coordinator
Instructor of Library Services
John Vaughan Library Room 305B
[email protected] – 918-444-3263
Sandra Martin Provides….
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Instruction
Research Assistance
Small Group Consulting
Database Searches
Collection Development (Selection of print and online
books, audiovisuals, journals and databases)
Assistance with any health-related information need
Office Hours: Tuesday 10 am to 4 pm
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Start your Search Here: http://library.nsuok.edu/collegeop/
OPT Resources are NOT on this page. Choose “College of Optometry” to
navigate to the Library Resources for Optometry page
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Start your Search Here: http://library.nsuok.edu/collegeop/
Optometry Journals A-Z
Remote Access
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Enter NT-NSU user id and password to access the
library’s electronic resources
Contact Tom Tinnell if you have problems with your user
id or password
Contact Sandra to report other technical problems or for
search assistance
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Helpful Tools
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Optometry Web Page
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Optometry Databases, e-journals, e-books, and other tools
available 24/7
Supports specific research, teaching, and patient care needs of
NSUOCO faculty, students, and residents
Start Here to find resources for all optometry and medical topics
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http://library.nsuok.edu/collegeop/index.html
Important: Link directly from the Optometry web page
to all “Optometry” journals A-Z that include full text
NOTE: Google Chrome Browser works best
Quick Access to Full Text Articles
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For All Optometry Journals by Title
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For other health sciences journals (non-Optometry)
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Click on the A-Z Pad from the Optometry web page
Links display to all Optometry journals with full text available
Click on the collection links (Clinical Key, Science Direct, NSU
Journals@Ovid) OR
Click on the link to “All Library e-Journals”
Enter the full journal title
If you cannot locate full text in a specific journal, place an
order for the article through Interlibrary Loan (free)
Interlibrary Loan/Document Delivery
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Services
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ILL Requests
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Scan and email pdf of articles from journals in the library’s
print collection – you do not have to pull print journals from
the shelf and scan or photocopy
Deliver books, audiovisuals, and journal articles not owned
by the library
Journal articles delivered electronically if possible
Click on Interlibrary Loan link from Optometry Web Page
Create the online Iliad Profile
Complete online request form for articles and books
Contact [email protected] for help
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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 http://www.nks.nhs.uk/.
Harmful practices once supported by expert opinion
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Time period
Accepted practice
Shown to
be harmful
Impact on clinical
practice
From 500 bc
Blood Letting
1820
Ceased in 1910
1957
Thalidomide for
morning sickness in
early pregnancy
1960
Withdrawn when first
case report of severe
malformations
appeared
From 1900
Bed rest for acute
low back pain
1986
Still advised by some
doctors
1960s
Benzodiazepines
for mild anxiety
1975
“Diazepam”
prescribing fell in
1990s due to severe
dependence and
withdrawal symptoms
Late 1990s
Cox-2 inhibitors to
treat arthritis
2004
Withdrawn following
legal cases in the US
Source: Adapted from How to read a paper: the basics of evidence-based medicine. 4th edition. By
Trisha Greenhalgh. 2010 Blackwell Publishing
Learning Objectives
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To familiarize residents with the information retrieval
process for evidence-based research & patient care
To enable residents to use synthesized/filtered/preappraised resources to answer clinical questions
To enable residents to use the 6S hierarchy of
organization of evidence to plan search strategies
What is EBM?
www.cebm.net
“EBM is a process of life-long, self-directed learning in which caring for
our own patients creates the need for clinically important
information about diagnosis, prognosis, therapy, and other clinical
and health care issues.”
Patient
Concerns
EBM
Best research Life-long
Learning
evidence
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.
What is EBM?
www.cebm.net
“Evidence-based medicine is the integration of research
evidence with clinical expertise and patient values.”best
Patient
Concerns
EBMClinical
Best research
evidence Expertise
Sackett, DL, Richardson, WS, Rosenberg, WMC, & Haynes, RB (1996). Evidence-Based Medicine: How to
practice and teach EBM. London: Churchill-Livingstone.
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Evolution of EBM in the Literature
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Term “evidence based medicine” coined by Dr. Gordon
Guyatt at McMaster University
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 2420-2425
Click on the “Evidence Based Medicine” tutorial from the
Optometry web page to view a brief video of EBM history
Fundamentally new approach
becomes widely recognized
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JAMA published a series of Users’ Guides to the Medical
Literature that served as the first learning tools
The first handbook, Evidence-Based Medicine: How to
practice and teach EBM, by Sackett, et al, was published
in 1996. Fourth edition published in 2010
Courses were developed in residency training and
medical school curricula beginning in the mid-1990s
EBM process has become basic in medicine, nursing,
speech pathology, occupational therapy, other health
care disciplines including psychology and the social
sciences
Integration of EBM into medical school
curricula patient-doctor courses
EBM Process – 5 Steps
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ASK: Convert need for information into answerable
question
ACQUIRE: Find best evidence to answer the question
APPRAISE: Critically appraise evidence for validity,
impact, and applicability
APPLY: Integrate evidence with clinical expertise and
patient values
ASSESS: Evaluate own effectiveness
New Approach Requires New Skills
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Clinical question formulation
Search and retrieval of best evidence
Critical appraisal of study methods to determine validity
of results
Information Retrieval for Evidence
Based Patient Care
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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
Is All Evidence Created Equal?
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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
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.
Clinical/Foreground Questions
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Arise in patient care setting
Fill gaps in clinical knowledge regarding
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Diagnosis
Therapy/prevention
Prognosis
Etiology
Answers to Clinical/Foreground
Questions
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Require:
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precise information about complex issues
trustworthy clinical research data with direct
application to patient problems
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Well Built Questions include
Elements of PICO Model
PICO-
Patient or population
Intervention
Comparison Intervention
Outcome
Evidence Based Search Strategy
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Includes search terms from the clinical question
Matches best study design for type of question
Retrieves answers at highest levels of evidence
Use PICO model to form a question
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Therapy/Prevention Question
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In patients with primary open angle glaucoma
or ocular hypertension [Patient/Population],
do topical medications to reduce intraocular
pressure [Intervention] versus no treatment
[Comparison Intervention], delay visual field
defect progression [Outcome]?
1. Search Terms
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Primary open angle glaucoma, POAG
Ocular hypertension, OHT
Intraocular pressure, IOP
Topical medications, eyedrops,
ophthalmic solutions
• Visual fields, VF
• Limit search results to “therapy” studies
2. Best Study Design for Type of Question
Type of Question
Study Design
Therapy/prevention
Randomized controlled
trials
Diagnosis
Prospective cohort, blind
comparison to a gold
standard
Prognosis
Cohort, Case Control, Case
Series
Etiology/Harm
Cohort, Case Control, Case
Series
Search First at Top Levels of 6S
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MEDLINE - major source of “primary” literature
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Process of searching, selecting, evaluating original research is
time consuming and requires critical appraisal skills
Filtered/Synthesized/Evaluated resources - “secondary”
literature
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Speed application of evidence at “point-of-care”
Grade strength of treatment recommendations
Rate quality of research evidence
Point-of-Care Resources
Evidence based summaries
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Provide rapid access to concise information for clinicians at the
point of care
Not a database of articles from books, journals, or guidelines
Original, current, summaries written by experts
Formal systems used to grade strength of recommendations
and quality of evidence
Available from Optometry web page
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UpToDate
First Consult
Summaries
• UptoDate
– Evidence based summaries of over 10,000
topics in over 22 specialties
– 8,500 Treatment Recommendations
– GRADE System used to score
recommendations and strength of evidence
– Updated continuously; Includes practice
changing updates
– Drug database; Patient education materials
– The Gold Standard of evidence summaries
UpToDate GRADE System
UpToDate GRADE System
Guyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence"
and why is it important to clinicians?. BMJ. 2008;336(7651):995-8.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364804/pdf
/bmj-336-7651-analysis-00995.pdf
Clinical Question
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Therapy/Prevention
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In patients with primary open angle glaucoma
or ocular hypertension [Patient/Population],
do topical medications to reduce intraocular
pressure [Intervention] versus no treatment
[Comparison Intervention], delay visual field
defect progression [Outcome]?
Simple UTD Search Answers
Clinical Question in Seconds
Summaries
• FirstConsult
– Search online in Clinical Key
– App available through NSU subscription to
Clinical Key for iPhone or iPad only
– Create a personal account in Clinical Key
– Download the app from the Apple app store
– Login with your CK username and password
– Concise summaries; sections on differential
diagnosis; quality of evidence graded
– Not updated as rapidly as UTD
Synopsis of Syntheses
• Database of Abstracts of Reviews of
Effects DARE
– Search online in OVID
– Part of OVID’s evidence based medicine
reviews collection
– Full text database contains critical
assessments of systematic reviews published
in various medical journals
Systematic Review
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Analyzes data from several primary studies to
answer a specific clinical question
Provides search strategies and resources used
to locate studies
Uses explicit methods to identify, select, and
critically appraise relevant research and to
collect and analyze data from the studies
Statistical methods (meta-analysis) may or may
not be used to analyze and summarize results
Benefits: Limits bias and increases confidence
in conclusions
Critical Assessment of Systematic Review cited in UTD and FC
Syntheses
• Cochrane Database of Systematic
Reviews (DSR)
– Part of the Cochrane Library (1996)
– Over 3,000 reviews & protocols (reviews in
the making)
– The Gold Standard of systematic reviews
– Eyes & Vision Research Group
• Contains over 200 reviews
– Full Text Available in Ovid
Synopses of Studies
• ACP Journal Club
– Contains abstracts of studies selected by ACP
editors as valid and clinically relevant
– Part of OVID’s evidence based medicine
reviews collection
– Primary care focus
Primary Care Focus
Not all topics fit the 6S Model
High levels of evidence may not exist for all questions
Overviews and Individual Studies
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Resources:
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Clinical Key (Includes MEDLINE)
Ovid MEDLINE (tools for “precise” search
strategies)
Science Direct – Best for scientific and
technical topics, e.g., pharmaceutics, contact
lenses, refraction (does not include MEDLINE)
eBooks and library print book collection
Visionet – vision therapy related topics
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Clinical Key
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“All in one” database with full text access to 1,000 books
and 500 journals in every medical and surgical specialty
Ophthalmology – Over 60 full text books
12 Content Types including MEDLINE, images & videos
Access to information at all levels from topic overview to
evidence-based data in one search
Smart search engine matches first few letters of search
word/words to relevant clinical content
No complicated search strategies or Boolean connectors
Easier than Google – but with reliable, evidence-based
results
MEDLINE
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U. S. National Library of Medicine’s premier database.
Contains over 20 million citations to journal articles in
medicine, nursing, allied health, and basic sciences as
they relate to health care
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Covers 1946-present
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Ovid and Clinical Key include “user friendly” interface.
Natural language processing of keywords eliminate
complicated searches
Must use Ovid or Clinical Key MEDLINE for links to full
text in our subscribed journals!!
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Science Direct
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Elsevier’s database of peer reviewed journal
articles (published by Elsevier) in both
subscription and open access journals
NSU subscribes to journals in life sciences,
health sciences, and some physical sciences
Does not include MEDLINE
Best for scientific and technical journals
Use “Advanced Search” to limit results to
available full text
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Visionet – produced by SCO
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Citations to articles in Optometry journals not found in
MEDLINE
Especially useful for articles on vision therapy, visual
training, vision screening, low vision, practice
management, etc.
No full text
Contact Sandra for help
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Take Home Points
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Focused clinical question (PICO) reveals your
search terms and best type of studies
Start your search at top of 6S hierarchy and
work down (UpToDate, First Consult)
Be aware of the filters: levels of evidence,
graded recommendations, speed of updating
Look at more than one resource in the
hierarchy. Findings may differ
Information is Ever Changing
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