EVIDENCE-BASED MEDICINE-DATABASES

MARYAM OKHOVATI

ASSOCIATE PROF.

MEDICAL LIBRARY & INFORMATION SCIENCE

KERMAN UNIVERSITY OF MEDICAL SCIENCES

OKHOVATI.MARYAM@GMAIL.COM

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