How to Find Best Current Evidence

How to find current best evidence How to find current best evidence

Unit Pengembangan & Evaluasi Pendidikan ( UPEP )Unit Pengembangan & Evaluasi Pendidikan ( UPEP )FacultY of MedicinE – UniversitY of SriwijayAFacultY of MedicinE – UniversitY of SriwijayA

Palembang Palembang

UPEP FK UNSRI UPEP FK UNSRI

IntroductionIntroduction

One solution for the problem of obsolescence of One solution for the problem of obsolescence of professional education is “problem-based learning” professional education is “problem-based learning” or “learning by inquiry”. or “learning by inquiry”.

That is, when confronted by a clinical question for That is, when confronted by a clinical question for which we are unsure of the current best answer, which we are unsure of the current best answer,

we need to develop the habit of looking for the we need to develop the habit of looking for the current best answer as efficiently as possible current best answer as efficiently as possible


The success of learning by inquiry depends heavily The success of learning by inquiry depends heavily on being able to find the current best evidence to on being able to find the current best evidence to manage pressing clinical problemsmanage pressing clinical problems

a task that can be either quick and highly rewarding a task that can be either quick and highly rewarding or time-consuming and frustrating. or time-consuming and frustrating.


ORIENTATION TO EVIDENCE-BASED ORIENTATION TO EVIDENCE-BASED INFORMATION RESOURCESINFORMATION RESOURCES

Where to find the best evidenceWhere to find the best evidence1. 1. Burn your traditional textbooksBurn your traditional textbooks2. Take a “4S” approach to evidence-based2. Take a “4S” approach to evidence-based information accessinformation access 3. Organize access to evidence-based information3. Organize access to evidence-based information services services 4. Is it time to change how you seek best evidence?4. Is it time to change how you seek best evidence?


1. 1. Burn your traditional textbooksBurn your traditional textbooks

begin with textbooks, only to dismiss all but the best begin with textbooks, only to dismiss all but the best of a new breed of them of a new breed of them

because textbooks are generally well organized for because textbooks are generally well organized for clinical use and much of their content will be current clinical use and much of their content will be current at any one time at any one time

Unfortunately, in most texts, there’s no way to tell Unfortunately, in most texts, there’s no way to tell what is what is up-to-dateup-to-date and what is not. and what is not.


we may find some useful information in texts about we may find some useful information in texts about ““background questionsbackground questions”, such as the ”, such as the pathophysiology of clinical problems.pathophysiology of clinical problems.

it is best not to use them for seeking the answers to it is best not to use them for seeking the answers to ““foreground questionsforeground questions”, such as the causal (risk) ”, such as the causal (risk) factors, diagnosis, prognosis, prevention or treatment factors, diagnosis, prognosis, prevention or treatment of a disorder if there is an up-to-date, evidence-of a disorder if there is an up-to-date, evidence-based alternative.based alternative.


2. Take a “4S” approach to evidence-based information 2. Take a “4S” approach to evidence-based information accessaccess


3. Organize access to evidence-based 3. Organize access to evidence-based information servicesinformation services

almost all the resources just reviewed are available on the almost all the resources just reviewed are available on the Internet Internet

added value of accessing these services on the Internet is added value of accessing these services on the Internet is considerable, including links to full-text journal articles, considerable, including links to full-text journal articles, patient information, and complementary texts. patient information, and complementary texts.

you need to be in a location, such as a medical library, you need to be in a location, such as a medical library, hospital or clinic hospital or clinic

You should ask your university, professional school, hospital, You should ask your university, professional school, hospital, or clinic librarian about what digital library licenses are or clinic librarian about what digital library licenses are available and how you can tap into them available and how you can tap into them


the UK National Health Service provides a broad range of the UK National Health Service provides a broad range of evidence-based and other information to all health evidence-based and other information to all health professionals and citizens through its National Electronic professionals and citizens through its National Electronic Library of Health (NeLH, Library of Health (NeLH, http://http://www.nelh.nhs.ukwww.nelh.nhs.uk//), and ), and Australia and Latin-American countries have free access to Australia and Latin-American countries have free access to the Cochrane Library the Cochrane Library

in a country with low resources, The Health Internetwork in a country with low resources, The Health Internetwork Access to Research Information program (HINARI, Access to Research Information program (HINARI, http://http://www.healthInternetwork.netwww.healthInternetwork.net//) provides institutional access to ) provides institutional access to a wide range of journals and texts at no or low cost.a wide range of journals and texts at no or low cost.

http://www.nelh.nhs.uk/



http://www.healthinternetwork.net/




. Free access to high-quality evidence-based information . Free access to high-quality evidence-based information abounds on the Internet; beginning with PubMed and its full-abounds on the Internet; beginning with PubMed and its full-text links; open-access journals, such as BioMed Central (text links; open-access journals, such as BioMed Central (http://http://www.biomedcentral.comwww.biomedcentral.com//), and the Public Library of ), and the Public Library of Science (Science (http://http://www.publiclibraryofscience.orgwww.publiclibraryofscience.org//); the many ); the many evidence-based resources available through SCHARR (evidence-based resources available through SCHARR (http://http://www.shef.ac.uk/~scharr/ir/nettingwww.shef.ac.uk/~scharr/ir/netting//) )

using free Internet services requires a commitment to finding using free Internet services requires a commitment to finding and appraising information; free, high-quality evidence-based and appraising information; free, high-quality evidence-based information is in much lower supply and concentration on the information is in much lower supply and concentration on the Internet than in the specialized resources mentioned above. Internet than in the specialized resources mentioned above.

http://www.biomedcentral.com/



http://www.publiclibraryofscience.org/



http://www.shef.ac.uk/~scharr/ir/netting/




4. Is it time to change how you seek best evidence?4. Is it time to change how you seek best evidence?

Compare the 4S approach with how you usually seek Compare the 4S approach with how you usually seek evidence-based information evidence-based information

it surprises that MEDLINE is low on the 4S list of resources it surprises that MEDLINE is low on the 4S list of resources for finding current best evidence, then this communication for finding current best evidence, then this communication will have served a purpose will have served a purpose

Resources for finding evidence have evolved in the past few Resources for finding evidence have evolved in the past few years, and searches can be a lot quicker and more satisfying years, and searches can be a lot quicker and more satisfying for answering clinical questions if the features of your quest for answering clinical questions if the features of your quest match those of one of the evolved services match those of one of the evolved services


to think of organizing your information needs is to think of organizing your information needs is ““prompt, pull, push”prompt, pull, push”

““Prompt”Prompt” corresponds to the highest “S” level corresponds to the highest “S” level—”systems” —”systems”

““Pull”Pull” corresponds to the three lower levels of the 4S corresponds to the three lower levels of the 4S approach: you go hunting to “pull” the evidence you approach: you go hunting to “pull” the evidence you need from available resources need from available resources

““Push”Push” refers to having evidence sent to you; refers to having evidence sent to you; controlling this is the subject of the next section. controlling this is the subject of the next section.


HOW TO DEAL WITH THE EVIDENCE THAT FINDS YOU: KEEPING UP HOW TO DEAL WITH THE EVIDENCE THAT FINDS YOU: KEEPING UP TO DATE EFFICIENTLYTO DATE EFFICIENTLY

1. Cancel your full-text journal subscriptions1. Cancel your full-text journal subscriptions 2. Invest in evidence-based journals and online 2. Invest in evidence-based journals and online

servicesservices


1. Cancel your full-text journal subscriptions1. Cancel your full-text journal subscriptions

Trying to keep up-to-date in your clinical practice by reading Trying to keep up-to-date in your clinical practice by reading full-text journals is a truly hopeless task. full-text journals is a truly hopeless task.

From an evidence-based perspective, for a broad-based From an evidence-based perspective, for a broad-based discipline discipline

the number of articles you need to read to find one article the number of articles you need to read to find one article that meets basic criteria for quality and relevance ranges that meets basic criteria for quality and relevance ranges from 86 to 107 for the top five full-text general journals from 86 to 107 for the top five full-text general journals


2 minutes per article, that’s about 3 hours to find one 2 minutes per article, that’s about 3 hours to find one article ready for clinical action; and then the article article ready for clinical action; and then the article may cover old ground or provide “me-too” evidence may cover old ground or provide “me-too” evidence of yet-another statin, or not be useful to you because of yet-another statin, or not be useful to you because of the way you have specialized the scope of your of the way you have specialized the scope of your practice practice

You should trade in your (traditional) journal You should trade in your (traditional) journal subscriptions. subscriptions.

It will save you time but won’t necessarily save you It will save you time but won’t necessarily save you money, because you will need to invest in better money, because you will need to invest in better resources for keeping current resources for keeping current


2. Invest in evidence-based journals and online 2. Invest in evidence-based journals and online servicesservices

A growing number of periodicals summarize the best A growing number of periodicals summarize the best evidence in traditional journals evidence in traditional journals

selections according to explicit criteria for merit, providing selections according to explicit criteria for merit, providing structured abstracts of the best studies and expert structured abstracts of the best studies and expert commentaries about the context of the studies and the commentaries about the context of the studies and the clinical applicability of their findings. clinical applicability of their findings.

synoptic journals include synoptic journals include ACP Journal ClubACP Journal Club, , Evidence Based Evidence Based Medicine, Evidence Based Mental Health, Evidence Based Medicine, Evidence Based Mental Health, Evidence Based Nursing, Evidence Based Health Care Policy and Practice, Nursing, Evidence Based Health Care Policy and Practice, Evidence Based Cardiovascular MedicineEvidence Based Cardiovascular Medicine, and a number of , and a number of others. others.


Synoptic journals do what traditional journals wish Synoptic journals do what traditional journals wish they could do in selecting the best studies, finding they could do in selecting the best studies, finding the best articles from all relevant journals and the best articles from all relevant journals and summarizing them in one place summarizing them in one place

Traditional journals can’t do this because they can Traditional journals can’t do this because they can only publish from among the articles that authors only publish from among the articles that authors choose to send them choose to send them


Searching for evidenceSearching for evidence to solve patient problems to solve patient problems

the use of evidence-based information resources is best learned by the use of evidence-based information resources is best learned by examples and practice, not by reading examples and practice, not by reading

Commit yourself to paper on three matters for each of the problems Commit yourself to paper on three matters for each of the problems below:below:1. The key question to seek an answer for (using the guidelines from 1. The key question to seek an answer for (using the guidelines from Ch. 1).Ch. 1).2. The best answer to the clinical problem that you currently have 2. The best answer to the clinical problem that you currently have stored in your brain (being as quantitative as possible).stored in your brain (being as quantitative as possible).3. The evidence resources (both traditional and avant garde) that you 3. The evidence resources (both traditional and avant garde) that you would consult to find best current answers.would consult to find best current answers.


Carrying out the searching steps


ProblemProblemType 2 diabetes and related cardiovascular risk.Type 2 diabetes and related cardiovascular risk.

Step 1. Asking answerable questionsStep 1. Asking answerable questions Step 2A. Selecting an evidence resourceStep 2A. Selecting an evidence resource Step 2B. Executing the search strategyStep 2B. Executing the search strategy Step 2C. Examining the evidenceStep 2C. Examining the evidence


Step 1. Asking answerable questionsStep 1. Asking answerable questions

Investigations have shown that Mrs Smothers has an A1c of 8.9%, Investigations have shown that Mrs Smothers has an A1c of 8.9%, microproteinuria and hyperlipidemia, with total cholesterol 6.48 mmol/L, microproteinuria and hyperlipidemia, with total cholesterol 6.48 mmol/L, LDL 3.4 mmol/L, HDL 0.9 mmol/L, and triglycerides 3.9 mmol/L. With LDL 3.4 mmol/L, HDL 0.9 mmol/L, and triglycerides 3.9 mmol/L. With this additional information, we pose the question: In a 56-year-old this additional information, we pose the question: In a 56-year-old woman with type 2 diabetes mellitus, microproteinuria, elevated blood woman with type 2 diabetes mellitus, microproteinuria, elevated blood pressure, and dyslipidemia, what is the evidence concerning increased pressure, and dyslipidemia, what is the evidence concerning increased risk for cardiovascular complications compared with people with risk for cardiovascular complications compared with people with diabetes without these risk factors (and does the risk calculator that diabetes without these risk factors (and does the risk calculator that Mrs Smothers found provide an evidence-based estimate of risk that Mrs Smothers found provide an evidence-based estimate of risk that fits her circumstances)? In such a patient, does “tight” control of fits her circumstances)? In such a patient, does “tight” control of glucose, blood pressure, cholesterol, and proteinuria reduce glucose, blood pressure, cholesterol, and proteinuria reduce subsequent morbidity and mortality? subsequent morbidity and mortality?


Step 2A. Selecting an evidence resourceStep 2A. Selecting an evidence resource

the focus will be on the best and quickest evidence-based the focus will be on the best and quickest evidence-based information sources for this clinical discipline, including information sources for this clinical discipline, including general and specialized bibliographic databases, in both print general and specialized bibliographic databases, in both print and electronic form. and electronic form.

electronic media with periodic updates (especially on the electronic media with periodic updates (especially on the Internet, with CD valuable when the Internet is not readily Internet, with CD valuable when the Internet is not readily accessible) are rendering paper sources obsolete for looking accessible) are rendering paper sources obsolete for looking up evidence up evidence


Electronic media are generally much more accessible, much Electronic media are generally much more accessible, much more thoroughly indexed, and, most importantly, have the more thoroughly indexed, and, most importantly, have the potential to be much more up-to-date than paper-based potential to be much more up-to-date than paper-based resources. resources.

hypertext and the Internet permit unlimited linkages to related hypertext and the Internet permit unlimited linkages to related and supplementary information and supplementary information

a good computer (whether ours or someone else’s) with an a good computer (whether ours or someone else’s) with an Internet link (or at least a CD-ROM drive), and a working Internet link (or at least a CD-ROM drive), and a working knowledge of the evidence resources that have been knowledge of the evidence resources that have been developed for our own clinical discipline, can make an developed for our own clinical discipline, can make an important difference to whether we will be successful in important difference to whether we will be successful in becoming evidence-based practitioners. becoming evidence-based practitioners.


How to deal with the evidence that finds youHow to deal with the evidence that finds you

The first piece of information to consider in this case The first piece of information to consider in this case falls into the general category of “evidence that finds falls into the general category of “evidence that finds you you

patients frequently find information that they want patients frequently find information that they want you to comment on you to comment on

you need an efficient approach to evaluating the you need an efficient approach to evaluating the pedigree and evidence base for claims they pedigree and evidence base for claims they encounter on the Internet or other media encounter on the Internet or other media


The patient brought along a web page (The patient brought along a web page (http://http://www.betterdiabetescare.org/TOOLBOXrisk.htmwww.betterdiabetescare.org/TOOLBOXrisk.htm) that she ) that she had found through Google, so it was easy to examine this had found through Google, so it was easy to examine this source source

This website has impeccable credentials, with material This website has impeccable credentials, with material prepared by the National Diabetes Education Program with prepared by the National Diabetes Education Program with sponsorship from the US National Institutes of Health, the sponsorship from the US National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney National Institute of Diabetes and Digestive and Kidney Diseases, and Centers for Disease Control, and without Diseases, and Centers for Disease Control, and without commercial advertising. commercial advertising.

This is not to say that the information on the website is This is not to say that the information on the website is necessarily either accurate or up-to-date, but it is more likely necessarily either accurate or up-to-date, but it is more likely to be so than websites that lack these features to be so than websites that lack these features

http://www.betterdiabetescare.org/TOOLBOXrisk.htm

http://www.betterdiabetescare.org/TOOLBOXrisk.htm


Two risk calculators for cardiovascular disease are Two risk calculators for cardiovascular disease are offered on the website, one from Framingham, which offered on the website, one from Framingham, which can be done with a pencil and paper (can be done with a pencil and paper (http://http://www.nhlbi.nih.gov/about/framingham/riskwom.pdfwww.nhlbi.nih.gov/about/framingham/riskwom.pdf), ), the other from the UK (the other from the UK (http://http://www.dtu.ox.ac.uk/index.html?maindocwww.dtu.ox.ac.uk/index.html?maindoc=/=/riskengineriskengine//). ).

http://www.nhlbi.nih.gov/about/framingham/riskwom.pdf

http://www.nhlbi.nih.gov/about/framingham/riskwom.pdf

http://www.dtu.ox.ac.uk/index.html?maindoc=/riskengine/






Where to find the best evidenceWhere to find the best evidence

Using the 4S approach, we begin with Ovid, the “4S Using the 4S approach, we begin with Ovid, the “4S supermarket”, and head for supermarket”, and head for Clinical EvidenceClinical Evidence, a , a systemsystem that integrates current best evidence for that integrates current best evidence for specified clinical questions specified clinical questions


Step 2B. Executing the search strategyStep 2B. Executing the search strategy

Using our library’s Ovid access from home Using our library’s Ovid access from home look up look up Clinical EvidenceClinical Evidence, browse the table of contents to , browse the table of contents to

Endocrine Disorders, and see five subtopics, two of which Endocrine Disorders, and see five subtopics, two of which are “Cardiovascular disease in diabetes” and “Glycemic are “Cardiovascular disease in diabetes” and “Glycemic control in diabetes”. control in diabetes”.

The first of these topics links to a summary of interventions The first of these topics links to a summary of interventions organized in three categories (“beneficial,” “likely to be organized in three categories (“beneficial,” “likely to be beneficial”, and “unknown effectiveness”), followed by key beneficial”, and “unknown effectiveness”), followed by key messages messages


The first of the topics links to a summary of interventions The first of the topics links to a summary of interventions organized in three categories (“beneficial,” “likely to be organized in three categories (“beneficial,” “likely to be beneficial”, and “unknown effectiveness”), followed by key beneficial”, and “unknown effectiveness”), followed by key messages messages

This section summarizes several recent trials with This section summarizes several recent trials with quantitative results (including “number needed to treat”, NNT; quantitative results (including “number needed to treat”, NNT; showing cardiovascular benefits from lowering blood showing cardiovascular benefits from lowering blood pressure, lipids, and blood sugar as well as from prescribing pressure, lipids, and blood sugar as well as from prescribing aspirin aspirin

bookmark and print the table for reference when you have bookmark and print the table for reference when you have completed your search completed your search


Step 2C. Examining the evidenceStep 2C. Examining the evidence

Discounting the side-trip to more traditional textbooks Discounting the side-trip to more traditional textbooks assembled the assembled the systemsystem, , synopsissynopsis, and , and studystudy level information needed to level information needed to

inform an evidence-based decision inform an evidence-based decision The Gaede study is summarized in The Gaede study is summarized in ACP Journal ClubACP Journal Club, so it has already , so it has already

passed muster for scientific merit and we can skip this critical appraisal passed muster for scientific merit and we can skip this critical appraisal step unless we want to look for details that don’t appear in the step unless we want to look for details that don’t appear in the ACP ACP Journal ClubJournal Club abstract abstract

The study investigated the benefits of intensive management of type 2 The study investigated the benefits of intensive management of type 2 diabetes in a diabetes clinic compared with conventional care by family diabetes in a diabetes clinic compared with conventional care by family practitioners with open access to consultation practitioners with open access to consultation

Documents

How to Find Best Current Evidence