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Searching forEvidence Based Medicine
Literature
Welcome
Aug 2012
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What is Evidence-Based Medicine?
The goal of (EBM) is to be aware of the evidence on
which ones practice is based, the soundness of the
evidence, and the strength of inference the evidence
permits. The strategy employed requires a cleardelineation of the relevant questions(s); a thorough
search of the literature relating to the questions;
a critical appraisal of the evidence, and its application
to the clinical situation; and a balanced application of
the conclusions to the clinical problem.a
aPreface (2002). In Guyatt GH, Rennie D. (Eds.),
Users Guides to the Medical Literature (pp. xiv). Chicago: AMA Press.
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The Exponential Growth of the Literature
PubMed "indexed journals represent an increasingly smaller
portion of the broader universe of medical information.
NLM (National Library of Medicine) estimates that currently
about 14,000 biomedical journals are published and it selects
only about one-quarter of new submissions for indexing based
on quality and relevance to biomedical topics. These biomedical
journals, in turn, represent only a small fraction of the growing
array of information sources on the Web."
Druss, BG, et al. Growth and decentralization of the medical literature:
implications of evidence-based medicine.JMLA. 2005;93(4):499-501
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Steps in the Evidence-Based Process are:
(Citrome, & Ketter, 2009)
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Step 1
Formulate the Question
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Clinical questions should be directly relevant to theproblem. The question can be phrased to facilitatesearching for a precise answer by using PICO:
the Patient, population or problem being addressed
the Intervention being considered
the Comparison intervention or exposure, whenrelevant
the clinical Outcomes of interest
(Washington Health Sciences Libraries, 2007)
Using PICO to focus the question:
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Definitions from McKibbon, 2009
Diagnosisthe process of identifying a disease or condition. Making the correctdiagnosis is the foundation for making decisions on clinical intervention.
What disease or condition does my patient have?
Clinical questions often arise from central issues:(Straus, 2005)
Therapyan action or intervention that can potentially improve care or prevent
diseases or conditions.
What is the best treatment for this disease or condition?
Etiologythe cause of a disease, condition or situation. It may also be referred to as
harm or causation.
What is the cause of my patients disease or condition?
Prognosisthe progression of a treated disease.
What outcome can be expected from the treatment/intervention used?
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Step 2
Search for the Answers
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Professor Archibald Cochrane,CBE FRCP FFCM,(1909 - 1988)
stressesthe importance of using evidence from randomizedcontrolled trials because these were likely to provide much more
reliable information than other sources of evidence
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A
awww.cochrane.org
prepared reviews
based on the
best available evidence
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www.thecochranelibrary.com
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Filtered Information
Unfiltered Information
Cochrane Database of Systematic Reviews
Topic Reviews in the Cochrane Database of Systematic Reviewsaa
Database of Abstracts of Reviews of Effectiveness (DARE)
NHS Economic Evaluation Database
Cochrane Methodology Register
ACP Journal Club
Cochrane Central Register of Controlled Trials
PubMed
PubMed
National Guideline Clearinghouse
Health Technology Assessment
PubMed
Hierarchy of Evidence and Corresponding Databases
(TTUHSC Preston Smith Library, 11/21/2008)
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Mouse over Databases
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and click Ovid
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Click All EBM Reviews
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Enter
as the first keyword search.
obesity
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Enter as the
second keyword search.
surgery
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For better results, enter keywords separately
and then combine with Boolean operators.
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AND
X
X
Click on the boxes
next to set 1 and set 2.
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Boolean Logic - AND
surgeryobesity and
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Results of AND combination.
(Note that AND narrows results.)
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3 AND obes*.ti.Enter to narrow to
articles with any suffix of obesity in the title.
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By entering obes*, the computersearches for any suffix of the word:
obese
obesity
This is called truncation.
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4 AND surgery.ti.Enter to narrow to
articles with surgery as a word in the title.
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Results are narrowed
to 87 articles.
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Other search techniques:
Look for additional terms such as bypass or banded
Use Boolean OR
banded
or
bypass
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Search
Results
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Click Display
to view articles
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Systematic Reviews assess randomized trials and provide a comprehensive
summary of the available evidence.
Over 800 international journals are searched to locate articles.a
Systematic Reviews contain all known reference to trials on a particular intervention.
Evidence is assessed with explicit quality criteria to minimize bias ensure reliability.
Trials that meet assessment criteria can be combined to produce a morestatistically reliable result.
Data from studies are often combined statistically to increase the power of the findings
of numerous studies, which on their own may be too small to produce reliable results.
Authors appraise, and synthesize evidence from as many relevant
scientific studies as possible.
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Click EBM Topic Review
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Systematic reviews are prepared by Cochrane Collaborative Groups.
EBM Topic Review
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PDF link.
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Click Search
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Click Ovid Resources
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Click Cochrane Database of Systematic Reviews
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Click Cochrane Database of Systematic Reviews
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Click Table of Contents
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Additional Articles to Review
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Cochrane Group s
Inflammatory Bowel Disease
Injuries Group
Lung Cancer
Menstrual Disorders & Sub-Fertility GroupMetabolic & Endocrine Disorders
Methodology Review Group
Movement Disorders
Multiple Sclerosis
Musculoskeletal Group
Musculoskeletal Injuries Group
Neonatal Group
Neuromuscular Disease
Oral Health
Pain, Palliative Care & Supportive Care
Peripheral Vascular Diseases
Pregnancy & Childbirth
Prostatic Diseases & Urologic Cancers
Renal Group
Schizophrenia Group
Sexually Transmitted Diseases Group
Skin Group
Stroke Group
Tobacco Addiction
Upper Gastrointestinal & Pancreatic Diseases
Wounds Group
Acute Respiratory Infections
Airways Group
Anesthesia Group
Back GroupBreast Cancer
Colorectal Cancer
Consumers & Communication
Cystic Fibrosis & Genetic Disorders
Dementia & Cognitive Improvement
Depression, Anxiety, & Neurosis
Developmental, Psychosocial & Learning Problems
Drugs & Alcohol
Ear, Nose and Throat Disorders
Effective Practice & Organization of Care
Epilepsy
Eyes & Vision
Fertility Regulation
Gynecological Cancer
Hematological Malignancies
Heart Group
Hepato-Biliary Group
HIV/AIDS
Hypertension
Incontinence
Infectious Diseases
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Click Search
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Click Ovid Resources
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Click All EBM Reviews
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Click Display
to view articles
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Click EBM Article Review
Scroll to article #3
ACP Journal Club is a joint online journal:
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Information summarizedin structured abstracts
include:aA
Methods Design
Intervention
Study categories include:aa
Prevention or treatment
Diagnosis
Prognosis
Etiology
EconomicsClinical prediction guides
Differential diagnosis
ACP Journal Club is a joint online journal:
ACP Journal Club by the American College of Physicians
Evidence-Based Medicine by the British Medical Journal Group
Over 100 clinical journals are screened for original studies that are methodologically sound & clinically relevant.
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ACP Journal Club includesbrief commentaries on:a
aa
Context
Methods
Clinical applications of findings
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ClickSearch Results
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For next article, type 8 and click Go
8 GO>
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Click EBM Article Review
O 3000 b t t f t ti i th t h b lit d
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Over 3000 abstracts of systematic reviews that have been quality assessed
Reviews answer questions about specific interventions
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Results of review and
critical commentary
About overall quality
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ClickSearch
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For next article, type in 22 and click Go
22 GO>
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Click Complete Reference
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CCRT does not contain
full-text. Access through
Gold Rush.
3/5ths of the records are
from PubMed
Relevant recordsfrom Embase
Other published and
unpublished sources
Reports from
conference proceedings
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Mouse over eJournals
and click Gold Rush
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journal of the american college of surgeonsType in
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Go back to Ovid Search.
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For the next article 59 GO>
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A
aReports on methods used in the conduct of controlled trials
Includes journal articles, books, and conference proceedings
Does not contain full text; access through Gold Rushaa
a
Click Next
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Completed and ongoing health technology assessments studies of:
medical, social, ethical, and economic implications of health care interventions
Aim is to improve the quality and cost-effectiveness of health care
Go to article #83
83
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Over 5000 abstracts
Systematically identifies
economic evaluations
from around the world
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Click Search
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Click Ovid Resources
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Click ACP Journal Club
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Click Expand
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Click to Select All
Click Remove Selected
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Step 3
Appraise the Evidence
L l f E id
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Levels of Evidence
* Medical evidence or recommendations can vary in quality
* Sources of evidence range from:
1. small laboratory studies to
2. well-designed large clinical studies with minimized bias
* Is a recommendation is strong or weak?
* Can you be confident in the recommendation?
* Grading by strength of recommendations is a systematicapproach which can minimize bias and aid interpretation
* Quality of evidence can be categorized as high, moderate,low, or very low
(The GRADE Working Group, 2005)
Strength of Recommendation
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gRecommendations to administer, or not administer, an intervention, should be basedon the tradeoffs between benefits on the one hand, and risks, burden and,potentially, costs on the other. If benefits outweigh risks and burden, experts willrecommend that clinicians offer a treatment to typical patients. The uncertaintyassociated with the tradeoff between the benefits and risks and burdens willdetermine the strength of recommendation. (The GRADE Working Group, 2005)
*Patient-oriented evidence measures outcomes that matter to patients: morbidity,
mortality, symptom improvement, cost reduction, and quality of life. Disease-
oriented evidence measures: immediate, physiologic, or surrogate end points that
may or may not reflect improvements in patient outcomes (e.g. blood pressure, blood
chemistry, physiologic function, pathologic findings).
Code Definition
A
B
C
Consistent, good-qualitypatient-oriented evidence *
Inconsistent or limited-qualitypatient-oriented evidence *
Consensus, disease-oriented evidence *: usual practice, expert opinion,
or case series for studies of diagnosis, treatment, prevention, or screening
StrengthOfRecommendationTaxonomy(SORT)
(Essential Evidence Plus EBM Guidelines Editorial Team, 2010)
G di f R d ti A t D l t d E l ti
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GradingofRecommendations,Assessment, Development, and Evaluation-
GRADE
(Essential Evidence Plus EBM Guidelines Editorial Team, 2010)
A High
B
C
D
Moderate
Low
Very Low
Further research is very unlikely to change our
confidence in the estimate of effect.
Several high-quality studies with consistent results
In special cases: one large, high-quality multi-
center trial
Further research is likely to have an important impact
on our confidence in the estimate of effect and may
change the estimate.
One high-quality study Several studies with some limitations
Further research is very likely to have an important
impact on our confidence in the estimate of effect
and is likely to change the estimate.
One or more studies with severe limitations
Any estimate of effect and is very uncertain.
Expert opinion
No direct research evidence
One or more studies with severe limitations
Code Quality of Evidence Definition
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EBM ToolkitEnterand click Google Search.
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http://www.ebm.med.ualberta.ca/
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Mouse over
Domains,
Study Category,
Look at Calculations.
Then look at
Systematic Review.
and select Worksheet.
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Step 4
Apply the Results
Step 5
Assess the Outcome
Step 6 Integrate with clinicalexpertise and patients values
Pl t t t
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Please con tac t us at:
Lubbock(806) 743-2200
Amarillo(806) 354-5448
El Paso(915) 545-6652
Odessa(432) 335-5171
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The
End