Evidence-based Practice for HINARI Users

(Module 6)

Table of Contents• EBM definition• 5 step EBM process• HINARI Resources

• Cochrane Library• Evidence-based Medicine Guidelines• Essential Evidence Plus• EBM Journals

• PubMed/Clinical Queries • PubMed Health• Other Resources

What is EBP?

The integration of best evidence* from current research, patient preferences and values, and clinical expertise to clinical questions in a timely fashion (Sackett, 2000).

*Best available evidence is: consistent research evidence with high quality and quantity

EBP

Why EBP?• Improve care

• To bridge the gap between research & practice• “Kill as few patients as possible” (O. London)• new treatment

• fewer side effects• cheaper or less invasive• resistance to existing therapies, etc.

• Keep knowledge and skills current (continuing education)

• To save time to find the best information

What are some Barriers for EBP?

• Time, effort & skills needed• Access to evidence• Overuse, underuse, misuse of evidence• Poor decision making• Environment not supportive of EBP• Intimidation by senior clinicians

How does EBP help? A patient comes to a clinic with a fresh dog bite. It looks clean and the nurse and patient wonder if prophylactic antibiotics are necessary. The nurse searches PubMed and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%.

•For every 100 people with dog bites, treatment with antibiotics will save 7 from infection

•Treating 14 (NNT) people with dog bites will prevent 1 infection•You explain these numbers to the patient along with possibleconsequences and patient decides not to take antibiotics.

•On a follow up visit you find out that he did not get infected.

Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.

The 5 Step EBP Process1. ASK: Formulate an answerable clinical question

2. ACCESS: Track down the bestEvidence

3. APPRAISE: Appraise the evidence for its validity and usefulness

4. APPLY: Integrate the results with your clinical expertise and your patient values/local conditions

5. ASSESS: Evaluate the effectiveness of the process

Background Questions• General questions - disorder

– What is the disorder?– What causes it?– How does it manifest?– Treatment options?

• Information Resources– books – narrative reviews

• general overview of a topic

Foreground Questions• Specific questions - patient

– INTERVENTION/PREVENTION – ETIOLOGY, RISK– DIAGNOSIS – PROGNOSIS

• Information Resources– journal articles– synopses of articles– systematic reviews

• answer specific questions

Step 1: ASK (questions, PICO)a focused (answerable) clinical question Ask

P = Patient, population or problem (Who are the patients or populations? What is the disease?)

I = Intervention (What do you want to do with this patient - treat, diagnose, observe)?

C = Comparison intervention (What is the alternative to the intervention - placebo, different drug, nothing?)

O = Outcome (What are the relevant outcomes - morbidity, mortality, death, complications)?

Step 1: ASKPICO Format Ask

Why should I use PICO?

• define problem - clarify it in your own mind• identify concepts/terms for searching • ask patient centered questions; treatment of

pneumococcal pneumonia SHOULD be different for – elderly, severely demented patient– terminal cancer Patient– young, mother of 2 children

Example: Intervention Questions

• A 54 year old male patient was diagnosed with intermediate grade prostate cancer and wants to know whether to get a radical prostatectomy or radiation treatment. He is concerned about death from prostate cancer and also risks of impotence and incontinence.

• Identify the 4 PICO components

Formulate the Clinical Question• PICO

P (patient) - 54 year old male with intermediate grade prostate cancerI (intervention) - radical prostatectomy C (comparison intervention) - radiation treatment O (outcome) - reduce risk of mortality, impotence, and incontinence

• Focused clinical questionIn 54 year old male patients with intermediate grade prostate cancer, is radical prostatectomy more effective compared to radiation treatment in reducing the risk of mortality, impotence, and incontinence?

Etiology and Risk QuestionsWhat causes a disease or health condition?• The reverse of intervention questions-they deal with

harmful outcomes of an activity or exposure (public health issues)

• Develop a clinical question for the case:S. is a smoker and just found out that she is 3 months pregnant. She quit smoking immediately. But she is worried if her developing baby was harmed and if the baby is at risk for having developmental problems. She is asking you if smoking during the first trimester can harm her baby?

Etiology or Risk Questions

• P-babies of mothers who smokeI- smoking in first trimesterC-nothingO-increase risk of developmental problems

• Question: Are babies of mothers who smoke during their first trimester at an increased risk of developmental disabilities?

Templates for EBP Questions• For a therapy: In _______(P), what is the effect of _______(I) on

______(O) compared with _______(C)?• For etiology: Are ____ (P) who have _______ (I) at ___

(Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C)?

• Diagnosis or diagnostic test: Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?

• Prevention: For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?

• Prognosis: Does __________ (I) influence ________ (O) in patients who have _______ (P)?

Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

Access

EBP Step 2: ACCESS (studies, hierarchies)Track Down the Best Evidence

Start “hunting” from the best resource:match your question to the best medical information resource for this question.

Hierarchy of EvidenceResearch Studies

experimental

observational

synthesis

AppraiseEBP Step 3: Appraise (validity, impact)• Appraisal principles (primary and secondary research)

– Does PICO of the study match my PICO question?– validity

• internal validity – methods–How well was the study done? Is it biased?

• external validity–generalizability

– impact • Does it matter to your patient?

• University of Oxford’s Center of EBM: http://www.cebm.net/index.aspx?o=1157• Evaluating the Evidence section in the EBM tutorial at:http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm

EBP Step 4: APPLY (patient, setting) Integrate the results with your clinical

expertise and your patient values

• Patient• Is my patient similar enough that the results of

the study apply?• Will the potential benefits outweigh the

potential harms of treatment ?• What does my patient think? What are his

cultural beliefs?– Setting

• Is the intervention feasible in my settings?• What alternatives are available?

Apply

EBP Step 5: ASSESS (patient, yourself)Evaluate the effectiveness of the process.

• Am I asking questions?• Am I writing down my information needs?• How is my searching going? Am I becoming more

efficient?• What is my success rate in the EBM steps?• Am I periodically syncing (checking) my skills and

knowledge with new developments?• Teach others EBP skills • Keep a record of your questions

Assess

HINARI Resources

• Cochrane Library – filtered

• PubMed – unfiltered

• Clinical Queries

• Filters

• PubMed Health

• HINARI EBM Journals

Cochrane Database of Systematic Reviews

The Cochrane Library (John Wiley)• high-quality, filtered, critically appraised

Systematic Reviews from all over the world• minimum bias: evidence is included/excluded

on the basis of explicit quality criteria• abstracts searchable for free on the Internet;

complete database is available via HINARI

From the Reference Sources menu, we now will click on the Cochrane Library link. The Cochrane Library contains high-quality, independent evidence including reliable evidence from Cochrane and other systematic reviews and clinical trials. It is published by John Wiley.

The initial page of this site has a title, abstract or keyword option Search engine. You also have various options to Browse by Topic and Browse by Review Group Open the Advanced Search.

We have opened the Advanced Search option and will complete a search diarrhea child* using the Title, Abstract, Keywords option with the wildcard (*) used to locate the terms child and children.

Note the Medical Terms (MeSH) optionSearch Manager – to view search history.

The Advanced Search for diarrhea child* Title, Abstracts and Keyword has retrieved 95 records that are Cochrane Reviews Reviews plus Other Reviews, Methods Studies and other options for a total of 2250 results.

You have the option to Export All Results (save).

The Advanced Search for diarrhea child* Title, Search All Text has retrieved 882 records that are Cochrane Reviews, a significantly higher number.

The screen displays the Abstract of the first systematic review listed in the search - Probiotics for treating acute infectious diarrhoea. Note the options for View Full Article (HTML), Summary (PDF) and Full (PDF).

Displayed is the Abstract of the systematic review that includes the Background, Objectives, Search methods, Selection criteria, Data collection and analysis, Main Results and Authors conclusions.

The final section of the Abstract is titled Plain language summary. This section is useful for disseminating the results to groups of health workers and patients.

Also note the Resume in French.

Now displayed is the PDF Full version of the Probiotics for treating acute infections diarrhoea systematic review. Other options include Summary and Standard files.

From the Cochrane Library initial page, we have clicked on the Browse by Topic hyperlink.. From this extensive list, you have another option for locating subject- specific material. Note the links to a list of Cochrane Reviews and also Trials.

From the Reference Sources list, we have opened the initial page of EBM Guidelines Evidence-Based Medicine. Also published by John Wiley, this resource is a collection of clinical guidelines for primary care combined with evidence-based research.

You can Search by keyword or Browse database contents by EBM Guidelines, Evidence summaries, Pictures, Audio samples, Videos and Programs.

We have completed a keyword search for Influenza. The results page includes summaries of the key issues including Related resources and References and links to important websites. PRIMARY and SECONDARY HITS

Also included are links to the Evidence summaries.

We have displayed the 2nd Evidence summary. Each link contains a brief review of the study and notes the reference(s).

From the Reference Sources list, we have opened the initial page of Essential Evidence Plus. Also published by John Wiley, it includes access to Cochrane Library and also a series of databases and tools to access the EBM material.

By keyword, you can Search all or some of the databases.

We have opened the EBMG evidence summaries database that, via broad subject categories, has access to 4440 articles.

We have opened the initial page of EBMG evidence summaries listing for Infectious disease. Material is listed by either a summary view or expanded view that includes a sentence describing each entry.

We have opened Decision Support Tools that has 406 tools and calculators that assist in clinical decision making.

HINARI Evidence-Based Journals(other journals may have EBM articles)

We have browsed the ‘E’ in the HINARI Find journals by title list and it notes several journals for evidence-based practice.