F. Hosseinpanah .MD

Sources of Evidence

Agenda

• Information mastery• Systems• Summaries• Synopsis• Synthesis• Studies• Alerting services

Five steps of EBM Practice

1.Translation to an answerable question

2. Track down with maximum efficiency the best evidence with which to answer them[Finding the evidence ; Using electronic health information resources in evidence-based practice]

3.Critical appraisal of the evidence for its validity and clinical applicability

4.Integration of that critical appraisal with clinical expertise and the patient’s unique biology and beliefs

5.Evaluation of one’s performance.

Information mastery

Usefulness of medical information =

Relevance × Validity

Work

How to hit the target?

All biomedical papers

Clinical studies

Relevant clinical studies

Relevant and valid clinical studies

Relevant, valid, new clinical studies

EBM Resources

• Journals

• Database

• Textbooks

Evidence based medicineACP journal clubBandolier

CochraneEBMR (ovid)Trip databaseInforetriever

Up to dateClinical evidence

Haynes’5S Model

• Systems

• Summaries

• Synopsis (selected individual studies or systematic reviews)

• Synthesis

• Studies

Haynes RB. ACP J Club. 2006;145:A8.

Systems

• “A perfect evidence-based clinical information system would integrate and concisely summarize all relevant and important research evidence about a clinical problem and would automatically link, through an electronic medical record, a specific patient's circumstances to the relevant information." (Haynes, 2001)

Summaries

• Some information resources provide regularly updated clinical evidence, sometimes integrated with other types of health care information, and provide guidance or recommendations for patient management.

Summaries

Value added books

• UpToDate

• Clinical evidence

UpToDate

• UpToDate is a well-referenced online textbook that is carefully updated every 4 months. It exists in digital format because it is too large to print.

• Although UpToDate, unlike Best Evidence and the Cochrane Database of Systematic Reviews, does not have a set of explicit methodologic quality criteria that included articles must meet, it does reference many high-quality studies chosen by its section authors

UpToDate

UpToDate

UpToDate

Up To Date

• Search strategy?• Appraisal strategy?• Not multidisciplinary authorities, • Select facts instead of opinion• Appraise yourselves

Clinical Evidence

• Clinical Evidence, published by the BMJ Publishing Group and American College of Physicians/American Society of Internal Medicine, is similar to UpToDate

• Although less oriented to provide bottom-line clinical advice from experts.

• (http://www.clinicalevidence.com/).

Clinical Evidence

Synopses

Synopses

• "When no evidence-based information system exists for a clinical problem, then synopses of individual studies and reviews are the next best source....The perfect synopsis would provide exactly enough information to support a clinical action." (Haynes, 2001)

Synopsis (Reappraised Resources)

• ACP Journal Club (http://www.acpjc.org/)

• Info-POEMs (http://www.infopoems.com/)

ACP journal club

• The editors of ACP Journal Club screen the top clinical journals on a regular basis and identify studies that are both methodologically sound and clinically relevant.

• They write an enhanced abstract of the chosen articles and provide a commentary on the value of the article for clinical practice.

ACP journal club

ACP journal club

ACP journal club

ACP journal club

ACP journal club

ACP journal club

Info-POEMs

• Similar to ACP Journal Club in that it provides alerting to well-done and important clinical advances and a searching service of its collected articles.

• Its main focus is family medicine• Clinical staff read more than 100 journals for

articles of direct application to common and uncommon diseases and conditions seen by family physicians

• (http://www.infopoems.com)

Synthesis

Syntheses

• "If more detail is needed or no synopsis is at hand, then databases of systematic reviews (syntheses) are available..." (Haynes, 2001)

Systematic Reviews

• Clear statement of purpose and scope• Comprehensive search and retrieval of the relevant

research• Explicit selection criteria• Critical appraisal of the primary studies• Reproducible decisions regarding relevance, selection,

and methodologic rigor of the primary research• When quantitative methodology applied meta-analysis

Cochrane Library

1. Cochrane Database of Systematic Reviews (CDSR)

2. Database of Abstracts of Reviews of Effectiveness (DARE)

3. Cochrane Controlled Trials Registry (CCTR)

Cochrane Library

DARE

• DARE is a Full Text database containing critical assessments of systematic reviews from a variety of medical journals.

• DARE is produced by the expert reviewers and information staff of the National Health Services' Centre for Reviews and Dissemination (NHS CRD) at the University of York, England

• consists of structured abstracts of systematic reviews from all over the world.

• DARE records cover topics such as diagnosis, prevention, rehabilitation, screening, and treatment.

Studies

Studies

• "If every other S fails (i.e., no system, synopses, or syntheses), then it's time to look for original studies” (Haynes, 2001)

• Medline, Cochrane Controlled Trials Register • Bibliographic Databases (Medline,Embase)

MEDLINE (www.pubmed.com)

• National Library of Medicine USA

• Numbers of Journals: 3600 (>4000)

• Bias: English Language, Strong American Bias

• Thesaurus: Uses Medical Subject Headings (MeSH)

• Subject Coverage: All Specialties of Medicine

• Materials Indexed: Letters, Editorials, Research Articles from 1966 onwards

• 60% of References contain Abstracts

• Update: Updated Monthly but can be 3 or more months behind

• Type of Database: Bibliographic

Medline (clinical query)

Medline(clinical query)

Turning Research Into Practice

• www.tripdatabase.com

TRIP Database

• The TRIP Database is produced by TRIP Database Ltd. • The aims of the TRIP Database :allowing health

professionals to easily find the highest-quality material available on the web.

• It is not a true database but looks like a mainstream search engine (such as Google or Yahoo)

• The content of the site is reviewed monthly and new material from the publications covered is added to the site.

• Typically 300-400 new articles are added monthly.

TRIP database

Alerting or Updating Services

Evidence updates

http://plus.mcmaster.ca/EvidenceUpdates/Default.aspx

Evidence updates

Which textbook?

• 1· it should be revised frequently (at least once a year)

• 2· it should be heavily referenced, at least for declarations about diagnosis and management (so readers can get to original sources for details and can also easily determine the date of a given claim)

• 3. the evidence in support of a statement should be selected according to explicit principles of evidence-based medicine.

Authority/Expert opinion

• Need relevant knowledge

• Need relevant expertise

• Mastery of reasoning

• Mastery of information

• No conflict of interest • No conflict with others

(authorities/fact)

Logic and critical thinking in medicine 2005

Search strategy

1. Search an appraise 2weeks

2. Search only 2w—6months

3. Replicate 6months

Search Cascade

Recommendations (necessary but not sufficient) • Low turnover information (Background Q,.), rare diseases, no time

– Textbooks– Expert opinion– …

• Rare cases (especially to write case reports) – Pubmed and other bibliographic databases, Google, ask experts sites,…

• Specific clinical questions (during round, MR, journal club…)– TRIP– CDSR for therapy Q, (Listen to audio summaries of selected reviews) – Up-to-date– PubMed: Clinical Queries

• International presentations– CDSR for therapy Q– PubMed: Clinical Queries

• Register BMJ update

• Updating general knowledge/common topics/broad questions– Narrative reviews

Thank you

Further Reading

• Ann Mckibbone ,Peter Wyer , Roman Jaeschke and Dereck Hunt User Ts guide to medical literature, second edition ,Mac Graw Hill, chapter3, Finding the evidence.

• Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to practice and teach EBM, Third edition. New York: Churchill Livingstone, chapter 2, How to find current best evidence.