EVIDENCE-BASED PSYCHIATRY: SEARCHING THE LITERATURE AND APPRAISING THE EVIDENCE

D I A N A J . C U N N I N G H A M , M L S , M P H , A H I PA S S O C I A T E D E A N A N D L I L L I A N H E T R I C K H U B E R E N D O W E D D I R E C T O R , H E A L T H S C I E N C E S L I B R A R Y , N E W Y O R K M E D I C A L C O L L E G E

A P R I L 9 , 2 0 1 4 M E T R O P O L I T A N H O S P I T A L

TODAY’S AGENDA1. Concepts:

Evidence-based medicine Evidence-based psychiatric practiceSystematic Review Levels of evidence: hierarchy of methodologies

2. Systematic review process

3. Applying the process & mapping to the literature

4. Finding the evidence: Today’s case

5. So what do we know?

TODAY’S OBJECTIVE:

By the end of this session, participants will be able to assess levels of evidence for a clinical psychiatric case and discuss examples from the literature

WHAT DOES IT MEAN: ENOUGH EVIDENCE?

In clinical decision-making there is NEVER enough evidence! Concepts:Evidence-based medicine: • Distinguish stronger evidence from weaker evidence• Appraise critically the available evidence and balance the benefits

and risks

Evidence-based psychiatric practice: Focuses on broader care of patients; more complicated patients with less precise diagnoses, co-morbidities and treatment over time. Gray, “Psychiatric clinical practice is not always evidence-based.”

Goal: to be aware of the evidence in one’s practice!

SYSTEMATIC REVIEW SAMPLE FLOW CHART

APPARENT LIFE THREATENING EVENTS (ALTE)

ALTE Search Methodology: September 2013Diana CunninghamActual MyNCBI Search: ((alte AND ((infant[MeSH]))) OR (altes AND ((infant[MeSH]))) AND

((infant[MeSH]))) OR ((apparent life threatening events AND ((infant[MeSH]))) OR (apparent life threatening event AND (infant[MeSH]))) OR (apparent life threatening event* AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((life threatening events AND ((infant[MeSH]))) OR (life threatening event AND ((infant[MeSH]))) OR (life threatening event* AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((near miss sids AND ((infant[MeSH]))) OR (near miss sudden infant death syndrome AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((aborted crib death AND ((infant[MeSH]))) OR (aborted sudden infant death syndrome AND ((infant[MeSH]))) OR (aborted sids AND ((infant[MeSH]))) OR (aborted cot death AND ((infant[MeSH]))) AND ((infant[MeSH]))) AND ((English[lang]) AND (infant[MeSH]))

REVIEWING PROCESS

CRITICAL APPRAISAL: IS IT HIGH QUALITY?

Are the results valid?Did the review explicitly address the clinical question?Was the search for relevant studies detailed and exhaustive?Were the primary studies of high methodological quality?

What are the results?What are the overall results of the reviewSelection or inclusion/exclusion criteriaComparability: randomized or notValidity of evaluation instrumentData-analysis

Can I apply the results to my patient?But must be relevant to your patient or it doesn’t matter!

Relevance ValidityFeasibility of an interventionPatient-disease oriented interventionRealistic generalizability (operational def of outcome)Does the study address the question at hand?Does the study address my population?

Appropriateness of study design • Adequacy of blinding • Allocation concealment • Randomization of group assignment • Invalid or biased measurement ("followed own protocol?") • Importance of comparison or control group • Intention to treat analysis • Consideration of appropriate covariates ("were other relevant factors considered?") • Conclusions consistent with evidence ("do the results make sense?") • Importance of follow-up of all study participants • Appropriate statistical analysis • Sample size / Power • Sponsorship • When study was conducted • Confirmation with other studies

DRILLING DOWN FOR EVIDENCE

Value = (Relevance + Validity) / TimeGrundage KK, Slawson DC, & Shaughnessy AF. When less Is More: A practical approach to

Searching for evidence answers. J Med Libr Assoc 2002 July; 90(3): 298-304

EVIDENCE PYRAMID: A HIERARCHY OF METHODOLOGIES

Grades or Levels of Evidence is now included in various resources (e.g. Dynamed)f Evidence for the Purported Quality of Study Design.L

CONCATO J ET AL. N ENGL J MED 2000;342:1887-1892.

Levels of Evidence

PEER-REVIEWED RESOURCES

B R E A D A N D B U T T E R

PubMed (see clinical queries option)

PsycINFOPsychology and

Behavioral Science Collection

Scopus

P R E - A P P R A I S E D

Cochrane (in PubMed)

UpToDateDynamedClinical EvidenceNational

Guidelines Clearinghouse (AHRQ)

AND NOW: SEARCH THE LITERATUREGoal: be aware of the evidence on which one’s practice is

based, the soundness of the evidence, and the strength of interference that the evidence permits:

1. Formulate the relevant (clinical) question2. Thorough search of the literature for answers pertaining to

the question3. Critically appraising the evidence for validity and

importance4. Apply results to your patient5. Assess the outcome

NYMC HEALTH SCIENCES LIBRARY

THE LIBRARY BARCODE IS YOUR KEY TO ACCESS…

Get your barcode at the library as soon as possible for:

Remote access to online databases and journals Borrowing privileges and access to the library.

To obtain a barcode, complete form on the library’s web page or visit

the Access Services Desk in the Library.

OUR CASEPatient is a 37 year old Caucasian woman with schizophrenia. She has been a smoker since she was 9 years old. She currently coughs so badly she can barely speak and has expressed the desire to quit smoking. You have read something in the literature about the use of Wellbutrin. You want to look at the evidence in the literature.

EBM PROCESS

FRESNO TEST MODEL:Metropolitan Psych Resident PICO Worksheet*

1What is your focused question? (3pts)

POPULATION/PATIENT INTERVENTION COMPARISON OUTCOME

2Where would you go to find an answer to questions like this? (8 pts)

1

2

3

3If you were to search PubMed, describe what your search strategy would be. Be as specific about terms, fields, & limits as possible. (8 pts.)Search terms

4What type of study design would best address your question? (12 pts.)

5When you find a report of original research, what characteristics of the study will you consider to determine it it is relevant, valid, & significant (12 pts.)

6What was the best report of original research that addressed your question and why (give cite)? (12 pts)

7What is the answer to your clinical question? (25 pt)

*Based upon the Fresno Test of Evidence-based MedicineComplete before Dec 30, 2011 (25 pts.) Email to diana_cunningham@nymc.edu

Metropolitan Psych Resident PICO Worksheet*What is your focused question? (3pts)

POPULATION/PATIENT INTERVENTION COMPARISON OUTCOME

Where would you go to find an answer to questions like this? (8 pts)

If you were to search PubMed, describe what your search strategy would be. Be as specific about terms, fields, & limits as possible. (8 pts.)Search terms

123What type of study design would best address your question? (12 pts.)

When you find a report of original research, what characteristics of the study will you consider to determine it it is relevant, valid, & significant (12 pts.)

What was the best report of original research that addressed your question and why (give cite)? (12 pts)

What is the answer to your clinical question? (25 pt)*Based upon the Fresno Test of Evidence-based Medicine

PICO

PatientInterventionComparisonOutcome

In (this type of patient), does (therapy A) vs (therapy B or control) (have a certain desired outcome)?

RESOURCES

WHICH DATABASES:

WHICH RESOURCES

SEARCH ENGINES

WOULD BE MOST USEFUL TO FIND AN ANSWER TO QUESTIONS LIKE THESE? 

SEARCH STRATEGYCombination of terms/keywords/headings arranged with

Boolean operators AND, OR, and NOT“use quotes for indexed phrases”Iterative process: Do search – does it need broadening or narrowing? To narrow – AND ; To broaden – OR Look for MeSH terms and synonyms

PUBMED “CLINICAL QUERIES”

PUBMED CLINICAL QUERY

PUBMED MESH SEARCH

PUBMED MESH AND KEYWORDS

THE EVIDENCE?