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 P

A 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 AGENDA

1. Concepts:

Evidence-based medicine

Evidence-based psychiatric practice

Systematic 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 2013

Diana Cunningham

Actual 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 review

Selection or inclusion/exclusion criteria

Comparability: randomized or not

Validity of evaluation instrument

Data-analysis

Can I apply the results to my patient?

But must be relevant to your patient or it doesn’t matter!

Relevance Validity

Feasibility 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)

PsycINFO

Psychology and Behavioral Science Collection

Scopus

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

Cochrane (in PubMed)

UpToDate

Dynamed

Clinical Evidence

National Guidelines Clearinghouse (AHRQ)

AND NOW: SEARCH THE LITERATURE

Goal: 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) question

2. Thorough search of the literature for answers pertaining to the question

3. Critically appraising the evidence for validity and importance

4. Apply results to your patient

5. 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 CASE

Patient 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*

1

What 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

3

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

4

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

5

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.)

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

123

What 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

Patient

Intervention

Comparison

Outcome

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 STRATEGY

Combination 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?