LIBR534 – Health information sources & services

Evidence-based medicine – Module II ’Filter’January 28th, 2010

Greg Rowell & Dean Giustini, SLAIS Adjunct faculty

“A new paradigm for medical practice is emerging…” (1992)Canadian Dr. Gordon Guyatt

[personal website] 1992 JAMA article

Agenda

• Module II

• What is evidence based medicine (EBM)?

• Health librarian roles in EBM

~ Break 7:15pm~

• Sources of information in EBM• Exercises

• Searching in EBM• Examples

Rowell-Giustini – LIBR534

Rowell-Giustini – LIBR534

Classic definition of EBM

“…EBM is the conscientious, explicit and judicious use of current best evidence in making clinical decisions about the care of individual patients.“

David Sackett (1996) - McMaster University

In your own words: What is evidence-based medicine ’about’?

How would you explain its ’steps’ to someone?

Rowell-Giustini – LIBR534

… the health librarian’s role is to explain what knowledge and skills

he brings to the clinical team

Health librarians – The Five Steps of EBM

see EBM tutorial,University of California

Rowell-Giustini – LIBR534

Lead to the evidence - when you can…

Haiti guide http://hlwiki.slais.ubc.ca/index.php/Haiti_earthquake_-_disaster_relief_information_sources

e.g., Cochrane Library - disease prevention & coping skills• Improving water quality & hand washing • Psychological treatment

H1N1 guide http://hlwiki.slais.ubc.ca/index.php/H1N1_(Human_Swine_Flu)_in_Canada_-_Information_Sources

• DynaMed http://www.ebscohost.com/dynamed/h1n1/ • MDConsulthttp://www.mdconsult.com/recommended-results/H1N1Influenza.lp• UpToDatehttp://www.uptodate.com/home/content/topic.do?topicKey=pulm_inf/19054

Other observations re: searching for evidence?

Rowell-Giustini – LIBR534

But first – is question ‘background’?

• First, let’s make distinction - background vs foreground questions

• Background questions are posed by novices looking for general knowledge or “facts” • who, what, when, why, which• What is H1N1? What is influenza?• How can H1N1 be diagnosed?• Which treatments are available for it?

• Best answered in textbooks or databases like MDConsult & UpToDate• The novice has more background questions than the expert…

Or a foreground question?

• Foreground questions are asked by experts

• Answers found by searching Medline but there are many tools

• PICO to structure foreground Qs:

Patient/Population/ProblemInterventionComparison/Control Outcome

• ‘Therapy’ ….most common domain• PubMed’s Clinical Queries to filter

http://www.ncbi.nlm.nih.gov/sites/pubmedutils/clinical

Rowell-Giustini – LIBR534

Reference: “Laikas MedLibLog”http://laikaspoetnik.wordpress.com/2009/09/

Rowell-Giustini – LIBR534

…and PICO to structure question

Patient

Population

Problem

Can I describe my patient or problem? Let’s start by framing the question…

Intervention What main intervention (or treatments) will be considered for him?

Comparison Do you want a placebo comparison or a drug comparison?

Outcomes What is the desired outcome or effect for the patient?

Exercise – Jonesy, a 68 yr old male with….

Rowell-Giustini – LIBR534

…where is the evidence?

• Should newborns be vaccinated against chicken pox if mothers have been exposed to the virus?

• What are the effects of Prozac for someone who is depressed?

• Does psychological counselling alleviate symptoms of Post Traumatic Stress Disorder (PTSD)?

• Are cox-II inhibitors effective in treating osteoarthritis in a geriatric population?

Rowell-Giustini – LIBR534

Strategy: filtered sources first

• EBM up-to-date textbooks• UpToDate, BMJ Clinical Evidence, First Consult, etc

• ‘Pre’ Filtered resources • ACP Journal Club• Cochrane Database of Systematic Reviews• SumSearch & TRIP Database

• Primary research • Medline (OvidSP, Pubmed) is unfiltered• EMBASE, CINAHL, PsycINFO, etc• But, some filtered information in databases

Rowell-Giustini – LIBR534

Roles for health librarians in evidence-based practice

Explain health librarian’s role to clinical team

• Respond to individual needs as appropriate

‘Frame’ or formulate clinical question in reference interview• Break question into categories, facets or ‘pearls’

Teach search techniques• Explain indexing practices in databases• How to limit for methodology i.e. publication types

Check search strategies • Collaborate on research & publication

Rowell-Giustini – LIBR534

• Split into groups of 2• Pick one category or question at a time• Listen to the “answer” being read• Determine correct “question” for answer• Try to get the most points

Build your EBM knowledge

Welcome to EBM Jeopardy for LIBR534

Rowell-Giustini – LIBR534

What is evidence-based medicine?

Rowell-Giustini – LIBR534

“…Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making clinical decisions about the care of

individual patients.“

David Sackett (1996) - McMaster University

Rowell-Giustini – LIBR534

Name the four parts of PICO…

Rowell-Giustini – LIBR534

PICO stands for:

• Patient/Population/Problem

• Intervention

• Comparison/Control

• Outcome

What are the four parts of PICO?

Rowell-Giustini – LIBR534

What is a systematic review& meta-analysis?

Rowell-Giustini – LIBR534

A meta-analysis is…

…a study design that attempts to have greater statistical power by pooling the results from many studies like RCTs

…the search strategies for a SR or a meta-analysis must be reproducible …

Rowell-Giustini – LIBR534

What is a tree structure?

Rowell-Giustini – LIBR534

A tree structure….

…is how broader and narrower terms are displayed along sixteen (16)

categories in the MeSH hierarchy

A. Anatomy B. Organisms C. Diseases D. Chemical and Drugs E. Analytical, Diagnostic and Therapeutic Techniques and Equipment F. Psychiatry and Psychology G. Phenomena and ProcessesH. Disciplines and Occupations I. Anthropology, Education, Sociology and Social Phenomena J. Technology, Industry, Agriculture K. Humanities L. Information Science M. Named Groups N. Health Care O. Publication Characteristics • Geographic Locations

Rowell-Giustini – LIBR534

What is the Cochrane Library?

Rowell-Giustini – LIBR534

The Cochrane Library is

… a collection of six databases of high-quality evidence to help health professionals make clinical decisions. (See also Cochrane Collaboration). In addition to Cochrane's database of systematic reviews, the CL provides access to other sources such as technology assessments, evaluations and clinical trials.

Two commercial products that provide access:OVID's Evidence-based medicine reviews (EBMR)

and Wiley's Cochrane Library

Rowell-Giustini – LIBR534

What is the ‘Clinical Queries’ feature in PubMed?

Rowell-Giustini – LIBR534

…a quick and efficient way to filter

along four domains using pre-defined search strategies or ‘search filters’

that have been created by Brian Haynes and Ann McKibbon at

McMaster University….

http://www.ncbi.nlm.nih.gov/sites/pubmedutils/clinical

The ‘Clinical Queries’ feature in PubMed is…