Introduction to EBM Resources

Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS

Consultant Physician & PulmonologistChairman, Knowledge Translation Committee

Department of Medicine KAMCRiyadh

Kingdom of Saudi Arabiaimadsahassan@gmail.com

What is Evidence-based Medicine “ Evidence-based medicine is the integration of:

best available research evidence with clinical expertise and patient values”

Sackett, et al 2001

EBP!

The Patient

ClinicalExpertis

e

BestEvidenc

e

3Clinically relevant research, the literature

Practitioner’s knowledge& experience

Patient’s characteristics, preferences & values

Three Pronged Approach

3

Integrates Evidence With Clinical expertise

Experience

Judgment

Patient values and preferences

Quality of life

Costs

Other important factors

Best Available Evidence

Clinical Expertise

Patient Values and Preferences

Quality of Life

Cost/Availability

What is Evidence-based Practice

EBP is about asking questions and searching for answers in the body of medical research, and having found a

likely source of information appraising the

paper for its scientific validity and then

applying the result to your problem.

Evidence-based Practice

Ask clinical Questions

Acquire the best evidence

Appraise the evidence

Applyevidence to your patient

5A’s !!Assess

effectiveness, efficiency of EBM

process

Evidence-based Practice

Ask clinical Questions: PICO

Acquire the best evidence:

Literature Searching

Appraise the evidence:

Critical Appraisal

Applyevidence to your patient:

Knowledge Translation(Implementation)

5A’s !!Assess

effectiveness, efficiency of EBM

process

Self-Education & Training in EBM EBM Resources: 

http://guides.mclibrary.duke.edu/content.php?pid=274373&sid=2262393

http://www.med.yale.edu/library/education/guides/feature/finditfast

 CEBM Website:  http://www.youtube.com/user/cebmed, http://www.cebm.net/index.aspx?o=1965

YouTube: http://www.youtube.com/watch?v=odfo9CQGi0c

Objectives

Why do Healthcare Professionals need to be competent in Literature Searching?

Who should be competent in Literature Searching?

Prerequisites for completing a successful Literature Searching exercise.

Rule 31 – Review the World Literature Fortnightly*

*"Kill as Few Patients as Possible" - Oscar London

0

500000

1000000

1500000

2000000

2500000

Trials MEDLINE BioMedical

Med

ical

Art

icle

s pe

r Yea

r

5,000?per day

1,400 per day

55 per day

The Decline in Knowledge and Patient Outcomes

Competency in Literature Searching for Professionals Dealing with the daily “challenge” to one’s

knowledge. Life-long learning. Evidence-based practice Valuable employee.

For Whom?

Chairman Nursing ManagerResident

Clinical DirectorQuality

Nurse

Competency in Literature Searching: For Whom? Healthcare Professionals IncludingPolicymakers etc Patients!

Competency in Literature Searching for Patients For successful incorporation of:

1. Values and Preferences 2. Patient-centered Care

The 6 Prerequisites for successful Literature Searching

1 •Know how to use a computer/electronic device.

2 •Know the Internet Jargon of Terms.

3 •Know the EBM Jargon of Terms.

4 •Know how to formulate your question.

5 •Know where to go.

6 •Know what to do when you get there: the site’s technical language/know-how.

Know how to use a computer/electronic

device.

Prerequisites for successful Literature Searching Know how to use a computer/electronic

device.

Computer Literacy

Prerequisites for successful Literature Searching Know the Internet Jargon of Terms e.g.

What is a Website? What is a Database? What is a Search Engine? What is a Meta-search Engine?

What is a Website?

• An internet site and an information resource on the

World Wide Web. Websites may provide information

on any topic.

• A collection of files that are arranged on the World

Wide Web under a common address and allows

retrieval via a browser.

• Examples: Pubmed, Yahoo, Guidelines Websites etc

What is a Database?

• A Database is an organized collection of information records that can be accessed electronically e.g. Medline (Pubmed), Cochrane etc

What is a Search Engine?

• A web-based computer-program that allows users to

electronically search and retrieve specific information

online.

• It searches documents and databases for specified

keywords and returns a list of the documents where the

keywords were found.

• Internet search engines help users find web pages on a given subject.• General: e.g. Google, Yahoo etc• Specialized: Google Scholar, Pubmed

What is a Meta-search Engine?

• A search engine that queries other search engines and then combines the results that are received from all.

• In effect, the user is not using just one search engine but a combination of many search engines at once to optimize Web searching.• General: dogpile• Specialized: TRIP, SumSearch.

“turning research into practice”

Prerequisites for successful Literature Searching Know the EBM Jargon of Terms.

EBM Terminology

• Knowledge: Foreground/Background• Types of Literature Articles: Primary

(Original)/Secondary (Pre-appraised)• Clinical Outcomes: Patient-oriented vs Disease

Oriented Outcomes• Reviews: Systematic/Non-systematic (Narrative)• CAT: Critically Appraised Topic• Clinical Practice Guidelines• Levels of Evidence: Hierarchy Pyramid• Sources of Evidence: Point-of-care etc• Knowledge Translation Resources

Ask clinical question Background /Foreground questions

• Background Question

• Asks for general knowledge about a disorder. Textbooks

are good for answering background questions

• Foreground Question

Asks for specific knowledge about managing patients

with a disorder; consists of three or four components

(PICO): Diagnosis, Therapy, Prognosis etc

Journal articles are good for answering foreground questions.

Background versus Foreground Information Case discussion: 27 year old woman with right lower

quadrant (RLQ) abdominal pain Background information available from textbooks-

What typically presents as RLQ pain What is the clinical course/complications of the different

diagnoses Specifically, what is typical presentation of appendicitis

Foreground information How good is a CT scan for appendicitis?

Ask clinical question

novice expert

Foreground questions

Background

question

Types of Literature

Primary (Original)

Secondary (Pre-appraised)

Types of Literature

Primary (Original)

Research publications e.g. in Pubmed Embase CINAHL

The Pre-appraised Literature

• Pre-appraised = The Secondary Literature• Useful for point-of-care searches• Databases with pre-appraised evidence will give you

the highest quality information in the shortest amount of time.

• Two types of pre-appraised databases– Those with pre-appraised Synthesis of studies e.g.

Guidelines and Systematic Reviews– Those with pre-appraised Individual studies:

Critically appraised Topics CATs

Important Outcomes Patient Oriented Outcomes: PO Evidence

outcomes patients actually care about Death (overall or disease-specific) Heart attacks, strokes, amputations, bed sores, broken hips,

renal failure, etc. Ability to perform activities of daily living

Versus Disease oriented outcomes: DO Evidence

Biochemical, physiologic, pharmacologic, or laboratory measures

Comparing DOE and POE

Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60.

ExampleDisease-Oriented Evidence

Patient-Oriented Evidence that

MattersComment

Anti-arrhythmic Therapy

Drug X PVCs on ECG

Drug X increases mortality

POE contradicts DOE

Type 2 Diabetes Aggressive Tx with insulin or oral agentscan keep BS low

Aggressive Tx does not reduce mortality or prevent most complications

POE contradicts standard teaching

ProstateScreening

PSA screening detects prostate cancer early

Does PSA screening mortality?

DOE exists, but POE is unknown

What is a Systematic Review?

• Systematic Reviews (SRs) – Use a systematic methodology to identify, critically

appraise, and synthesize relevant studies– Individual studies assessed for validity– Differ from traditional review articles (Narrative

Reviews) in that conclusions are evidence-based rather than commentary

What is a Systematic Review?

Comparison ChartSystematic vs. Narrative Review

Systematic Review Article Review Article

Narrow focus, answers foreground questions

Broad focus, answers background questions

Systematic scientific approach to finding, evaluating and summarizing the evidence

Depends on the author’s inclination

Comprehensive search for relevant articles Author gets to pick using any criteria

Explicit methods of appraisal and synthesis Methods usually not specified

Meta-analysis may be used to combine data Vote count or narrative summary

What is a Meta-analysis?

• Meta-analyses

– Uses studies from a Systematic Review and applies statistical techniques for combining quantitative data.

– A systematic review that uses quantitative methods to summarize the results.

Evidence-based Practice Guidelines

• Systematically gather and “grade” evidence on a topic

• Developed by professional groups, government agencies, local practices etc

What is a Clinical Practice Guideline?

Level of evidence/Grades of Recommendations

Ia

II

III

IV

V

Oxford Centre of EBM

Systematic reviews (meta-analyses) of RCTs

Cohort studies

Case-control-studies

Case-series

Expert opinion

Grades of Recommendations

Ib Randomized controlled trials

BiasBiasBias

Bias

Bias

Bias

Validity/Strength of Inference

What is Critical Appraisal? Critical Appraisal: The process of assessing and interpreting the

evidence by systematically considering its validity, results and relevance to the area of work considered.

It answers 3 important questions: How well is this study performed? What does it show? Can I use it?

What is a Critically Appraisal Topic?

A standardized one-page summary of the evidence. It consists of a declarative title, clinical bottom line, the clinical question (PICO), search terms, a summary of the study methods, a table summarizing the key results and additional comments (Sackett).

Critically-Appraised Topic (CAT):

What is the Best Evidence? Hierarchy of Levels of Evidence

What is a Randomised Controlled Trial?

A group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables/outcomes of interest.

Randomized Controlled Clinical Trial (RCT)

Prerequisites for successful Literature Searching Know how to formulate your question.

Evidence-based Practice

Ask clinical questions

Acquire the best evidence

Appraise the evidence

Applyevidence to Your patient

5A’s !!Assess

effectiveness, efficiency of EBM

process

Evidence-based Practice

Ask clinical questions PICO

Ask: Refine ability to convert need for information (e.g., therapy, prevention, diagnosis, prognosis) into an answerable question. PICO format for foreground questions.

Ask clinical question

Ask Clinical Questions: PICO

Patient/Population OutcomeIntervention/

Exposure Comparison

Components of Clinical Questions

In patients withacute MI

In post-menopausal

women

In women withsuspected

coronary disease

does early treat-ment with a statin

what is the accuracy of

exercise ECHO

does hormonereplacement

therapy

compared to placebo

compared to exercise

ECG

compared to noHRT

decrease cardio-vascular mortality?

for diagnosingsignificant

CAD?

increase therisk of

breast cancer?

Prerequisites for successful Literature Searching Know where to go.

Evidence-based Practice

Acquire the best evidence

LiteratureSearch

Acquire: Select “best evidence” resources to answer clinical questions using criteria of:Validity – Can I trust the evidence?Relevance – Does the evidence apply to my patient?Time efficiency – Can I get the evidence fast?

Types of Resources

Characteristics of a Good Resource

“Finding Evidence”: Sources Primary: PubMed, EmBase, Cinahl, Pyschlit

Primary Resources

Primary Resources

“Finding Evidence”: Sources Secondary: Systematic Reviews: Cochrane Library, PubMed Guidelines websites: Guidelines Clearinghouse, Guidelines

International Network CATS: BestBets, ACP Journal Club Point of Care: Clinical Evidence, EvidencePlus, UpToDate etc

Secondary Resources

Secondary Resources

Secondary Resources

“Finding Evidence”: Sources Tertiary resources (meta search engines, databases of

databases): TRIP+ (Translating Research Into Practice) SumSearch

Tertiary Resources

Know what to do when you get there: the site’s technical

language/know-how.

Resources For EBM Knowledge Translation

EBM Resources

Point of Care Clinical

Resources

Updates New Evidence

Decision Support Systems

Critical Appraisal

Tools

Evidence-Based QualityImprovement

Evidence-Based

Guidelines & Policies

•DynaMed•Essential Evidence Plus •First Consult•UpToDate•Clinical Evidence•ACP PIERS 

•Mc Master Plus: STAT REF•BMJ Evidence Updates/Alerts•ACP Journal Club

•Open Clinical•Dxplain•Emergency Medicine on the Web•Clinical Decision Making Calculators

•EBM toolbox•CATmaker•Evidence based medicine toolkit•EBM Calculator

•National Guidelines Clearinghouse• NHS Evidence• ICSI Institute for Clinical Systems Improvements

•AHRQ•Institute for Healthcare Improvement•Knowledge Translation Clearinghouse•NICE

Advanced EBM SkillsEBM Hunting Tools

Types of Resources

1. Point of Care Clinical Resources/Decision Support Systems

2. Up-Dates & New Evidence3. Evidence-Based Guidelines, Policies and

Protocols4. Evidence-Based Quality Improvement5. Critical Appraisal Tools6. EBM Audiovisual Training7. Innovations Exchange for New Ideas of Care8. Portals to All

Resources For EBM Literature Searching

1 •Point of Care Clinical Resources/Decision Support Systems

2 •Up-Dates & New Evidence

3 •Evidence-Based Guidelines, Policies Pathways and Protocols

4 •Evidence-Based Quality Improvement

Resources For EBM Literature Searching

5 •Critical Appraisal Tools

6 •EBM Audiovisual Training

7 •Innovations Exchange for New Ideas of Care

8 •Portals to All

2009 NCKUFM-YCY

Systematic ReviewCochrane reviews

Evidence based journals EBM, EBN, EBMH, ACP J club

Computerized Decision Support System (CDSS)

5S Information Resources: Information in top 4 are used

Original articles: BMJUpdates, PubMed Clinical Queries

Evidence based textbooks : UpTo Date, DynaMed, ACP PIER, BMJ Clinical Evidence

Studies

Syntheses

Synopses

Summaries

Systems

Haynes, R. (2006, November). Of studies, syntheses, synopses, summaries, and systems: the 5S evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), A8-A9.

POCRaTs