Vanderbilt Sports Medicine

Chapter 2: Chapter 2: How to find current best evidence How to find current best evidence

and have current best evidence find usand have current best evidence find us

Tara Holmes, PA-C, MPHWarren R. Dunn, MD, MPH

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Keeping up-to-date with current best evidence for the care of our patients is challenging.One solution is “problem-based learning” or “learning by inquiry”The success of problem-based learning depends heavily on being able to find the current best evidenceBest-evidence resources must be in formats that facilitate rapid searching to find exact matches for clinical questionsImportant features are portability and easy navigation from clinical questions to evidence-based answers

My students are dismayed when I say to them “Half of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is, none of your

teachers knows which half.”

Dr. Sydney Burwell, Dean of Harvard Medical School

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Orientation to Evidence-Based Information ResourcesWhere to find the best evidence

1. Burn your traditional textbooks

Textbooks are generally well organized for clinical use and much of their content will be current at any one time; Unfortunately, in most texts, no way to tell what’s up-to-date & what’s not.

May be very useful for finding information about “background questions” but not very useful for seeking answers to “foreground questions”.

The authors suggest using money saved from buying textbooks on better sources of current knowledge for clinical practice.

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2. Take a “4S” approach to evidence-based information access

• Even though the ideal format would be a perfect evidence-based clinical information system it is important to remember that such a system would not tell decision-makers what to do. These judgments need to integrate the system’s evidence with the patient’s circumstances and wishes.

Orientation to Evidence-Based Information ResourcesWhere to find the best evidence

Figure 1: A 4S hierarchical structure

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SystemsSome excellent, but less-developed systems are readily available through EDL:

Clinical Evidence, UpToDate, Clinical Evidence, UpToDate, ACP MedicineMedicine

Systems, Synopses, SynthesesInternet-based “aggregators” provide a special “4S supermarket” servicefor evidence-based information.

OVID provides access to a huge collection of texts, journals, & databases,including systems (i.e. Clinical Evidence), synopses (i.e. ACP Journal Club &Evidence Based Medicine), and syntheses (i.e. Cochrane Database of Sys. Reviews.

StudiesSystems, synopses and syntheses follow the publication of original studies, usually by at least 6 months (sometimes by years). If every other “S” fails, thenit’s time to look for original articles.

May be helpful to use a “meta” search engine tuned for health care content.

Example: SUMSearch (http://sumsearch.uthscsa.edu/ ) is attentive to issues of quality of evidence

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Important Things to Consider When Seeking Evidence-based Systems:

Look for texts and websites that:Are revised at least once a year; each chapter or section should have a date of most recent revision

Select and appraise evidence in an explicit way: the introductory section of the text should give a blow-introductory section of the text should give a blow-by-blow, reproducible description of the procedure by-blow, reproducible description of the procedure usedused

Cite evidence in support of declarations about clinical Cite evidence in support of declarations about clinical care: readers can thus get to original sources for care: readers can thus get to original sources for details and can also easily determine the date of details and can also easily determine the date of publication of evidence cited to support a given claimpublication of evidence cited to support a given claim

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3. Organize access to evidence-based information services

Almost all resources are available on the internet

Should ask librarian about what digital library licenses are available and how you can tap into them

Don’t assume your institution will make evidence-based choices about the publications and services it provides

Orientation to Evidence-Based Information ResourcesWhere to find the best evidence

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Orientation to Evidence-Based Information ResourcesWhere to find the best evidence

4. Is it time to change how you seek best evidence?

Resources for finding evidence have evolved in the past few years

Searches can be a lot quicker and more satisfying for answering clinical questions if the features of your quest match those of one of the evolved services

MEDLINE is low on the 4S list of resources for finding current best evidence. This is not a knock against MEDLINE, which continues to serve as a premier access route to the studies and reviews that form the foundation for all other more specialized databases reviewed above

Another way to think of organizing your information needs is “prompt, pull, push”

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Prompt, Push, Pull

Prompt Prompt ((Corresponds to “systems”)When you interact with an EMR it should prompt you if a feature of your patient corresponds to an evidence-based care guideline that you haven’t incorporated into your care plan.

Pull Pull ((Corresponds to the 3 lower levels of the 4S approach)

You go hunting to ‘pull’ the evidence you need from available resources

PushPushRefers to having evidence sent to you

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How to Deal with the Evidence that Finds You:Keeping up to Date Efficiently

Cancel your full-text journal subscriptions Trying to keep up-to-date by reading full-text journals can be difficultTrade in your (traditional) journal subscriptions for evidence-based journals (not realistic for most subspecialties at this point)

Invest in evidence-based journals and online services

A growing number of periodicals summarize the best evidence in traditional journals, making their selections according to explicit criteria for merit

Synoptic journals do what traditional journals wish they could do in selecting the best studies, finding the best articles from all relevant journals and summarizing them in one place.

For the most part, these evidence-based synopsis journals are targeted for generalists. Subspecialties may have to build their own current awareness service

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Search Results for “osteoarthritis AND knee AND glucosamine” Using Different Resources

OVID MEDLINE – 107 matches

PubMed - 110

Journals@OVID Full Text – 317

ACP Journal Club – 1

Cochrane Database of Systematic Reviews – 11

Database of Abstracts of Reviews of Effects – 6

Cochrane Central Register of Controlled Trials – 33

UpToDate – 0

Clinical Evidence – 13

Evidence-based HealthCare – 21

EBM Reviews Full Text – Cochrane DSR, ACP Journal Club, DARE - 18

All EBM Reviews – 51

SUMSearch - 56

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Clinical Evidence

Features:•Gives a summary of interventions organized into 3 categories – beneficial, likely to be beneficial, and unknown effectiveness

•Under Benefits and Harms it breaks down the SRs into two categories: glucosamine vs. placebo & glucosamine vs. oral NSAIDs - gives summaries of each

•It has a post script explaining that one SR has been updated since the search of this chapter; it gives the new search date, details of the SR (i.e. total # of RCTs reviewed) and the results.

•Gives the original search date and the references

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SUMSearch Features:

Gives a summary box at top which stratifies results

Lists all of the results at the bottom according to category (color coded)

Gives a link for an online EBP calculator

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Take Home Points

Evidence does not make decisions; it helps guide you towards Evidence does not make decisions; it helps guide you towards the best decision based on the best available evidence but you the best decision based on the best available evidence but you must take into account the patient’s wishes and circumstancesmust take into account the patient’s wishes and circumstancesDo not take anything (text, journal article, website) at face Do not take anything (text, journal article, website) at face value; must know criteria for selecting/publishing/updating value; must know criteria for selecting/publishing/updating datadataKnow your resources before you begin searching – Know your resources before you begin searching – i.e. i.e. Clinical EvidenceClinical Evidence does not include diagnostic evidence does not include diagnostic evidence If you do not know where to start, try SUMSearchLearn about the different resources offered at the Eskind Biomedical Library and use them! Example: assistance with literature reviews (eblprotocolhelp@vanderbilt.edu or call 936-1383)