Evidencebased Practice for HINARI Users Advanced Course Module

Evidence-based Practice for HINARI Users (Advanced Course Module 6 Part A) 06 July 2017

Table of Contents – Part A • Evidence & EBM definitions • 5 step EBM process • HINARI Resources • Cochrane Library • Evidence-based Medicine Guidelines • Essential Evidence Plus • EBM Journals 06 July 2017

Table of Contents – Part B • • • Pub. Med/Clinical Queries Pub. Med Filters Pub. Med Health Evidence Aid Other (Internet) Resources 06 July 2017

What is Evidence? Evidence concerns facts intended for use to support a conclusion • A fact is something known by experience or observation • Evidence is used to support a conclusion; it is not the conclusion itself Context-free scientific evidence (medical effectiveness or biomedical research) Evidence Tacit evidence (views and realities of doctors and patients) Context sensitive scientific evidence (putting evidence into a particular operational setting) Source: Lomas J et al. Conceptualizing and combining evidence for health system guidance. Canadian Health Services Research Foundation, 2005. 06 July 2017

What is EBP? The integration of best evidence* from current research, patient preferences and values, and clinical expertise to clinical questions in a timely fashion (Sackett, 2000). Best Evidence Patient Values/Local Conditions EBP Clinical Expertise *Best available evidence is: consistent research evidence with high quality and quantity 06 July 2017

Why EBP? • Improve care • To bridge the gap between research & practice • “Kill as few patients as possible” (O. London) • new treatment • fewer side effects • cheaper or less invasive • resistance to existing therapies, etc. • Keep knowledge and skills current (continuing education) • To save time to find the best information 06 July 2017

What are some Barriers for EBP? • • • Time, effort & skills needed Access to evidence Overuse, underuse, misuse of evidence Poor decision making Environment not supportive of EBP Intimidation by senior clinicians 06 July 2017

How does EBP help? A patient comes to a clinic with a fresh dog bite. It looks clean and the nurse and patient wonder if prophylactic antibiotics are necessary. The nurse searches Pub. Med and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%. • For every 100 people with dog bites, treatment with antibiotics will save 7 from infection • Treating 14 (NNT) people with dog bites will prevent 1 infection • You explain these numbers to the patient along with possible consequences and patient decides not to take antibiotics. • On a follow up visit you find out that he did not get infected. Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2 nd. ed. BMJ Books, 2007. 06 July 2017

Types of EBM resources: Pre-appraised literature vs. Non-appraised literature* • Pre-appraised literature uses an explicit review process – by experts - to find appraise evidence; to provide clinicians with the best evidence, often at the point of care (evidence summaries, journals that summarize research, clinical practice guidelines). https: //learn. maricopa. edu/courses/804760/pages/understanding-preappraised-sources? module_item_id=5387411; 23 September 2016 • Non-appraised or primary sources (individual research articles) answer very specific questions and provide the most recent data. One must be able to search efficiently and critically appraise the information. https: //www. pdqa. gov. hk/english/ebeplatform/ebm_bestevid. php 23 September 2016 *Regardless of category, sources must be appraised by the user 06 July 2017

Select sources to find primary studies: Filtered (pre-appraised) or Not-filtered (not appraised)? Not-filtered (not-appraised) sources: Medline (Pub. Med), Scopus, Google/Scholar. . . • Create comprehensive searches • Conduct systematic reviews • Conduct synonym searching using thesauri • Set up and distribute alerts • Limit to populations & publication types 06 July 2017 Filtered (appraised) sources: Cochrane Library, Joanna Briggs… • ‘Not all clinicians will need or want to do lit searches and clinical appraisal’ • Save Time • Ask the experts • Use quality research only • Use at the point of care

Pyramid of Evidence 06 July 2017 Source: JBI Levels of Evidence Developed by the Joanna Briggs Institute of Evidence and Grades of Recommendation Working Party, 2013.

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EBM resources: searching priorities • Priority 1: Cochrane Library, Joanna Briggs - preappraised sources but may not discuss the topic or could be out of date • Priority 2: Clinical Queries – non pre-appraised source; search tool that focuses on ‘clinical study categories’ and ‘systematic reviews’ and could lead to up-to-date information; tool to quickly identify ebm literature • Priority 3: Pub. Med with appropriate filters (metaanalysis, systematic reviews, randomized controlled trials) – also non pre-appraised sources but another way of searching whole database 06 July 2017

The 5 Step EBP Process 1. ASK: Formulate an answerable clinical question 2. ACCESS: Track down the best Evidence 3. APPRAISE: Appraise the evidence for its validity and usefulness 4. APPLY: Integrate the results with your clinical expertise and your patient values/local conditions 5. ASSESS: Evaluate the effectiveness of the process 06 July 2017 Ask Assess Access Apply Appraise

Step 1: ASK (questions, PICO) a focused (answerable) clinical question Background Questions Ask Foreground Questions • General questions - disorder • Specific questions - patient – – What is the disorder? What causes it? How does it manifest? Treatment options? • Information Resources – books – narrative reviews • general overview of a topic – – INTERVENTION/PREVENTION ETIOLOGY, RISK DIAGNOSIS PROGNOSIS • Information Resources – journal articles – synopses of articles – systematic reviews • answer specific questions 06 July 2017

Step 1: ASK PICO Format Ask P = Patient, population or problem (Who are the patients or populations? What is the disease? ) I = Intervention (What do you want to do with this patient - treat, diagnose, observe)? C = Comparison intervention (What is the alternative to the intervention - placebo, different drug, nothing? ) O = Outcome (What are the relevant outcomes morbidity, mortality, death, complications)? 06 July 2017

Why should I use PICO? • • • define problem - clarify it in your own mind identify concepts/terms for searching ask patient centered questions; treatment of pneumococcal pneumonia SHOULD be different for – elderly, severely demented patient – terminal cancer Patient – young, mother of 2 children 06 July 2017

Templates for EBP Questions • For a therapy: In adult patients w/total hip replacements (P), what is the effect of PCA pain Medication (I) on postoperative pain(O) compared with prn IM pain Medication(C)? • For etiology: Are adult males (P) who have a vasectomy (I) at an increased (Increased/decreased) risk for/of testicular cancer (O) compared with adult males (P) with/without no vasectomy (C)? • Diagnosis or diagnostic test: Are (is) mammogram(I) more accurate in diagnosing breast cancer (P) compared with clinical breast exam (C) for earlier diagnosis of breast cancer (O)? • Prevention: For women under the age of 60 (P) does the use of low-dose aspirin (I) reduce the future risk of stroke (O) compared with none (C)? • Prognosis: Does smoking education (I) influence young people not to smoke (O) in patients who have high risk of smoking (P)? Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins. 06 July 2017

Example: Intervention Questions • A 54 year old male patient was diagnosed with intermediate grade prostate cancer and wants to know whether to get a radical prostatectomy or radiation treatment. He is concerned about death from prostate cancer and also risks of impotence and incontinence. • Identify the 4 PICO components 06 July 2017

Formulate the Clinical Question • PICO P (patient) - 54 year old male with intermediate grade prostate cancer I (intervention) - radical prostatectomy C (comparison intervention) - radiation treatment O (outcome) - reduce risk of mortality, impotence, and incontinence • Focused clinical question In 54 year old male patients with intermediate grade prostate cancer, is radical prostatectomy more effective compared to radiation treatment in reducing the risk of mortality, impotence, and incontinence? 06 July 2017

Formulate the Clinical Question • PICO P (patient) - 30 year old male with a fresh dog bite I (intervention) – prophylactic antibiotics C (comparison intervention) – clean and bandage; no antibiotics O (outcome) - reduce risk of infection • Focused clinical question In 30 year old male patients with a fresh dog bite, is prophylactic antibiotics more effective then cleaning & bandaging the would in reducing the risk of infection? • Deconstruct your PICO Keywords: dog OR animal* bite* antibiotics infection* Limiter: Adult, age 18 – 45 English Only 06 July 2017

Etiology and Risk Questions What causes a disease or health condition? • The reverse of intervention questions-they deal with harmful outcomes of an activity or exposure (public health issues) • Develop a clinical question for the case: S. is a smoker and just found out that she is 3 months pregnant. She quit smoking immediately. But she is worried if her developing baby was harmed and if the baby is at risk for having developmental problems. She is asking you if smoking during the first trimester can harm her baby? 06 July 2017

Etiology or Risk Questions • P-babies of mothers who smoke I- smoking in first trimester C-nothing O-increase risk of developmental problems • Question: Are babies of mothers who smoke during their first trimester at an increased risk of developmental disabilities? 06 July 2017

EBP Step 2: ACCESS (studies, hierarchies) Track Down the Best Evidence Access Start “hunting” from the best resource: match your question to the best medical information resource for this question. Filtered (pre-appraised) vs. Not-filtered (not appraised) 06 July 2017

‘Dog Bite’ Example: Nurse Search • The nurse searches Pub. Med and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%. • For every 100 people with dog bites, treatment with antibiotics will save 7 from infection • Treating 14 (NNT) people with dog bites will prevent 1 infection 06 July 2017

EBP Step 3: Appraise (validity, impact) Appraise • Appraisal principles (primary and secondary research) – Does PICO of the study match my PICO question? – validity • internal validity – methods – How well was the study done? Is it biased? • external validity – generalizability – impact • Does it matter to your patient? • • University of Oxford’s Center of EBM: http: //www. cebm. net/index. aspx? o=1157 Evaluating the Evidence section in the EBM tutorial at: http: //www. hsl. unc. edu/Services/Tutorials/ebm/welcome. htm 06 July 2017

EBP Step 4: APPLY (patient, setting) Integrate the results with your clinical expertise and your patient values Apply • Patient • Is my patient similar enough that the results of the study apply? • Will the potential benefits outweigh the potential harms of treatment ? • What does my patient think? What are his cultural beliefs? – Setting • Is the intervention feasible in my settings? • What alternatives are available? 06 July 2017

‘Dog Bite’ Example: Application/Recommendation/Decision • You explain these numbers to the patient along with possible consequences • Probability of infection, based on age, health, etc, is low. • But leaves the decision to the patient. • Patient decides not to take antibiotics. 06 July 2017

EBP Step 5: ASSESS (patient, yourself) Evaluate the effectiveness of the process. Assess • Am I asking questions? • Am I writing down my information needs? • How is my searching going? Am I becoming more efficient? • What is my success rate in the EBM steps? • Am I periodically syncing (checking) my skills and knowledge with new developments? • Teach others EBP skills • Keep a record of your questions 06 July 2017

‘Dog Bite’ Example: Follow Up • On a follow up visit you find out that he did not get infected. • Keep records 06 July 2017

HINARI Resources • Cochrane Library – filtered • Joanna Briggs Institute - filtered • Pub. Med – unfiltered • Clinical Queries • Filters • HINARI EBM Journals 06 July 2017

Cochrane Database of Systematic Reviews The Cochrane Library (John Wiley) • high-quality, filtered, critically appraised Systematic Reviews from all over the world • minimum bias: evidence is included/excluded on the basis of explicit quality criteria • abstracts searchable for free on the Internet; complete database is available via HINARI 06 July 2017

Enter your HINARI USER NAME and PASSWORD in the appropriate boxes, change the language of the portal (if necessary), then click on the Login button. Note: To have access to the full text articles, you must properly sign in. 06 July 2017

Click on the Hinari logo to open the program. All the programs your institution is registered for are listed. Login to any of the other programs by returning to this page (use the R 4 L Portal – Applications tab at the top of the web browser). To open another program, click on the specific logo. Your Hinari username and password will grant access to the other programs (and ditto for your institution’s AGORA, ARDI or OARE logins). 06 July 2017

Once you are logged in to the HINARI Content page, access Pub. Med by clicking on Reference sources. 06 July 2017

From the Reference Sources menu, we now will click on the Cochrane Library link. The Cochrane Library contains high-quality, independent evidence including reliable evidence from Cochrane and other systematic reviews and clinical trials. It is published by John Wiley. 06 July 2017

The initial page of this site has a title, abstract or keyword option Search engine. You also have various options in Cochrane Reviews to Browse by Topic and Browse by Review Group Open the Browse by CDSR Notice the More Resources List. 06 July 2017

The Search for diarrhea child* Title, Abstracts and Keyword has retrieved 122 records that are Cochrane Reviews plus, for All Results, Other Reviews, Methods Studies and other options - a total of 3313 results. You have the option to Export All Results (save). 06 July 2017

The Search for diarrhea child* Title, Search All Text has retrieved 1006 records that are Cochrane Reviews and 4620 for All Results – a significantly higher number. 06 July 2017

The screen displays the Abstract and links to other features of the first systematic review listed in the search - Vaccines for preventing rotavirus diarrhoea. Scroll down to view all the features/ sections of the Abstract. Note the option to open the complete PDF and other features. 06 July 2017

The final section of the Abstract is titled Plain language summary. This section is useful for disseminating the results to groups of health workers and patients. Many abstracts include a Resume in French. 06 July 2017

From the Cochrane Library drop down menu, open Browse by Topic. 06 July 2017

The extensive Browse by Topic list is another option for locating subject- specific material. 06 July 2017

Open the Joanna Briggs Institute EBP Database - another option for locating subject- specific material. Note: you now are in the Search inside Hinari full-text through database… (Browse databases) listing and not the Reference Sources one. 06 July 2017

Check Joanna Briggs Institute EBP Database and click on OK. 06 July 2017

Similar to Cochrane Library, the diarrhea child will be completed. Note the Limits option. 06 July 2017

The results for the diarrhea child are ranked by up to ***** for relevance. Note the Filter by options in the right column. 06 July 2017

The Limits options are displayed. Note the Open Access Results listing. For other articles, return to the Hinari Journals collection A-Z list. 06 July 2017

The Advanced Search feature under Search allows you to see where your results are pulling from, and there are some (very limited) limiters available. Once you have conducted your search, you will notice that there are some articles available in PDF format, some are unavailable and some are pay per view. If conducting a Systematic Review through the JBI center, it is possible to contact JBI Headquarters for full text that are not available below. 06 July 2017

JBI resources are primarily found through the Ovid platform, however, when it is feasible, some of the SR Protocols will be published through PROSPERO, which is Open Access (free on the internet). JBI, like Cochrane, publishes more than just Systematic Review, it publishes Best Practice Information Sheets, Consumer Information Sheets, Evidence Summaries, Recommended Practices, Systematic Review Protocols, Systematic Reviews and Technical Reports. The platform will be more easily searchable through the Search tab at the top of the screen. 06 July 2017

Return to the Reference Sources menu – to open the next two resources – EBM Guidelines: Evidence-Based Medicine & Essential Evidence Plus. These are other John Wiley EBM resources that are available to many of the Hinari institutions. 06 July 2017

From the Reference Sources list, we have opened the initial page of EBM Guidelines Evidence-Based Medicine. Also published by John Wiley, this resource is a collection of clinical guidelines for primary care combined with evidence-based research. You can Search by keyword or Browse database contents by EBM Guidelines, Evidence summaries, Pictures, Audio samples, Videos and Programs. Influenza will be searched. 06 July 2017

We have completed a keyword search for Influenza. The results page includes summaries of the key issues. Note also the PRIMARY and TEXT HITS that include EBM Guidelines and Evidence Summaries. 06 July 2017

We have displayed the 1 st Evidence summary. Each link contains a brief review of the study and notes the reference(s). 06 July 2017

From the Reference Sources list, we have opened the initial page of Essential Evidence Plus. Also published by John Wiley, it includes access to Cochrane Library and also a series of databases and tools to access the EBM material. By keyword, you can Search all or some of the databases. 06 July 2017

We have opened the EBMG evidence summaries database that, via broad subject categories, has access to 4343 articles. 06 July 2017

We have opened the initial page of EBMG evidence summaries listing for Infectious disease. Material is listed by either a summary view or expanded view that includes a sentence describing each entry. 06 July 2017

We have opened Browse Databases and Tools that has 277 tools and calculators that assist in clinical decision making. 06 July 2017

For journal titles with Evidence in the title, open the Complete list of journals, click on control F and enter Evidence in the search box. 36 titles with Evidence will be highlighted. Note – this list does not have hypertext links. Access will be in the Journal collections A-Z list. 06 July 2017