Evidencebased Practice for Hinari Users Part A Advanced
Evidence-based Practice for Hinari Users Part A (Advanced Course Module 6) 01 March 2018
Table of Contents – Part A • Evidence & EBM definitions • 5 step EBM process • Hinari Resources (partial) • Cochrane Library • Joanna Briggs Institute Resources 01 March 2018
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 01 March 2018
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 01 March 2018
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 01 March 2018
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. 01 March 2018
The 5 Step EBP Process 1. ASK: Formulate an answerable clinical question 2. ACCESS: Track down the best Evidence Ask Assess Access 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 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 – guidelines (best practice) – narrative reviews • general overview of a topic – treatment of heart disease – INTERVENTION/PREVENTIO N – ETIOLOGY, RISK – DIAGNOSIS – PROGNOSIS • Information Resources – journal articles – synopses of articles – systematic reviews • answer specific questions – best medication to reduce blood pressure
Step 1: ASK PICO Format Ask P = Patient, population or problem I = Intervention C = Comparison intervention (optional) O = Outcome
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: – Terminal Cancer Patient – Young, mother of 2 children
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 the risk of impotence. • Identify the 4 PICO components 02 February 2018
Formulate the Clinical Question • PICO P (patient) - 54 year old male / prostate cancer I (intervention) - radical prostatectomy C (comparison intervention) - radiation treatment O (outcome) - reduce risk of impotence • 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 impotence? 02 February 2018
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 01 March 2018
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. 02 February 2018
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.
Hierarchy of Evidence Research Studies synthesis experimental observational primary literature – comes directly from a study secondary literature – combines findings from primary literature
Hierarchy of Evidence - Medical Literature Track Down access at the level that will give you the best evidence Filtered & Critically Appraised Expert Opinion and Not Filtered Background info. Most clinically relevant (at the top) Least clinically relevant (at the bottom)
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 01 March 2018
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 01 March 2018 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
Hierarchy of Evidence – Question Type Therapy/Prevention What should I do about this problem? RCT>cohort > case control > case series Diagnosis Does this person have the problem? cross-sectional study with blind comparison to a gold standard Etiology/Harm What causes the problem? RCT > cohort > case control > case series Prognosis/Prediction Who will get the problem? RCT >cohort study > case control > case series Frequency and Rate How common is the problem? cohort study > cross-sectional study A well designed systematic review of RCTS (randomized controlled trials) is best as it is least biased therefore more valid. After that, start with the least biased study type for the question.
‘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 01 March 2018
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? GATE Appraisal Form: https: //www. fmhs. auckland. ac. nz/en/soph/about/our-departments/epidemiology-andbiostatistics/research/epiq/2015 -evidence-based-practice-and-cats. html • 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 •
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?
‘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. 01 March 2018
EBP Step 5: ASSESS (patient, yourself) Evaluate the effectiveness of the process. • 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 Assess
‘Dog Bite’ Example: Follow Up • On a follow up visit you find out that he did not get infected. • Keep records 01 March 2018
To learn more about EBM, go to the online tutorial Introduction to Evidence-Based Medicine. Developed by Duke University Medical Center Library and Health Sciences Library/University of North Carolina/Chapel Hill. http: //guides. mclibrary. duke. edu/ebmtutorial
SUNY Downstate also provides a comprehensive online tutorial about EBM. http: //library. downstate. edu/EBM 2/contents. htm Case Series / Reports
Hinari Resources • Cochrane Library – filtered • Joanna Briggs Institute Resources filtered 01 March 2018
The Cochrane Library by The Cochrane Collaboration • The Cochrane Collaboration (http: //www. cochrane. org/) – Independent non-for-profit international collaboration – Reviews are among the studies of highest scientific evidence – Minimum Bias: Evidence is included/excluded on the basis of explicit quality criteria; A panel of experts reviews the evidence, peer-reviewed, dynamic (updated regularly) – Reviews involve exhaustive searches for all RCT, both published and unpublished, on a particular topic – Abstracts searchable for free on the Internet; – Some of Cochrane Library resources searchable in Pub. Med 199514 March 2018
The Cochrane Library Content • Cochrane Database of Systematic Reviews (CDSR) – Cochrane Reviews & Protocols primarily on interventions • Database of Abstracts of Reviews of Effects (DARE) – Structured abstracts on other reviews also on diagnosis, prevention, rehabilitation, screening (not available in CDSR or Medline) • Cochrane Central Register of Controlled Trials (CENTRAL) – The largest single source of RCTs from all over the world (from Medline, Embase, conference proceedings, and more) • Cochrane Methodology Register (CMR) - Methods Studies • Health Technology Assessment Database (HTA) – Technology Assessments • NHS Economic Evaluation Database (NHSEED)- Economic Evaluations 14 March 2018
From the Hinari Content page, open the Reference sources list to access Cochrane Library and other EBM resources. 14 March 2018
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. 14 March 2018
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. 14 March 2018
Searching the Cochrane Library 1. 2. 3. 4. 5. 6. 14 March 2018 Select Search manager 1. Select Search manager Search for PICO terms one at a time 2. Search for PICO terms one at a time Combine synonyms with OR 3. Combine synonyms with OR 4. Combine different terms with AND 5. You retrieved 20 results 6. Scroll down to view results
Displaying Results in the Cochrane Library All results CDSR (default) DARE CENTRAL 1. 2. 3. 4. 5. 6. 14 March 2018 Search all Cochrane databases at once Results from CDSR display as default Notice results from DARE, CENTRAL, etc. Systematic reviews are available Click on 1 st one to view If not satisfied view reviews from DARE or Randomized Control Trials from CENTRAL
Viewing Results in the Cochrane Library Note that you can download the PDF. 14 March 2018
Review Key Information 14 March 2018
Review Abstract to see if your PICO matches review’s criteria 14 March 2018
View Main Results and Conclusions 14 March 2018
Plain Language Summary for Your Patient 14 March 2018
Viewing Randomized Control Trials from CENTRAL 14 March 2018
From the Cochrane Reviews drop down menu open Browse by Topic. 14 March 2018
From the extensive Browse by Topic list, you have another option for locating subject- specific material. 14 March 2018
JBI Database of Systematic Reviews and Implementation Reports (JBI) JBI resources are primarily found through the Ovid platform, however, when it is feasible, some of the Protocols will be published through PROSPERO which is Open Access. Besides Systematic Reviews, JBI publishes: • Best Practice Information Sheets • Consumer Information Sheets • Evidence Summaries • Recommended Practices • Systematic Review Protocols • Systematic Reviews • and Technical Reports 14 March 2018
Two Methods for Searching JBI: The first is article searching • No advanced Search • Best bet when you have an article title/volume/issue • Retrieval Path • Click on J from the Journals Collection • Find the JBI Database of Systematic Reviews and Implementation Reports • Note: There are two options. Choose the year range that is appropriate for your citation. 14 March 2018
JBI Database of Systematic Reviews and Implementation Reports: Article Searching Note the Article searching options. 14 March 2018
Article Searching through JBI Database Search the journal issue list • Using Date, Volume, issue and page number 14 March 2018 Advanced Search • The Advanced Search is a simple title, author, etc search. Keyword/subject search; generally used when you have no citation available; this method searches 2003 to present; from volume 1/issue 1
Open the Joanna Briggs Institute EBP Database from the Browse databases list -another option for locating subject- specific material. 14 March 2018
Check All Resources and click on OK. 14 March 2018
To search for just JBI materials, perform a Multi-Field Search. Type JBI in the search box, and in the drop down menu select Journal Words. Enter specific search – Blood donation with All Fields – in the box below. Open Search History above to see more details. 14 March 2018
Field limiters available in the OVID Database for JBI: • Abstract – to ensure you are coming up with the best search possible, search for keyword; should only be used for main phrase terms; note: you will lose any material without an abstract • Title - this is very specific and searchers should be very careful to only search the most specific term using this method • Text Word – the text word limiter searches both Abstract and Title 14 March 2018
Example Search – JBI & infectious diseases and Africa The results for this search are 26 that will be opened by clicking on Display Results. 14 March 2018
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