Download - PUBMED and the EVIDENCE-BASED UNIVERSE Holly Ann Burt Outreach and Exhibits Coordinator NN/LM GMR
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PUBMED and the EVIDENCE-BASED UNIVERSE
http://nnlm.gov/training/pubmedebm/
Holly Ann Burt
Outreach and Exhibits Coordinator
NN/LM GMR
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OBJECTIVES
By the end of this class, attendees will be able to:
Define evidence based research, identify process steps and know where the library services fit
Recognize types of studies and understand how they related to levels of evidence
Formulate literature searches to find such evidence
Know where to go for additional information
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AGENDA
Introduction Just What IS Evidence Based? Asking the Right Question Studies, Studies, Studies Taking it to the Next Level
To Literature and Beyond Evidence-Based MeSH
MeSH Terms, Subsets, Clinical Queries Critical Appraisal
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JUST WHAT IS EVIDENCE BASED?
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TERMINOLOGY
Evidence-Based Medicine (EBM) Evidence-Based Practice (EBP) Evidence-Based Practice in xxx (EBPx) Evidence-Based Health Care (EBHC) Evidence-Based Nursing (EBN) Evidence-Based Public Health (EBPH) Evidence Based Library and Information Practice
(EBLIP) Research Based Evidence (RBE)
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DEFINITIONS - EBM
Evidence-based medicine requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances.
Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine: how to practice and teach EBM 3d ed. London:
Churchill Livingstone, 2005
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DEFINITIONS - EBPH
Evidence-Based Public Health (EBPH): The process of systematically finding, appraising and using contemporaneous clinical and community research findings as the basis for decisions in public health.
Jenicek M, Stachenko S. Evidence-based public health, community medicine, preventive care. Med Sci Monit. 2003 Feb;9(2):SR1-7.
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DEFINITIONS - EBP
Evidence-Based Practice: A way of providing health care that is guided by a thoughtful integration of the best available scientific knowledge with clinical expertise. This approach allows the practitioner to critically assess research data, clinical guidelines, and other information resources in order to correctly identify the clinical problem, apply the most high-quality intervention, and re-evaluate the outcome for future improvement.
NLM MeSH 2009
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STEPS IN EVIDENCE BASED RESEARCH
1. Asking answerable questions2. Finding the best evidence3. Critically appraising the evidence4. Applying a decision5. Evaluation
Heneghan C, Badenoch D. Evidence-based medicine toolkit. 2d ed. Malden, MA: Blackwell, 2007
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STEP 1 - QUESTION
Asking answerable questions – focused, searchable, clinical PICO
Patient, Problem, Population Intervention or therapy Comparison, Control, Context Outcome
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STEP 2 - STUDIES
Finding the best evidence with which to answer the question through structured searches and understanding the literature Primary Studies
Clinical trials Randomized Controlled Trials Multicenter studies
Secondary (synthesized, summarized) Studies Reviews Meta-analyses
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STEP 3 – CRITICAL APPRAISAL
Critically appraising the evidence for its validity (closeness to the truth), impact (size of the effect) and applicability (usefulness in clinical practice)Is it valid?Is it important?Can it help?
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STEP 4 - APPLICATION
Applying a decision - Combining findings to make a recommendation, placing the evidence into context, incorporating recommendation into a specific patient situation, clinical setting or organizationHow much will it help a patient or
population?Does it meet their values and goals?Is it cost-effective?
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STEP 5 - EVALUATION
Evaluation - Determining and measuring the effectiveness of the practice change over timeHow could it be done better next
time?What is the outcome of using (or not
using) particular information and its impact on clinical practice?
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ASKING THE RIGHT QUESTION
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MY BROTHER DIED OF STROKE, WILL I?
Glasziou P. Why bother with evidence-based practice? Oxford: Centre For Evidence-based Medicine; 2010
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PICO QUESTIONS
PICO Patient, Problem, Population
(subjects)
Intervention or therapy – may include coalition-building and/or collaborative programs (study groups)
Comparison, Control, Context (study groups)
Outcome (results)
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STUDIES, STUDIES, STUDIES
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STUDIESRESEARCH DESIGN
Cambron JA. Study Design. Lombard: National University of Health Sciences; 2008.
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STUDIESRESEARCH DESIGN – DESCRIPTIVE
Investigator studies people and exposures in nature, observational
No control or comparison group Studies
Correlational – statistical association between variables
Case studies – new diseases & treatments, etc. Case report – documenting research’s experience Case series – following a group over time Cross sectional study – survey
Community Survey Qualitative study– interview w/open-ended question Migrant studies
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STUDIESRESEARCH DESIGN – OBSERVATIONAL ANALYTIC
Investigator collects data without making changes to patient’s life or introducing treatments
Control/Comparison group, not randomized Studies
Case Control – etiology; examine associations between disease/disorder/health issue and one or more risk factors
Cohort Study – measurement of one characteristic, outcome, or issues across two groups Prospective Cohort Retrospective Cohort Time Series Study
Cross sectional – to determine prevalence
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STUDIESRESEARCH DESIGN – EXPERIMENTAL
Investigator chooses and tests intervention, treatment or exposure
Decision as to group allocation can be by either random or non-random methods
Control and/or comparison group used Note: Random allocation of subjects to is
used to reduce selection bias by investigator and evenly allocate subjects on basis of known and unknown characteristics
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STUDIESRESEARCH DESIGN – EXPERIMENTAL STUDIES
Studies Clinical trials
Non-randomized trials (quasi-experiment)• Interrupted time series
Randomized Controlled Trials (RCT)• Double-blind randomized trial• Single-blind randomized trial• Non-blind trial• Crossover trial (may also be observational)
Community trials – conducted directly through doctors and clinics
Laboratory trials
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STUDIES - RCTRANDOMIZED CONTROL TRIAL
Gold standard – especially for therapy studies Participants are randomly allocated into
intervention (treatment) and control (placebo) Phase I – Healthy subjects Phase II – Small group Phase III – Large group prior to marketing Phases IV – Post-marketing study
Rigorous evaluation of a single variable Seeks to falsify (rather than confirm) it’s own
hypotheses PubMed MeSH: Randomized Controlled Trial [PT]
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Glasziou P. Why bother with evidence-based practice? Oxford: Centre For Evidence-based Medicine; 2010
Survey
BROTHER DIED OF STROKE, WILL I? 2
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Cohort Study
BROTHER DIED OF STROKE, WILL I? 3
Glasziou P. Why bother with evidence-based practice? Oxford: Centre For Evidence-based Medicine; 2010
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Inception Cohort Study
BROTHER DIED OF STROKE, WILL I? 4
Glasziou P. Why bother with evidence-based practice? Oxford: Centre For Evidence-based Medicine; 2010
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BROTHER DIED OF STROKE, WILL I? 5
Glasziou P. Why bother with evidence-based practice? Oxford: Centre For Evidence-based Medicine; 2010
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Treatments
Randomised Trial
BROTHER DIED OF STROKE, WILL I? 6
Glasziou P. Why bother with evidence-based practice? Oxford: Centre For Evidence-based Medicine; 2010
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LEVELS OF EVIDENCE
Kramer BS. Weighing scientific evidence. Washington DC: National Academies Press; 2009
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TAKING IT TO THE NEXT LEVEL
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LEVELS OF PEER REVIEWED INFORMATION
Primary: original research
Secondary: review articles
Tertiary: textbooks, summaries
Clark N, IT Applications of EBM Principles. Tallahassee, FL: Florida State University College of Medicine, 2003
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REVIEW
Review of a body of data that uses explicit methods to locate primary studies and explicit criteria to asses their quality
PubMed: Review [PT]
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SYSTEMATIC REVIEW
Review of a body of data that uses explicit methods to locate primary studies and explicit criteria to asses their quality
PubMed: No separate MeSH heading; use the Systematic Review option in Clinical Queries
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META-ANALYSIS
Works consisting of studies using a quantitative method of combining the results of independent studies (usually drawn from the published literature) and synthesizing summaries and conclusions which may be used to evaluate therapeutic effectiveness, plan new studies, etc.
A statistical analysis combining or integrating the results of several independent clinical trials considered by the analyst to be “combinable” usually to the level of re-analysing the original data. Pooling, quantitative synthesis.
PubMed MeSH: Meta-Analysis [PT]
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SECONDARY SOURCES
Clark N, 2003
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LEVELS OF EVIDENCE – 5S
Straus S, Haynes RB. Managing evidence-based knowledge: the need for reliable, relevant and readable resources. CMAJ. 2009 April 28; 180(9): 942–945.
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SYSTEMS, SUMMARIES, SYNOPSES
Systems: the ideal. A perfect evidence-based clinical information system would integrate and concisely summarize all relevant and important research evidence about a clinical problem and would automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information.
Summaries/Synopses. Synthesized by experts being extremely reliable and authoritative. Enough and exact information needed to support a clinical action. Removes the patient from the picture and practitioner from the primary literature. Lag between study results, analysis, publication and summary
Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine: how to practice and teach EBM 3d ed. London: Churchill Livingstone, 2005
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EVIDENCE PYRAMID
Clark N, 2003
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HOWEVER:
The types of studies that give the best evidence are different for the different types of questions
In every case, however the best evidence comes from studies where the methods used maximize the chance of eliminating bias
Glasziou P, Del Mar C. Evidence-based practice workbook: Bridging the gap between healthcare research
and practice. Malden, MA: Blackwell; 2007.
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IDENTIFYING THE BEST STUDY
Type of Question Suggested best type of Study
Therapy RCT>cohort > case control > case series
Diagnosis Prospective, blind comparison to a gold standard
Etiology/Harm RCT > cohort > case control > case series
Prognosis Cohort study > case control > case series
Prevention RCT>cohort study > case control > case series
Clinical Exam Prospective, blind comparison to gold standard
Cost Economic analysis
Introduction to Evidence Based Medicine. Chapel Hill, NC: Health Sciences Library, UNC-Chapel Hill. 2004.
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EVIDENCE BASED MESH
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CLINICAL QUERIES
Search by Clinical Study CategoryCategory
Etiology Diagnosis Therapy (default) Prognosis Clinical prediction
Scope Narrow specific search Broad sensitive search(default)
Systematic Reviews Medical Genetics Searches
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SPECIAL QUERIES
Comparative Effectiveness Research Health Services Research (HSR)
Queries Research Reporting Guidelines and
Initiatives Veterinary Medicine/Animal Health
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MESH TERMS
Evidence Based Practice [MH] (under Health Occupations) Evidence-Based Dentistry Evidence-Based Medicine (also listed
under (Clinical Medicine) Evidence-Based Emergency Medicine
Evidence-Based Nursing
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MESH TERMS – PT
Study Characteristics [PT]
• Case Reports• Clinical Conference• Clinical Trial +• Comparative Study• Census Development
Conference (CDC)o CDC, NIH
• Evaluation Studies
• In Vitro• Meta-Analysis• Multicenter Study • Scientific Integrity
Review• Twin Study• Validation Studies
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MESH TERMS – CLINICAL TRIAL
Clinical Trial [PT] (under Study Characteristics)
• Clinical Trial, Phase I• Clinical Trial, Phase II• Clinical Trial, Phase III• Clinical Trial, Phase IV• Controlled Clinical Trial• Multicenter Study• Randomized Controlled Trial
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MESH TERMS – TW/TIAB
Useful text words – use [TW] or [TIAB]Blind MaskRandomPlaceboEfficacyEffectiveCrossover [mh] Cohort [mh]
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CRITICAL APPRAISAL
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CRITICAL APPRAISAL QUESTIONS
Is the study valid? Are the results important? What were the results? Will the results help me in caring for my
patients?
Questions depend on the type of study being appraised
Heneghan C, Badenoch D. Evidence-based medicine toolkit. 2d ed. Malden, MA: Blackwell, 2007
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CONSORT – Consolidated Standards of Reporting Trials
MOOSE – Meta-analysis of Observational Studies in Epidemiology
QUORUM – Quality of Reporting for Meta-analysis
STROBE – Strengthening the Reporting of Observations Studies in Epidemiology
Brand RA. Standards of reporting: The CONSORT, QUORUM, and STROBE guidelines. Clin Orthop Relat Res. 2009 (467):1383-1394.
REPORTING STANDARDS
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CRITICAL APPRAISAL EXAMPLE
de Haen M, Spigt MG, van Uden CJ, van Neer P, Feron FJ, Knottnerus A. Efficacy of duct tape vs placebo in the treatment of verruca vulgaris (warts) in primary school children. Arch Pediatr Adolesc Med. 2006 Nov;160(11):1121-1125. http://archpedi.ama-assn.org/cgi/content/full/160/11/1121
Van Cleave J, Kemper AR, Davis MM. Interpreting negative results from an underpowered clinical trial: warts and all. Arch Pediatr Adolesc Med. 2006 Nov;160(11):1126-1129.http://archpedi.ama-assn.org/cgi/content/full/160/11/1126
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THE END OF THE BEGINNING
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FOR MORE INFORMATION Centre for Evidence-Based Medicine - CEMB:
http://www.cebm.net/index.aspx?o=1157
EMB Tools (Centre for Health Evidence): http://www.cche.net/usersguides/ebm_tips.asp
Tools to support evidence-informed decision making (Health-evidence.ca): http://www.health-evidence.ca/tools/
EPIQ - Critical Appraisal and Evidence-based Practice (University of Auckland): http://www.fmhs.auckland.ac.nz/soph/depts/epi/epiq/ebp.aspx
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PUBMED and the EVIDENCE-BASED UNIVERSE II
http://nnlm.gov/training/pubmedebm/
Holly Ann Burt
Outreach and Exhibits Coordinator
NN/LM GMR