Doctors and Librarians: How can Evidence-Based Medicine promote partnership?

1. Doctors and Librarians: How can Evidence-Based Medicine promote partnership? Dr Karla Soares-WeiserRabin Medical Center, Israel

2. Physicians need information! • In order to make their clinical decisions, physicians need to be up-to-date with the medical literature. • However, to keep up-to-date, a physician would need to read at least 6 to 8 hours every day. • The physician would also need to acquire and keep up-to-date his/her search and appraisal skills.

3. Physicians need information! • Taking into consideration the burden that a busy physician already has in his/her daily clinical practice, it is not likely that evidence-based medicine can be practiced without the partnership and support of medical librarians.

4. What is needed for this partnership? • In order for this partnership to work it is necessary that both professionals cooperate to: • Formulate a relevant clinical question; • Define a search strategy that will efficiently retrieve the information; • Filter and critically appraise the retrieved information; and • Provide feedback for both partners about the effectiveness of the strategy.

5. Case Report • A 55 years old woman, previously diagnosed with cirrhosis secondary to chronic hepatitis C infection, was admitted to our department of general internal medicine because of fever. She appeared well and there were no focal symptoms or signs of infection. Based on the ascitic leucocyte count our patient was diagnosed with spontaneous bacterial peritonitis [SBP]. She denied previous episodes of SBP or prophylactic antibiotic treatment…

6. Case Report • It was decided that empirical antibiotic treatment should be started. • There is, however, a controversy about what is the best available antibiotic therapy for the treatment of this patient. • Her physician decides to call the consultant infectologist and seek help from the hospital’s librarians.

7. Spontaneous Bacterial Peritonitis • An infection of the fluid that can accumulate in the abdomen (ascites). • Any intra-abdominal, surgically treatable source of infection is not present. • SBP occurs in the presence of liver cirrhosis. • SBP occurs in 10-30% of hospitalized cirrhotic patients with ascites.

8. Dealing with the case • A final decision has to be made in the next few hours.The physician seeks the help of the librarian to search for the best available evidence for the antibiotic treatment of cirrhotic patients with ascites that developed spontaneous bacterial peritonitis.

9. Dealing with the case • The physician and the librarian’s goal are to find one or two papers that would help to make a decision answering the following questions: • What is the best antibiotic therapy for this patient, given her excellent condition? • What is the strength of evidence supporting antibiotic therapy for SBP? • What should be the ideal dosage or duration of therapy?

10. Searching the Evidence • Defining a search strategy: • What is the relevant research design to answer the physician’s question? • Would it be worth to perform a search with restrictions on: • Language? • Year of publication? • Type of publication? • Research performed in human(s)? • Based on his/her experience in the field, would the physician expect a handful or a large amount of papers?

11. Possible Resources for Search Strategy • Evidence-Based Search Filters: • PubMed Clinical Queries - http://www.ncbi.nlm.nih.gov/PubMed • IHS Library Filters – http://wwwlib.jr2.ox.ac.uk/caspfew/filters • NHS Centre for Reviews & Dissemination – http://www.york.ac.uk/inst/crd/search.htm • Evidence-Based Filters for OVID (Medline) – http://www.urmc.rochester.edu/Miner/Educ/Expertsearch.html • UIC University Library – http://www.uic.edu/depts/lib/lhsp/resources/filters.shtml

12. Medline Search Strategy

13. Results of the search strategy • 96 references were located. • After scanning the titles, the librarian identified 15 controlled trials and gave this list to the physician. • The physician critically appraised the quality of the trials and was left with 6 possibly relevant randomized trials.

14. Results of the search strategy • The published trials were too small and not able to provide a final answer to the physician. For example: • Only a single and small trial was found (72 patients randomized to cefotaxime or ampicillin-tobramycin) to support the consultant’s first choice. The results were not different in the two groups. • The same occurs for the consultant’s second choice – ofloxacin. • The same applies for dosage and duration of treatment.

15. Frustration...

16. Back to the Librarian • The results so far were not relevant for the physician’s decision regarding treatment for his/her patient. • The physician decides to go back to the librarian and ask for suggestions. • The librarian decides to search the Cochrane Library for randomized trials and systematic reviews.

17. Cochrane Database of Systematic Reviews (1,947 ref) Database of Abstracts of Reviews of Effectiveness (2,793 ref) Cochrane Controlled Trials Register (307,872 ref) Cochrane Database of Methodology Reviews (5 ref) Cochrane Methodology Register (3,407 ref) Health Technology Assessment Database (2,187 ref) NHS Economic Evaluation Database (6,822 ref) The Cochrane Library

18. Cochrane Library Search Results • The search strategy used was: “[((peritonitis*.ME or peritonitis) and spontaneous) AND (liver-cirrhosis*.ME or cirrhosis) AND (antibiotics*.ME or antibiotic*)]” • 20 references were founded • 2 references, not founded in Medline, were relevant to the physician: • A systematic review about “antibiotic therapy for SBP” • A consensus document published by the International Ascites Club

19. Recommendations based on the new evidence • Cochrane Systematic Review: • Nine studies dealing with 684 patients with spontaneous bacterial peritonitis were included. No placebo-controlled trial was found. Each of the included trials compared different antibiotics, and no meta-analysis could be performed. We were unable to establish the optimal dose or duration of antibiotic therapy and found no convincing evidence that cefotaxime is more effective than ampicillin-tobramycin or that oral quinolones should be recommended for patients with less severe manifestations of the disease. Source: Soares-Weiser et al. Cochrane Database of Systematic Reviews, 2001, Issue 2

20. Recommendations based on the new evidence • Consensus of the International Ascites Club • This consensus recommends cefotaxime, amoxycillin-clavulanic acid in standard dosages, or ofloxacin for patients with uncomplicated SBP. These recommendations are based, according to the consensus document, on the evidence from at least one properly randomised, controlled trial (cefotaxime and ofloxacin), or one well designed controlled trial and/or meta-analysis (other cephalosporins and amoxycillin-clavulanic acid). Source: Rimola et al.Journal of Hepatology, 2000, 32:142-53

21. Lessons to learn The physician: • The large amount of literature and the need to critically appraise the information available, make it impossible to keep up-to-date unless we are open for partnerships with other health care professionals, such as medical librarians.

22. Lessons to learn The librarian: • Greater attention should be paid in training medical librarians in the skills of critically appraising the literature. As these are important skills nowadays to support physicians on their daily needs, in a busy department, anywhere.