Mastering Evidence-Based Medicine: Accessing Reliable Resources for Clinical Decisions

1. Evidence Based Medicine Resources Payam Kabiri, MD. PhD.Clinical EpidemiologistTehran University of Medical Sciences

2. Finding resources for practicing EBM The widespread practice of Evidence Based Medicine requires that we get the right information to the right person at the right time. Current systems frequently fail: important information is missing, presented inappropriately, distorted in reporting, nevergathered, hard to search, and hard to find.

3. Objectives • You will: • Formulate a clinical question • Identify and utilize EBM online resources to answer your questions • EBM Databases & Resources • Guidelines • Apply rules for levels of evidence to make clinical decisions

4. Information Mastery Creating a culture of inquiry Usefulness of medical information Relevance x Validity = work

5. Medical Sources Types A primary sourceis firsthand testimony or direct evidence concerning a topic under investigation not interpreted. Primary resources are generally articles that appear in peer-reviewed journals and are found primarily by searching Medline. Secondary sourcesdescribe or analyze the primary sources. are summaries and analyses of the evidence derived from and based on primary sources. A secondary source is a work that appraises, interprets or analyzes. Secondary resources available as Clinical Evidence, ACP Journal Club, and Cochrane Library, EBMR. Tertiary resources list, compile, digest or index primary or secondary sources.  Examples of tertiary resources include UpToDate, DynaMed, TripDatabase.

6. EBM Resources • Systematic Literature Searches • Cochrane Library (OVID) • Clinical Evidence • Systematic Literature Surveillance • ACP Journal Club (OVID) • DARE • DynaMed • Medical InfoRetriever • EMB Search Engine • TRIP Database EBM Resources

7. Guidelines • What is a guideline? • Guidelines may be • Explicit evidence-based • Evidence-based • Research-based (highly referenced) • Opinion-based • “expert consensus” EBM Resources

8. Levels of Evidence • Level 1: Randomized Clinical Trials • Level 2: Head to Head Trial or Systematic Review of Cohort Studies • Level 3: Case-Control Studies • Level 4: Case-series • Level 5: Expert Opinion

9. Levels of Evidence Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

10. Guidelines Resources • www.guideline.gov (AHRQ) • www.mdconsult.com (MD Consult) • www.nice.org.uk/Guidance/ (NICE) • www.sign.ac.uk/guidelines (SIGN clinical guidelines) • www.g-i-n.net (Guidelines International Network (G-I-N)

11. Cochrane Database • Included in OVID subscription • Limitations • limited to English • only addresses questions amenable to randomized trials • most of medicine has not been studied enough to allow for conclusions EBM Resources

12. Cochrane Databases • The Cochrane Database of Systematic Reviews (CDSR) • The Cochrane Database of Reviews of Effects (DARE) • The Cochrane Central Register of Controlled Trials (CENTRAL) • The Cochrane Database of Methodology Reviews (CDMR) • Health Technology Assessment Database (HTA) • NHS Economic Evaluation Database (NHS EED) • THE COCHRANE METHODOLOGY REGISTER (CMR) • About The Cochrane Collaboration and the Cochrane Collaborative Review Groups The Cochrane Library is a collection of 6 main databases and 1 additional databases that describe Cochrane as an organization. These are:

13. The Cochrane Library 2007, Issue 4

14. ACP Journal Club • About 100 journals systematically surveyed • Highest-validity articles abstracted • Structured abstracts to guide critical appraisal • Clinical commentary • Included in our OVID subscription EBM Resources

15. UpToDate • & you know UpToDate …. ! EBM Resources

16. DynaMed • Designed as entry point to information • Textbooks and Medline not efficient • Intuitive clinical organization • Brief summarized information presented • Links and references if more details needed • ICD-9 codes and links to patient information handouts EBM Resources

17. E-Books • MD Consult • http://www.mdconsult.com • Free Books 4 Doctors • http://www.freebooks4doctors.com/ • Gigapedia • http://gigapedia.com/

18. EBM Calculators • Statistics for Diagnostic, Prospective, Case Control & Randomized studies • Can graph pre- and post test probability with likelihood ratio for Diagnostic Studies. • Can save results and view at another time EBM Calculator – Centre for EBM – University Health Network

19. EBM Online Calculators Some Examplses: http://www.graphpad.com/quickcalcs/NNT1.cfm http://www.ebem.org/nntcalculator.html http://www.cebm.net/index.aspx?o=1160

20. Selected Electronic Health Information Resources

21. Bandolierhttp://www.medicine.ox.ac.uk/bandolier/ A monthly newsletter about evidence-based health care; top source for such information on the net.

22. Evidence-Based Medicinehttp://www.evidence-basedmedicine.com Bi-monthly journal which summarises important recent articles from major clinical fields (family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, public health, surgery). (Note: Best Evidence is the cumulated contents of ACP Journal Club (since 1991) and Evidence-Based Medicine (since 1995) in an annual CD.

23. BestBETShttp://www.bestbets.org Provides rapid evidence-based answers to reallife clinical questions in emergency medicine, using a systematic approach to reviewing the literature. BETs take into account the shortcomings of much current evidence, allowing physicians to make the best of what there is. Developed in the Emergency Department of Manchester Royal Infirmary, UK.

24. Clinical Evidencehttp://www.clinicalevidence.com Clinical Evidence is an updated directory of evidence on the effects of clinical interventions. It summarises the current state of knowledge, ignorance, and uncertainty about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature. It covers 20 specialties and includes 134 conditions. Updated/expanded coverage every six months in print and CD.

25. TRIP Databasehttp://www.tripdatabase.com Searches several different evidence-based resources including PubMed, Bandolier, and the ATTRACT question-answering service. Only allows title searches, but does allow AND, OR, NOT

26. How to Search? Use the components of the PICO to direct your search • (Population OR synonym1 OR synonym2…) AND • (Intervention OR synonym1 OR synonym2…) AND • (Comparator OR synonym1 OR synonym2…) AND • (Outcome OR synonym1 OR synonym2…)

27. EBM “Systems” vs Traditional Textbook Model Traditional textbook: • Author is an “authority” • Author selects, reports on own • One-year production line from manuscript to bookstand • Three-year production schedule

28. Updating in EBM Systems Authors are provided with new studies and reviews that are: • Assessed for validity • Rated by clinicians for relevance • Rated by clinicians for newsworthiness • Within a month of original publication

29. Computerized Decision Support System (CDSS) Evidence-based textbook Systems Evidence-based Journals Synopses Cochrane reviews Syntheses Original published Articles like Medline Studies

30. بزنید ! Email اگر میل داشتید payam.kabiri@gmail.com