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PUBMED and the EVIDENCE-BASED UNIVERSE http://nnlm.gov/training/pubmedebm

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Title: PUBMED and the EVIDENCE-BASED UNIVERSE http://nnlm.gov/training/pubmedebm


1
PUBMED and the EVIDENCE-BASED UNIVERSEhttp//nn
lm.gov/training/pubmedebm/
  • Holly Ann Burt
  • Outreach and Exhibits Coordinator
  • NN/LM GMR

2
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

3
Agenda
  • Introduction
  • Just What IS Evidence Based?
  • Studies, Studies, Studies
  • Taking it to the Next Level
  • To Literature and Beyond
  • Evidence-Based MeSH
  • MeSH Terms, Subsets, Clinical Queries
  • Critical Appraisal

4
JUST WHAT IS EVIDENCE BASED?
5
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)

6
Definitions
  • Evidence-based medicine requires the
    integration of the best research evidence with
    our clinical expertise and our patients 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
7
Definitions
  • 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 Feb9(2)SR1-7.

8
Definitions
  • 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

9
Steps in Evidence Based Research
  • Asking answerable questions
  • Finding the best evidence
  • Critically appraising the evidence
  • Applying a decision
  • Evaluation
  • Heneghan C, Badenoch D. Evidence-based medicine
    toolkit. 2d ed. Malden, MA Blackwell, 2007

10
Step 1
  • Asking answerable questions focused,
    searchable, clinical
  • 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)

11
Step 2
  • 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

12
Step 3
  • 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?

13
Step 4
  • Applying a decision - Combining findings to make
    a recommendation, placing the evidence into
    context, incorporating recommendation into a
    specific patient situation, clinical setting or
    organization
  • How much will it help a patient or population?
  • Does it meet their values and goals?
  • Is it cost-effective?

14
Step 5
  • Evaluation - Determining and measuring the
    effectiveness of the practice change over time
  • How could it be done better next time?
  • What is the outcome of using (or not using)
    particular information and its impact on clinical
    practice?

15
STUDIES, STUDIES, STUDIES
16
STUDIESResearch Design
Case Studies/Reports
Cambron JA. Study Design. Lombard National
University of Health Sciences 2008.
17
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 researchs experience
  • Case series following a group over time
  • Cross sectional study survey
  • Community Survey
  • Qualitative study interview w/open-ended
    question
  • Migrant studies

18
STUDIESResearch Design Observational Analytic
  • Investigator collects data without making changes
    to patients 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

19
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

20
STUDIESResearch Design Experimental
  • 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

21
STUDIESRandomized Control Trial (RCT)
  • 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) its own
    hypotheses
  • PubMed MeSH Randomized Controlled Trial PT

22
My Brother Died of Stroke, Will I? Glasziou P.
Why bother with evidence-based practice? Oxford
Centre For Evidence-based Medicine 2010
Cohort Study
Inception Cohort Study
Survey
Frequency
Prognosis
Risk Factors
Treatments Randomised Trial
Treatment Effect
Symptoms Signs, Tests
Cause(s)
Past Current
Future
23
Levels of Evidence
Kramer BS. Weighing scientific evidence.
Washington DC National Academies Press 2009
24
Taking it to the Next Level
25
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
26
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

27
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

28
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

29
Secondary Sources
Clark N, 2003
30
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)
942945.
31
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 patients
    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
32
Evidence Pyramid
Type of Study


Meta-Analysis
Systematic Review
Randomized Controlled Trial
Cohort studies
Case Control studies
Case Series/Case Reports
Animal research
Clark N, 2003

33
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.
34
Identifying the Best Study
Type of Question Suggested best type of Study
Therapy RCTgtcohort gt case control gt case series
Diagnosis Prospective, blind comparison to a gold standard
Etiology/Harm RCT gt cohort gt case control gt case series
Prognosis Cohort study gt case control gt case series
Prevention RCTgtcohort study gt case control gt 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.
35
EVIDENCE BASED MESH
36
Clinical Queries
  • Search by Clinical Study Category
  • Category
  • Etiology
  • Diagnosis
  • Therapy (default)
  • Prognosis
  • Clinical prediction
  • Scope
  • Narrow specific search
  • Broad sensitive search(default)
  • Systematic Reviews
  • Medical Genetics Searches

37
Special Queries
  • Comparative Effectiveness Research
  • Health Services Research (HSR) Queries
  • Research Reporting Guidelines and Initiatives
  • Veterinary Medicine/Animal Health

38
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

39
MeSH Terms
  • Study Characteristics PT
  • Case Reports
  • Clinical Conference
  • Clinical Trial
  • Comparative Study
  • Census Development Conference (CDC)
  • CDC, NIH
  • Evaluation Studies
  • In Vitro
  • Meta-Analysis
  • Multicenter Study
  • Scientific Integrity Review
  • Twin Study
  • Validation Studies

40
MeSH Terms
  • 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

41
MeSH Terms
  • Useful in text words - use TW
  • Blind
  • Mask
  • Random
  • Placebo
  • Efficacy
  • Effective
  • Crossover mh Cohort mh

42
Critical Appraisal
43
Critical Appraisal
  • 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
44
Reporting Standards
  • 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.

45
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 Nov160(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 Nov160(11)1126-1129.
  • http//archpedi.ama-assn.org/cgi/content/full/160
    /11/1126

46
For More Information
  • Centre for Evidence-Based Medicine - CEMB
    http//www.cebm.net/index.aspx?o1157
  • 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-evi
    dence.ca/tools/
  • EPIQ - Critical Appraisal and Evidence-based
    Practice (University of Auckland)
    http//www.fmhs.auckland.ac.nz/soph/depts/epi/epiq
    /ebp.aspx

47
The End of the Beginning
48
PUBMED and the EVIDENCE-BASED UNIVERSEhttp//nn
lm.gov/training/pubmedebm/
  • Holly Ann Burt
  • Outreach and Exhibits Coordinator
  • NN/LM GMR
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