Clinical Information Resources/ Evidence Based Practice

1. Clinical Information Resources/Evidence Based Practice Sandra A. Martin, M.L.I.S. Health Sciences Resource Coordinator Instructor of Library Services John Vaughan Library Room 305B marti004@nsuok.edu – 918-444-3263

2. Sandra Martin Provides…. • Instruction • Research Assistance • Small Group Consulting • Database Searches • Collection Development (Selection of print and online books, audiovisuals, journals and databases) • Assistance with any health-related information need • Office Hours: Tuesday 10 am to 4 pm

3. If you need Help, contact Sandra, marti004@nsuok.edu

5. Start your Search Here: http://library.nsuok.edu/collegeop/

6. OPT Resources are NOT on this page. Choose “College of Optometry” to navigate to the Library Resources for Optometry page

7. Start your Search Here: http://library.nsuok.edu/collegeop/

8. Optometry Journals A-Z

9. Remote Access • Enter NT-NSU user id and password to access the library’s electronic resources • Contact Tom Tinnell if you have problems with your user id or password • Contact Sandra to report other technical problems or for search assistance

10. Helpful Tools • Optometry Web Page • Optometry Databases, e-journals, e-books, and other tools available 24/7 • Supports specific research, teaching, and patient care needs of NSUOCO faculty, students, and residents • Start Here to find resources for all optometry and medical topics • http://library.nsuok.edu/collegeop/index.html • Important: Link directly from the Optometry web page to all “Optometry” journals A-Z that include full text • NOTE: Google Chrome Browser works best

11. Quick Access to Full Text Articles • For All Optometry Journals by Title • Click on the A-Z Pad from the Optometry web page • Links display to all Optometry journals with full text available • For other health sciences journals (non-Optometry) • Click on the collection links (Clinical Key, Science Direct, NSU Journals@Ovid) OR • Click on the link to “All Library e-Journals” • Enter the full journal title • If you cannot locate full text in a specific journal, place an order for the article through Interlibrary Loan (free)

12. Interlibrary Loan/Document Delivery • Services • Scan and email pdf of articles from journals in the library’s print collection – you do not have to pull print journals from the shelf and scan or photocopy • Deliver books, audiovisuals, and journal articles not owned by the library • Journal articles delivered electronically if possible • ILL Requests • Click on Interlibrary Loan link from Optometry Web Page • Create the online Iliad Profile • Complete online request form for articles and books • Contact ill@nsuok.edufor help

14. Existing knowledge can prevent… Waste Errors Poor quality clinical care Poor patient experience Adoption of interventions of low value Failure to adopt interventions of high value Source: Sir Muir Gray, Chief Knowledge Officer of Britain’s National Health Service. Quoted on http://www.nks.nhs.uk/.

15. Harmful practices once supported by expert opinion • Source: Adapted from How to read a paper: the basics of evidence-based medicine. 4th edition. By Trisha Greenhalgh. 2010 Blackwell Publishing

16. Learning Objectives • To familiarize residents with the information retrieval process for evidence-based research & patient care • To enable residents to use synthesized/filtered/pre-appraised resources to answer clinical questions • To enable residents to use the 6S hierarchy of organization of evidence to plan search strategies

18. “EBM is a process of life-long, self-directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy, and other clinical and health care issues.” Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2. Patient Concerns Bestresearch evidence Life-long Learning EBM What is EBM?

19. “Evidence-based medicine is the integration of research evidence with clinical expertise and patient values.”best . Patient Concerns Best research evidence Clinical Expertise EBM What is EBM? Sackett, DL, Richardson, WS, Rosenberg, WMC, & Haynes, RB (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

20. Evolution of EBM in the Literature • Term “evidence based medicine” coined by Dr. Gordon Guyatt at McMaster University • Term first appeared in the literature in a 1991 editorial in ACP Journal Club Volume 114, Mar-April 1991, pp A-16 • Seminal article by the Evidence-Based Medicine Working Group published in JAMA Volume 268, No. 17, 1992, pp 2420-2425 • Click on the “Evidence Based Medicine” tutorial from the Optometry web page to view a brief video of EBM history

21. Fundamentally new approach becomes widely recognized • JAMA published a series of Users’ Guides to the Medical Literature that served as the first learning tools • The first handbook, Evidence-Based Medicine: How to practice and teach EBM, by Sackett, et al, was published in 1996. Fourth edition published in 2010 • Courses were developed in residency training and medical school curricula beginning in the mid-1990s • EBM process has become basic in medicine, nursing, speech pathology, occupational therapy, other health care disciplines including psychology and the social sciences

22. Integration of EBM into medical school curricula patient-doctor courses

23. EBM Process – 5 Steps • ASK: Convert need for information into answerable question • ACQUIRE: Find best evidence to answer the question • APPRAISE: Critically appraise evidence for validity, impact, and applicability • APPLY: Integrate evidence with clinical expertise and patient values • ASSESS: Evaluate own effectiveness

24. New Approach Requires New Skills • Clinical question formulation • Search and retrieval of best evidence • Critical appraisal of study methods to determine validity of results

25. Information Retrieval for Evidence Based Patient Care • Using research findings versus conducting research • Retrieving and evaluating information that has direct application to specific patient care problems • Selecting resources that are current, valid and available at point-of-care • Developing search strategies that are feasible within time constraints of clinical practice

26. Is All Evidence Created Equal? • Small portion of medical literature is immediately useful to answer clinical questions • Understanding “wedge or pyramid of evidence” is helpful in finding highest level of evidence • High levels of evidence may not exist for all questions due to nature of medical problems and research limitations

27. As you move up the pyramid the amount of available literature decreases, but it increases in its relevance to the clinical setting. Source:  Sackett, D.L., Richardson, W.S., Rosenberg, W.M.C., & Haynes, R.B. (1996). Evidence-Based Medicine: How to practice and teach EBM. London: Churchill-Livingstone.

28. Clinical/Foreground Questions • Arise in patient care setting • Fill gaps in clinical knowledge regarding • Diagnosis • Therapy/prevention • Prognosis • Etiology

29. Answers to Clinical/Foreground Questions • Require: • precise information about complex issues • trustworthy clinical research data with direct application to patient problems

30. Well Built Questions include Elements of PICO Model P - Patient or population I - Intervention C - Comparison Intervention O - Outcome

32. Evidence Based Search Strategy • Includes search terms from the clinical question • Matches best study design for type of question • Retrieves answers at highest levels of evidence

33. Use PICO model to form a question • Therapy/Prevention Question • In patients with primary open angle glaucoma or ocular hypertension [Patient/Population], do topical medications to reduce intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field defect progression [Outcome]?

34. 1. Search Terms • Primary open angle glaucoma, POAG • Ocular hypertension, OHT • Intraocular pressure, IOP • Topical medications, eyedrops, ophthalmic solutions • Visual fields, VF • Limit search results to “therapy” studies

35. 2. Best Study Design for Type of Question

36. 3. Highest Level of Evidence – 6S Hierarchy

38. Search First at Top Levels of 6S MEDLINE - major source of “primary” literature Process of searching, selecting, evaluating original research is time consuming and requires critical appraisal skills Filtered/Synthesized/Evaluated resources - “secondary” literature Speed application of evidence at “point-of-care” Grade strength of treatment recommendations Rate quality of research evidence

39. Point-of-Care Resources • Evidence based summaries • Provide rapid access to concise information forclinicians at the point of care • Not a database of articles from books, journals, or guidelines • Original, current, summaries written by experts • Formal systems used to grade strength of recommendations and quality of evidence • Available from Optometry web page • UpToDate • First Consult

40. Summaries • UptoDate • Evidence based summaries of over 10,000 topics in over 22 specialties • 8,500 Treatment Recommendations • GRADE System used to score recommendations and strength of evidence • Updated continuously; Includes practice changing updates • Drug database; Patient education materials • The Gold Standard of evidence summaries

41. UpToDate GRADE SystemUpToDate GRADE SystemGuyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence" and why is it important to clinicians?. BMJ. 2008;336(7651):995-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2364804/pdf/bmj-336-7651-analysis-00995.pdf

42. Clinical Question • Therapy/Prevention • In patients with primary open angle glaucoma or ocular hypertension [Patient/Population], do topical medications to reduce intraocular pressure [Intervention] versus no treatment [Comparison Intervention], delay visual field defect progression [Outcome]?

43. Simple UTD Search Answers Clinical Question in Seconds

44. Summaries • FirstConsult • Search online in Clinical Key • App available through NSU subscription to Clinical Key for iPhone or iPad only • Create a personal account in Clinical Key • Download the app from the Apple app store • Login with your CK username and password • Concise summaries; sections on differential diagnosis; quality of evidence graded • Not updated as rapidly as UTD

46. Synopsis of Syntheses • Database of Abstracts of Reviews of Effects DARE • Search online in OVID • Part of OVID’s evidence based medicine reviews collection • Full text database contains critical assessments of systematic reviews published in various medical journals

47. Systematic Review • Analyzes data from several primary studies to answer a specific clinical question • Provides search strategies and resources used to locate studies • Uses explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies • Statistical methods (meta-analysis) may or may not be used to analyze and summarize results • Benefits: Limits bias and increases confidence in conclusions

49. Critical Assessment of Systematic Review cited in UTD and FC

50. Syntheses • Cochrane Database of Systematic Reviews (DSR) • Part of the Cochrane Library (1996) • Over 3,000 reviews & protocols (reviews in the making) • The Gold Standard of systematic reviews • Eyes & Vision Research Group • Contains over 200 reviews • Full Text Available in Ovid