Evidence-based Practice for HINARI Users (Advanced Course Module 6 Part A)

1. Evidence-based Practice for HINARI Users(Advanced Course Module 6 Part A)

2. Table of Contents • Evidence & EBM definitions • 5 step EBM process • HINARI Resources • Cochrane Library • Evidence-based Medicine Guidelines • Essential Evidence Plus • EBM Journals • PubMed/Clinical Queries • PubMed Filters • Evidence Aid • Other (Internet) Resources

3. What is Evidence? Evidence concerns facts intended for use to support a conclusion • A fact is something known by experience or observation • Evidence is used to support a conclusion; it is not the conclusion itself Evidence Source: Lomas J et al. Conceptualizing and combining evidence for health system guidance. Canadian Health Services Research Foundation, 2005.

4. What is EBP? The integration of best evidence* from current research, patient preferences and values, and clinical expertise to clinical questions in a timely fashion (Sackett, 2000). EBP *Best available evidence is: consistent research evidence with high quality and quantity

5. Why EBP? • Improve care • To bridge the gap between research & practice • “Kill as few patients as possible” (O. London) • new treatment • fewer side effects • cheaper or less invasive • resistance to existing therapies, etc. • Keep knowledge and skills current (continuing education) • To save time to find the best information

6. What are some Barriers for EBP? • Time, effort & skills needed • Access to evidence • Overuse, underuse, misuse of evidence • Poor decision making • Environment not supportive of EBP • Intimidation by senior clinicians

7. How does EBP help? A patient comes to a clinic with a fresh dog bite. It looks clean and the nurse and patient wonder if prophylactic antibiotics are necessary. The nurse searches PubMed and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%. • For every 100 people with dog bites, treatment with antibiotics will save 7 from infection • Treating 14 (NNT) people with dog bites will prevent 1 infection • You explain these numbers to the patient along with possible consequences and patient decides not to take antibiotics. • On a follow up visit you find out that he did not get infected. Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.

8. Types of EBM resources: Pre-appraised literature vs. Non-appraised literature* • Pre-appraised literature uses an explicit review process – by experts - to find and appraise evidence; to provide clinicians with the best evidence, often at the point of care (evidence summaries, journals that summarize research, clinical practice guidelines). https://learn.maricopa.edu/courses/804760/pages/understanding-pre-appraised-sources?module_item_id=5387411; 23 September 2016 • Non-appraised or primary sources (individual research articles) answer very specific questions and provide the most recent data. One must be able to search efficiently and critically appraise the information. https://www.pdqa.gov.hk/english/ebeplatform/ebm/ebm_bestevid.php 23 September 2016 *Regardless of category, sources must be appraised by the user

9. Select sources to find primary studies: Filtered (pre-appraised) or Not-filtered (not appraised)? Not-filtered (not-appraised) sources: Medline (PubMed), Scopus, Google/Scholar... Filtered (appraised) sources: Cochrane Library, Joanna Briggs… • Create comprehensive searches • Conduct systematic reviews • Conduct synonym searching using thesauri • Set up and distribute alerts • Limit to populations & publication types • ‘Not all clinicians will need or want to do lit searches and clinical appraisal’ • Save Time • Ask the experts • Use quality research only • Use at the point of care

10. Pyramid of Evidence Source: JBI Levels of Evidence Developed by the Joanna Briggs Institute of Evidence and Grades of Recommendation Working Party, 2013.

11. What is a systematic review? “…a scientific investigation that focuses on a specific question and uses explicit, pre-specified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies.” Source: “Finding What Works in Health Care”, Institute of Medicine, Available from https://www.ncbi.nlm.nih.gov/books/NBK209518/ In general, a systematic review aims to decrease bias and increase reproducibility and transparency. They provide guidance for practice and policy-making, and identify gaps in knowledge and a need for research.

12. Systematic review vs. traditional literature review For more information about Systematic Reviews, see Hinari_Advanced_Course_Module_6_Appendix

15. EBM resources: searching priorities • Priority 1: Cochrane Library, Joanna Briggs - pre-appraised sources but may not discuss the topic or could be out of date • Priority 2: Clinical Queries – non pre-appraised source; search tool that focuses on ‘clinical study categories’ and ‘systematic reviews’ and could lead to up-to-date information; tool to quickly identify ebm literature • Priority 3: PubMed with appropriate filters (meta-analysis, systematic reviews, randomized controlled trials) – also non pre-appraised sources but another way of searching whole database

16. The 5 Step EBP Process • 1. ASK: Formulate an answerable clinical question • 2. ACCESS: Track down the best • Evidence • 3. APPRAISE: Appraise the evidence for its validity and usefulness • 4. APPLY: Integrate the results with your clinical expertise and your patient values/local conditions • 5. ASSESS: Evaluate the effectiveness of the process

17. Ask Step 1: ASK (questions, PICO) a focused (answerable) clinical question Background Questions Foreground Questions Specific questions - patient INTERVENTION/PREVENTION ETIOLOGY, RISK DIAGNOSIS PROGNOSIS Information Resources journal articles synopses of articles systematic reviews answer specific questions • General questions - disorder • What is the disorder? • What causes it? • How does it manifest? • Treatment options? • Information Resources • books • narrative reviews • general overview of a topic

18. Ask Step 1: ASK PICO Format P = Patient, population or problem (Who are the patients or populations? What is the disease?) I = Intervention (What do you want to do with this patient - treat, diagnose, observe)? C = Comparison intervention (What is the alternative to the intervention - placebo, different drug, nothing?) O = Outcome (What are the relevant outcomes - morbidity, mortality, death, complications)?

19. Why should I use PICO? • define problem - clarify it in your own mind • identify concepts/terms for searching • ask patient centered questions; treatment of pneumococcal pneumonia SHOULD be different for • elderly, severely demented patient • terminal cancer Patient • young, mother of 2 children

20. Templates for EBP Questions • For a therapy: In adult patients w/total hip replacements (P), what is the effect of PCA pain Medication (I) on postoperative pain(O) compared with prn IM pain Medication(C)? • For etiology: Are adult males(P) who have a vasectomy (I) at an increased (Increased/decreased) risk for/oftesticular cancer(O) compared with adult males (P) with/without no vasectomy(C)? • Diagnosis or diagnostic test: Are (is) mammogram(I) more accurate in diagnosing breast cancer(P) compared with clinical breast exam(C) for earlier diagnosis of breast cancer(O)? • Prevention: For women under the age of 60(P) does the use of low-dose aspirin(I) reduce the future risk of stroke (O) compared with none (C)? • Prognosis: Does smoking education(I) influence young people not to smoke(O) in patients who have high risk of smoking(P)? Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

21. Example: Intervention Questions • A 54 year old male patient was diagnosed with intermediate grade prostate cancer and wants to know whether to get a radical prostatectomy or radiation treatment. He is concerned about death from prostate cancer and also risks of impotence and incontinence. • Identify the 4 PICO components

22. Formulate the Clinical Question • PICO P (patient) - 54 year old male with intermediate grade prostate cancer I (intervention) - radical prostatectomy C (comparison intervention) - radiation treatment O (outcome) - reduce risk of mortality, impotence, and incontinence • Focused clinical questionIn 54 year old male patients with intermediate grade prostate cancer, is radical prostatectomy more effective compared to radiation treatment in reducing the risk of mortality, impotence, and incontinence?

23. Formulate the Clinical Question • PICO P (patient) - 30 year old male with a fresh dog bite I (intervention) – prophylactic antibiotics C (comparison intervention) – clean and bandage; no antibiotics O (outcome) - reduce risk of infection • Focused clinical questionIn 30 year old male patients with a fresh dog bite, is prophylactic antibiotics more effective then cleaning & bandaging the would in reducing the risk of infection? • Deconstruct your PICO Keywords: dog OR animal* bite* antibiotics infection* Limiter: Adult, age 18 – 45 English Only

24. Etiology and Risk QuestionsWhat causes a disease or health condition? • The reverse of intervention questions-they deal with harmful outcomes of an activity or exposure (public health issues) • Develop a clinical question for the case: S. is a smoker and just found out that she is 3 months pregnant. She quit smoking immediately. But she is worried if her developing baby was harmed and if the baby is at risk for having developmental problems. She is asking you if smoking during the first trimester can harm her baby?

25. Etiology or Risk Questions • P-babies of mothers who smoke I- smoking in first trimester C-nothing O-increase risk of developmental problems • Question: Are babies of mothers who smoke during their first trimester at an increased risk of developmental disabilities?

26. EBP Step 2: ACCESS (studies, hierarchies)Track Down the Best Evidence Access • Start “hunting” from the best resource: • match your question to the best medical information resource for this question. • Filtered (pre-appraised) vs. Not-filtered (not appraised)

27. ‘Dog Bite’ Example: Nurse Search • The nurse searches PubMed and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%. • For every 100 people with dog bites, treatment with antibiotics will save 7 from infection • Treating 14 (NNT) people with dog bites will prevent 1 infection

28. EBP Step 3: Appraise (validity, impact) • Appraisal principles (primary and secondary research) • Does PICO of the study match my PICO question? • validity • internal validity – methods • How well was the study done? Is it biased? • external validity • generalizability • impact • Does it matter to your patient? • University of Oxford’s Center of EBM: http://www.cebm.net/index.aspx?o=1157 • Evaluating the Evidence section in the EBM tutorial at: http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm Appraise

29. EBP Step 4: APPLY (patient, setting)Integrate the results with your clinicalexpertise and your patient values • Patient • Is my patient similar enough that the results of the study apply? • Will the potential benefits outweigh the potential harms of treatment ? • What does my patient think? What are his cultural beliefs? • Setting • Is the intervention feasible in my settings? • What alternatives are available? Apply

30. ‘Dog Bite’ Example: Application/Recommendation/Decision • You explain these numbers to the patient along with possible consequences • Probability of infection, based on age, health, etc, is low. • But leaves the decision to the patient. • Patient decides not to take antibiotics.

31. EBP Step 5: ASSESS (patient, yourself)Evaluate the effectiveness of the process. Assess • Am I asking questions? • Am I writing down my information needs? • How is my searching going? Am I becoming more efficient? • What is my success rate in the EBM steps? • Am I periodically syncing (checking) my skills and knowledge with new developments? • Teach others EBP skills • Keep a record of your questions

32. ‘Dog Bite’ Example: Follow Up • On a follow up visit you find out that he did not get infected. • Keep records

33. HINARI Resources • Cochrane Library – filtered • Joanna Briggs Institute - filtered • PubMed – unfiltered • Clinical Queries • Filters • HINARI EBM Journals

34. The Cochrane Library by The Cochrane Collaboration • The Cochrane Collaboration (http://www.cochrane.org/) • Independent non-for-profit international collaboration • Reviews are among the studies of highest scientific evidence • Minimum Bias: Evidence is included/excluded on the basis of explicit quality criteria; A panel of experts reviews the evidence, peer-reviewed, dynamic (updated regularly) • Reviews involve exhaustive searches for all RCT, both published and unpublished, on a particular topic • Abstracts searchable for free on the Internet; • Some of Cochrane Library resources searchable in PubMed 1995-

35. The Cochrane Library Content • Cochrane Database of Systematic Reviews (CDSR) • Cochrane Reviews & Protocols primarily on interventions • Database of Abstracts of Reviews of Effects (DARE) • Structured abstracts on other reviews also on diagnosis, prevention, rehabilitation, screening (not available in CDSR or Medline) • Cochrane Central Register of Controlled Trials (CENTRAL) • The largest single source of RCTs from all over the world (from Medline, Embase, conference proceedings, and more) • Cochrane Methodology Register (CMR) - Methods Studies • Health Technology Assessment Database (HTA) – Technology Assessments • NHS Economic Evaluation Database (NHSEED)- Economic Evaluations

36. From the HINARI Content page, open the Reference sources list to access Cochrane Library and other EBM resources.

37. From the Reference Sources menu, we now will click on the Cochrane Library link. The Cochrane Library contains high-quality, independent evidence including reliable evidence from Cochrane and other systematic reviews and clinical trials. It is published by John Wiley.

38. The initial page of this site has a title, abstract or keyword option Search engine. You also have various options in Cochrane Reviews to Browse by Topic and Browse by Review Group Open the Browse by CDSR Notice the More Resources List.

39. Searching the Cochrane Library • Select Search manager • Search for PICO terms one at a time • Combine synonyms with OR • Combine different terms with AND • You retrieved 20 results • Scroll down to view results • Select Search manager • Search for PICO terms one at a time • Combine synonyms with OR • Combine different terms with AND • You retrieved 20 results • Scroll down to view results

40. Displaying Results in the Cochrane Library All results CDSR (default) DARE CENTRAL • Search all Cochrane databases at once • Results from CDSR display as default • Notice results from DARE, CENTRAL, etc. • Systematic reviews are available • Click on 1st one to view • If not satisfied view reviews from DARE or Randomized Control Trials from CENTRAL

41. Viewing Results in the Cochrane Library Note that you can download the PDF.

42. Review Key Information

43. Review Abstract to see if your PICO matches review’s criteria

44. View Main Results and Conclusions

45. Plain Language Summary for Your Patient

46. Viewing Randomized Control Trials from CENTRAL

47. From the Cochrane Reviews drop down menu open Browse by Topic.

48. From the extensive Browse by Topic list,you have another option for locating subject- specific material.