1. Evidence-based Practice Resources for HINARI Users (Module 7.2)
This module explains why HINARI users might want to start by searching evidence-based resources and highlights HINARI, as well as, freely available resources that support evidence-based practice.

2. Evidence-based Practice Resources for HINARI Users
Instructions - This part of the:
course is a PowerPoint demonstration intended to introduce you to Evidence-based Practice and related HINARI resources.
module is off-line and is intended as an information resource for reference use.

3. Table of Contents – Part A
Evidence-based Medicine (EBM)
Definition
What, why and how of EBM
5 step EBM process – ask, access, appraise, apply
and access
Limitations of EBM

4. Table of Contents – Part B
HINARI Resources
Clinical Evidence
Cochrane Library
EBM Guidelines
BMJ Practice
Essential Evidence Plus
HINARI EBM Journals

5. Table of Contents – Part C
Other (Internet) Resources:
PubMed’s Clinical Queries and ‘Type of Article’ Limits
Clinical Practice Guidelines – definition & examples
Cochrane Library ‘Abstracts’
PubMed Health – clinical effective research
Trip Database
Evidence Updates - BMJ and McMaster University
Knowledge Translation Learning Modules – Canadian Institutes of Health Research
Essential Health Links gateway – annotated links
Other useful websites

6. Evidence-based Practice (EBP) Definition
"Evidence-Based Practice requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources."
Sicily statement on evidence-based practice. BMC Medical Education, 2005 Jan 5;5(1):1

7. Patient Values/Local Conditions
What is EBP?
The integration of best evidence* from current research, patient preferences and values, and clinical expertise to clinical questions (Sackett, 2000) in a timely fashion.
Best Evidence
Clinical Expertise
Patient Values/Local Conditions
EBP
*Best available evidence is: consistent research evidence with high quality and quantity

8. Why EBP? To improve care To bridge the gap between research & practice
“Kill as few patients as possible” (O. London)
A new treatment might have fewer side effects.
A new treatment could be cheaper or less invasive
A new treatment may be necessary in case people develop resistance to existing therapies, etc.
To keep knowledge and skills current (continuing education)
To save time to find the best information

9. 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.

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

11. The 5 Step EBP Process
ASK: Formulate an answerable clinical question
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
ASSESS: Evaluate the effectiveness of the process
Ask
Access
Appraise
Apply
Assess

12. Step 1: ASK a focused (answerable) clinical question
Background questions (What do I know about this?)
Foreground (Clinical) Questions 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 (e.g. treat, diagnose, observe)? C = Comparison intervention (What is the alternative to the intervention (e.g. placebo, different drug, nothing?)
O = Outcome (What are the relevant outcomes (e.g. morbidity, mortality, death, complications)?
Good questions are the backbone of EBM practicing. It is important to use all parts of the question if possible when you are building the question.
Patient specific, real patient related outcomes
Morbidity: The proportion of patients with a particular disease during a given year per given unit of population
Mortality: All deaths reported in a given population. Statistical Term

13. Why should I use PICO?
To help define problem in clarify it in your own mind
To prepare for searching
To ask patient centered questions. Treatment of Pneumococcal Pneumonia SHOULD be different for
Terminal Cancer Patient
Elderly, Severely Demented Patient
Young, mother of 2 children
Developing the question requires:
Some background knowledge of the condition
Understanding of the patient and what are the outcomes and beliefs that matter to this patient
Death? Disability? Quality of life? Cost? Improvement of symptoms?

14. Example: Intervention Questions
Identify background questions, create a PICO and a focused clinical question for this case:
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.

15. Formulate the Clinical Question
PICO P - 54 year old male with intermediate grade prostate cancer
I - radical prostatectomy
C- radiation treatment
O- reduce risk of mortality, impotence, and incontinence
Focused clinical question In 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?

16. EBP Step 1a: Classify the type of the question
What is the treatment? Question of INTERVENTION/PREVENTION
What causes the problem? Question of ETIOLOGY, RISK
Does this person have the problem? Question of DIAGNOSIS
Who (and how likely) will get the problem? Question of PROGNOSIS
Phenomena – Can relate to any category questions (diagnosis, treatment…) only involves a population (P) or an outcome (O) the outcome is a broad category (ideas, beliefs, concerns) e.g, For mothers of children with a fever what are the principle concerns?

17. Etiology and Risk Questions What 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?
-e.g. if eating certain foods increases the risk of heart disease; or smoking increases the risk of cancer)

18. 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?

19. Diagnosis Questions
These questions are concerned with how accurate a diagnostic test is in various groups and in comparison to other tests or usually to a “gold standard test”.
As part of your clinic assessment of elderly patients, there is a hearing check. You think that a simple whispered voice test is very accurate compared to other methods. You want to do a literature search. What is your question? (1)
Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.

20. Example P-elderly people I-whispered voice test
C-no test (or other tests)
O-accurate diagnosis of hearing problems
Question: In elderly people, does the whispered voice compared to other tests give an accurate diagnosis of hearing problems?
Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.

21. Templates for EBP Questions
For a therapy: In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C)?
For etiology: Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C)?
Diagnosis or diagnostic test: Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?
Prevention: For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?
Prognosis: Does __________ (I) influence ________ (O) in patients who have _______ (P)?
Melnyk B. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. New York: Lippincott Williams & Wilkins.

22. EBP Step1b:
Decide on the best type of study for question For each type of question there is a hierarchy of evidence
Therapy/Prevention What should I do about this problem?
RCT>cohort > case control > case series
Diagnosis Does this person have the problem?
cross-sectional study with blind comparison to a gold standard
Etiology/Harm What causes the problem?
RCT > cohort > case control > case series
Prognosis/Prediction Who will get the problem?
RCT >cohort study > case control > case series
Frequency and Rate
How common is the problem?
cohort study > cross-sectional study
Phenomena – Can relate to any category questions (diagnosis, treatment…) only involves a population (P) or an outcome (O) the outcome is a broad category (ideas, beliefs, concerns) e.g, For mothers of children with a fever what are the principle concerns?
NOTE: A well designed systematic review of RCTS (randomized controlled trials) is best as it is least biased therefore more valid.

23. Hierarchy of Study Designs for Intervention
Least
Bias
Randomized Controlled Trial
Cohort Studies
Case-Controlled Studies
Most
Case reports/Clinical Observations
Experimental
Observational
Observational
Observational
To recognize the type of study ask the questions:
Is intervention randomly assigned? Yes-RCT; No-Observational study
When were the outcomes determined?
After the exposure-cohort study (prospective study)
During the exposure-cross-sectional study
Before the exposure-case-control study (retrospective study based on recall)

25. EBP Step 2: ACCESS Track Down the Best Evidence
Start “hunting” from the best resource: Match your question to the best medical information resource for this question.
Well designed Systematic Reviews¹ can be a great place to start they contain commentary about validity ¹A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question.
Cook DJ, Mulrow CD, Haynes RB. Annals of Internal Medicine March 1, 1997; 126 (5) 376.

26. Hierarchy of Evidence- Access evidence at the level that will give you the best evidence
Track Down
Filtered & Critically Appraised
This model suggests that you start your search at the top of the pyramid with systematic reviews from the Cochrane Database of Systematic Reviews. Cochrane is small in the amount of information it currently contains, making it easier to search, but large in the validity and relevance of the information it contains for answering therapeutic questions.
Depending on the success of your search in Cochrane, you would work your way down the pyramid of resources in order of decreasing relevance/validity and increasing work, until you find an answer.
Journal articles form the base of the pyramid because they represent large amounts of "unrefined" information, and the burden of determining the validity and relevance is up to the user. The work part of the "Usefulness Equation" is also very high for journal articles as it may require a lengthy MEDLINE database search to locate them.
Expert Opinion and Not Filtered
Background info.
Most clinically relevant (at the top) Least clinically relevant (at the bottom)

27. Why not get info only from textbooks and review articles?
Texts and review articles?
Dated – perhaps by several years
Often biased
Author chooses article that he/she agrees with (or has written)
Author chooses articles of his/her friends
Author does not identify all the relevant literature
Review’s methods are not explained
These resources help with background knowledge (learn about disease) not foreground (answer the specific clinical question for this patient)

28. Why not get info only from guidelines?
They can assure standards of care but:
Can be biased
May not always be developed by experienced experts
Are not always evidence-based
Can work for most patients but not for all
Can work in some circumstances but not in all
Can be dated
There may not be guidelines for everything

29. Filtered and Critically Appraised Evidence-Based Resources
The Cochrane Library by The Cochrane Collaboration via Wiley
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
Reviews involve exhaustive searches for all RCT, both published and unpublished, on a particular topic
Abstracts searchable for free on the Internet; complete database is available via HINARI for most countries
1995-

30. Benefits for using not-evaluated databases for EBM research (PubMed, Cinahl)
Create comprehensive search strategies
Conduct systematic reviews of the literature
Conduct synonym searching utilizing thesauri
Set up and distribute alerts relating to evidence-based medicine
Limit to specific populations & publication types
Utilize EBM built-in filters (search strategies)

31. EBP Step 3: Appraise: Determine if the results are valid and useful
Appraisal principles (primary and secondary research)
What is the PICO of the study? Does it match my question?
How well was the study done? Is it biased?
What do the results mean? Are they real and relevant?
More: University of Oxford’s Center of EBM:
Tools for evaluating studies can be found in the Evaluating the Evidence section in the EBM tutorial at:

32. Apply
EBP Step 4: APPLY: Integrate the results with your clinical expertise and your patient values
Question to ask:
Is the intervention feasible in my settings?
What alternatives are available?
Is my patient so different then those in the study that the results cannot apply ?
Will the potential benefits outweigh the potential harms of treatment ?
What does my patient think? What are his cultural beliefs?
Individual decision making/group decision making/choice
Explaining risks and benefits to patients:
Visual Rx:

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

34. Limitations of EBP Limited scope of evidence-it will never be complete
The quality of research available
Keeping it patient centered, cost effective
Evidence from Randomized Controlled Trials for real life patients
Communicating uncertainties
Decision making