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Agenzia sanitaria e sociale regionale Luca Vignatelli and Chiara Bassi International Course of Neuroepidemiology Chișinău,

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Presentation on theme: "Agenzia sanitaria e sociale regionale Luca Vignatelli and Chiara Bassi International Course of Neuroepidemiology Chișinău,"— Presentation transcript:

1 Agenzia sanitaria e sociale regionale Luca Vignatelli and Chiara Bassi International Course of Neuroepidemiology Chișinău, Moldova September 24-28, 2012 Literature search in neurology: an evidence-based approach

2 Agenzia sanitaria e sociale regionale 1.Basic principles to organize the search for Evidence-Based literature 2.Main websites of Evidence-Based literature Focus on - neurology - free websites We will cover …

3 Agenzia sanitaria e sociale regionale 1 Medical literature: resource or problem?

4 Agenzia sanitaria e sociale regionale 2010 … AND NOW?

5 Agenzia sanitaria e sociale regionale Hierarchy of evidence: the pyramid model (DiCenso et al. 2009)

6 Agenzia sanitaria e sociale regionale Production of medical literature: bottom-up process

7 Agenzia sanitaria e sociale regionale 2 How to organize your search strategy TIPS

8 Agenzia sanitaria e sociale regionale 1 st TIP Clarify yourself what kind of information you need

9 Agenzia sanitaria e sociale regionale 1)Information on clinical background … ? 2)New ideas, innovations, emerging technologies or drugs (horizon scanning) … ? 3)A prompt answer on specific clinical questions (focused search) … ? 4)An exhaustive analysis of literature on a specific argument (systematic search) … ? Are you looking for …

10 Agenzia sanitaria e sociale regionale evidence for clinical background: clinical practice guidelines evidence for a specific clinical question (focused search) –systematic reviews –health technology assessment documents –… but also primary studies I will focus on …

11 Agenzia sanitaria e sociale regionale 2 nd TIP Formulate an answerable clinical question: PICO model

12 Agenzia sanitaria e sociale regionale P opulation one patient, or a group of patients with a particular condition or a health problem I ntervention the intervention of interest, which can be therapeutic (e.g. a drug), preventive (e.g. vaccination), diagnostic (e.g. blood pressure measure), prognostic (e.g. a risk factor), etc… C omparator a standard intervention, a placebo or no intervention O utcome Expected clinical result (death risk, quality of life, adverse events) Clinical question: PICO model

13 Agenzia sanitaria e sociale regionale P opulation People with mild memory impairment I ntervention Positron Emission Tomography C omparator Standard practice O utcome Sensitivity and specificity compared to reference standard of Alzheimers disease Example: Diagnostic accuracy Subject with mild memory impairment. You wonder if PET is useful for diagnosis of Alzheimers disease.

14 Agenzia sanitaria e sociale regionale P opulation People with drug-resistant mesial temporal lobe epilepsy I ntervention Anteromesial temporal resection C omparator Standard practice O utcome freedom from disabling seizures during year 2 of follow-up Example: Therapeutic effectiveness Subject with drug-resistant mesial temporal lobe epilepsy. You wonder if surgery (anteromesial temporal resection) is effective in obtaining freedom from disabling seizure.

15 Agenzia sanitaria e sociale regionale P opulation Asymptomatic subject I ntervention = risk or predictive factor Incidental MRI abnormalities suggestive of demyelinating disease C omparator Standard practice O utcome clinical progression at 2 years of follow-up Example: Prognosis Asymptomatic subject with incidental MRI abnormalities suggestive of demyelinating disease. You wonder what is the 2-year risk of clinical progression.

16 Agenzia sanitaria e sociale regionale 2 nd TIP … then, choose 1 or more keywords from the PICO to search databases

17 Agenzia sanitaria e sociale regionale 3 rd TIP Which database? … apply a hierarchical approach … from high-quality summary/synthesis documents to single studies

18 Agenzia sanitaria e sociale regionale Search for evidence: top-down approach

19 Agenzia sanitaria e sociale regionale 4 th TIP Searching a large database is different from searching a small database

20 Agenzia sanitaria e sociale regionale 4th TIP Small database: use few words Large database: use more words

21 Agenzia sanitaria e sociale regionale 3 Searching in practice

22 Agenzia sanitaria e sociale regionale Guidelines Your perspective: general clinical background Why should we need clinical practice guidelines? to define the clinical pathway of a disease to assist decisions about appropriate health care for a specific disease to choose relevant clinical questions

23 Agenzia sanitaria e sociale regionale What are they? "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances Essential features: identification and assessment of the evidence: systematic review judgment of the strength of the evidence: grading review and critique of all these elements by methodologists, clinicians, and other relevant parties: multidisciplinary Field and Lohr, Institute of Medicine, 1992 Clinical Practice Guidelines

24 Agenzia sanitaria e sociale regionale Who produces clinical practice guidelines? INTERNATIONAL HEALTH AGENCIES guidelines published on their websites SCIENTIFIC SOCIETIES guidelines published in medical journals or on their websites

25 Agenzia sanitaria e sociale regionale The search method Main websites a guidelines database: NGC some guidelines websites: national health agencies: NICE, SIGN scientific societies: AAN, EFNS*, ILAE

26 Agenzia sanitaria e sociale regionale an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services database: 2421 guidelines (access 6th June 2012) search engine and index by argument you can find – summary of single guidelines and link to full text – comparitve documents (guidelines syntheses) free access: National Guideline Clearinghouse

27 Agenzia sanitaria e sociale regionale NICE - National Institute for Health and Clinical Excellence

28 Agenzia sanitaria e sociale regionale SIGN – Scottish Intercollegiate Guidelines Network

29 Agenzia sanitaria e sociale regionale Clinical Practice Guidelines in Neurology American Academy of Neurology (AAN) Practice Parameters and Assessments Free full text European Federation of Neurological Societies (EFNS) More than 70 guidelines since 2000 Very recently: access restricted only to EFNS members International League Against Epilepsy (ILAE) Few documents Free full text Scientific societies X

30 Agenzia sanitaria e sociale regionale EXAMPLE PIschemic stroke IThrombolysis C O How thrombolysis should be provided in subjects with major ischemic stroke?

31 Agenzia sanitaria e sociale regionale EXAMPLE

32 Agenzia sanitaria e sociale regionale EXAMPLE

33 Agenzia sanitaria e sociale regionale EXAMPLE

34 Agenzia sanitaria e sociale regionale EXAMPLE P IHealthy Lifestyles C O How healthy lifestyles recommendations should be provided in subjects with vascular risk factors?

35 Agenzia sanitaria e sociale regionale Health Technology Assessment Your perspective: utility of a single technology Why should we need HTA documents? to assist decisions on acquiring, buying or applying a technology Technology = any intervention used to promote health, to prevent, diagnose or treat acute or chronic disease, or for rehabilitation

36 Agenzia sanitaria e sociale regionale What is it? The systematic evaluation of properties, effects, and impacts of health care technology Its main purpose is to inform technology-related policymaking in health care HTA is conducted by interdisciplinary groups using explicit analytical frameworks drawing from a variety of methods from HTA glossary - Health Technology Assessment

37 Agenzia sanitaria e sociale regionale Who produces HTA reports? INTERNATIONAL HEALTH AGENCIES HTA reports published on their websites AHRQ (US) NICE (UK) HTA – NETSCC (UK) CADTH (CAN)

38 Agenzia sanitaria e sociale regionale The search method Main websites one database: HTA database included in the Centre for Reviews and Dissemination website, University of York, UK national health agencies websites: AHRQ, NICE, HTA – NETSCC, CATDH

39 Agenzia sanitaria e sociale regionale 3 databases: DARE, HTA database, ECON Centre for Reviews and Dissemination, University of York, funded by National Institute of Health Research, (National Health System, UK) focused on systematic reviews and HTA reports that evaluate the effects of health care interventions and the delivery and organization of health services Free access: abstracts and critical appraisal of 9,000 systematic reviews, and 10,000 HTA documents Centre for Reviews and Dissemination

40 Agenzia sanitaria e sociale regionale EXAMPLE P IDaTscan C O Is DaTSCAN (123I-Ioflupane; GE Healthcare) useful to diagnose central neurodegerative disorders?

41 Agenzia sanitaria e sociale regionale EXAMPLE

42 Agenzia sanitaria e sociale regionale Systematic Reviews Your perspective: focused clinical question

43 Agenzia sanitaria e sociale regionale What are they? a review that has been prepared using a systematic approach to minimising biases and random errors which is documented in a materials and methods section A systematic review may, or may not, include a meta-analysis: a statistical analysis of the results from independent studies, which generally aims to produce a single estimate of a treatment effect Chalmers and Altman 1995 Systematic Reviews

44 Agenzia sanitaria e sociale regionale Who produces Systematic Reviews? International health agencies Cochrane Collaboration Scientific societies Single researchers

45 Agenzia sanitaria e sociale regionale The search method Main websites two databases: Cochrane Database of Systematic Reviews, included in the Cochrane Library DARE, included in the Centre for Reviews and Dissemination website, University of York, UK

46 Agenzia sanitaria e sociale regionale Best reliable source for information on the effectiveness of healthcare interventions Electronic publication updated monthly 5102 systematic reviews (access June 2012) Since 2008: you can find also few Diagnostic Test Accuracy systematic reviews Published by Wiley Interscience (www.thecochranelibrary.com) Free access: abstracts of systematic reviews With fee: full-text of systematic reviews Cochrane Database of Systematic Reviews

47 Agenzia sanitaria e sociale regionale A source of useful information for people around the world who are involved with or interested in the practice of evidence-based neurology The primary aims and activities – Facilitate the production of systematic reviews in neurology and neurosurgery – Serve as liaison for neurological Cochrane Review Groups – Facilitate access to Cochrane reviews and disseminate reviews to a worldwide neurological audience – Promote an evidence-based approach to healthcare in the field of neurology Cochrane Neurological Field

48 Agenzia sanitaria e sociale regionale EXAMPLE Pfirst demyelinating event I C O Are interferon or glatiramer effective in delaying conversion of the first demyelinating event to multiple sclerosis?

49 Agenzia sanitaria e sociale regionale EXAMPLE

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51 EXAMPLE

52 Agenzia sanitaria e sociale regionale Primary Literature Your perspective: focused clinical question

53 Agenzia sanitaria e sociale regionale U.S. National Library of Medicine's® (NLM) premier bibliographic database Over 19 million references to journal articles in life sciences with a concentration on biomedicine Citations from biomedical journals published in 70 countries Goes back to 1950 Access free (from 1997): http//www.pubmed.gov PubMed

54 Agenzia sanitaria e sociale regionale An electronic search strategy should generally have different sets of terms: 1)terms to search for the health condition of interest [P] 2) terms to search for the intervention(s) evaluated [I] 3)terms to search for the types of study design to be included filters from the CLINICAL QUERIES function PubMed: some tips

55 Agenzia sanitaria e sociale regionale EXAMPLE Pfirst demyelinating event Iinterferon / glatiramer C O Are interferon or glatiramer effective in delaying conversion of the first demyelinating event to multiple sclerosis?

56 Agenzia sanitaria e sociale regionale EXAMPLE

57 Agenzia sanitaria e sociale regionale EXAMPLE

58 Agenzia sanitaria e sociale regionale Too much information, too little time

59 Agenzia sanitaria e sociale regionale Meta-engines Sistemi di Monitoraggio

60 Agenzia sanitaria e sociale regionale … is not a database but … a search engine designed to allow clinicians to quickly find answers to their clinical questions using the best available evidence It permits the simultaneous searching of multiple websites (mainly EBM) Free access: TRIPdatabase

61 Agenzia sanitaria e sociale regionale

62 P.S. … 2 final suggestions

63 Agenzia sanitaria e sociale regionale … a reporting guideline, i.e. recommendations on how to write your clinical research papers … … search EQUATOR Network … when You need …

64 Agenzia sanitaria e sociale regionale

65 … FREE tools for practice and teaching of evidence-based medicine … … go to the Centre for Evidence-based Medicine (CEBM), University of Oxford … when You need…

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