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.

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.

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

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

Table of Contents – Part C Other (Internet) Resources: HINARI/PubMed’s Clinical Queries (Clinical Study Categories & Systematic Reviews citations) and ‘Type of Article’ Limits (Meta-Analysis, Randomized Control Trial & Clinical Practice) 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 Summary

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

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

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

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.

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

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 Ask Access Appraise Apply Assess

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

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?

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.

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?

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?

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)

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?

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.

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.

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.

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.

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)

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.

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)

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)

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

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-

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)

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: http://www.cebm.net/index.aspx?o=1157 Tools for evaluating studies can be found in the Evaluating the Evidence section in the EBM tutorial at: http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm

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: https://docs.google.com/View?id=d7k3gkg_679hnvn54c8 Visual Rx: http://www.nntonline.net/visualrx/

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

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

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

If you are interested in learning more about EBM, go to the online tutorial Introduction to Evidence-Based Medicine from the Health Sciences Library, University of North Carolina (USA): http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm

Logging on to HINARI 1 To access the HINARI Evidence-based Medicine resources, we must Login to the HINARI website using the URL http://www.who.int/hinari/

Logging into HINARI 2 We will need to enter our HINARI User Name and Password in the appropriate boxes, then click on the Login button. Note: If you do not properly sign on, you will not have access to Evidence-based Medicine resources that are located in the Reference Sources drop down menu.

From the HINARI Reference Sources drop down menu, we also can find tutorials for learning more about EBM. In this example, we will link to BMJ Learning.

From the BMJ Learning’s Browse our modules listing, we have clicked on Clinical Epidemiology and located four EBM-related tutorials. Four learning resources are available.

From the Reference Sources drop down menu, there are four valuable EBM- related sites. First, we will click on the Clinical Evidence link, a resource for informing treatment decisions and improving patient care. It is published by the BMJ Publishing group. Most of the evidence-based resources deal with clinical questions so we will look at those first. Later, we’ll look at resources useful to public health practitioners. Of course, there is some overlap between the two areas of interest. We’ll start by looking at the resource called Clinical Evidence.

In the Clinical Evidence site, you can search by Sections, Full review list or (keyword) Search this site. Also note that there is a Clinical Evidence Userguide in multiple languages and links to the Latest updated reviews. Take a minute to look at the various features of this resource. Note that there are 3 ways to search, by general section (e.g., Infectious Diseases), Full review (browse titles of individual reviews, e.g., AIDS: Tuberculosis in people with HIV), and Search (use keywords here). Note also, the availability of a Userguide.

Using the Search this site option, we have completed a keyword search for tuberculosis and identified 73 documents. The links include clinical evidence Guidelines, Keypoints, Interventions and Updates about this topic. Searching the term tuberculosis results in 73 matches. Perhaps we should limit our search to be more specific.

We have further limited this search by combining tuberculosis and HIV We have further limited this search by combining tuberculosis and HIV. This has resulted in 56 documents. We will click on the link to Tuberculosis in people with HIV. Adding HIV to the Search box results in 56 matches. You can keep adding terms, with , of course, the possibility of missing some useful articles.

The initial page of HIV: treating tuberculosis initially displays Interventions based on clinical questions. Note that also you have access to Key points, About this condition, Updates, Guidelines and References. We will click on the Guidelines hyperlink.

The Guidelines page contains the title, name of organization and hyperlink to 10 documents from key health agencies. The guidelines have been sourced from the National Guidelines Clearinghouse (USA).

We have clicked on the Full review list option and displayed the topics under the A alphabetical list. This A-Z subject access contains an extensive list of topics and clinical evidence material.

From the Reference Sources drop down 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. Note the full-text reviews are available to Band 1 only while Abstracts can be accessed by all users. Next we are going to look at one of the first and most respected evidence-based information resources, The Cochrane Library. Also, technically the Reference Sources drop down, no?

The Cochrane Library COCHRANE LIBRARY : The Cochrane Collaboration. Oxford: Update Software; 1996-. Updated quarterly. Cochrane Database of Systematic Reviews (CDSR) High-quality pre-evaluated systematic reviews from all over the world International, not-for-profit organization Complete reviews and protocols (reviews that are still in progress) CDSR abstracts are in Medline but there is no link to full-text of the review Specific topics, explicit evaluation criteria to minimize bias

The initial page of this site has a title, abstract or keyword option Search engine. You also can Browse Cochrane Database by broad subject heading . The initial page also highlights New and Updated Cochrane Reviews. We will go to the Advanced Search. Also from the initial page, there is a link to the Cochrane Journal Club. Take a minute to review the main page of the Cochrane Library. Note in the upper right you can browse Cochrane Reviews and there are other sources as well, such as individual clinical trials. There is a search box and field options for searching. One can also click on Advanced Search to construct a search by filling in boxes and making selections.

We have opened the Advanced Search option where you can specify search fields and have the ability to combine terms using AND/OR/NOT operators. In this text Advanced Search, we have combined diarrhea child* using the Search All Text option with the wildcard (*) used to locate the terms child and children. Note that you also can complete a MeSH Search, look at your Search History or Saved Searches. Here we see the Advanced Search box and search for items that discuss both diarrhea AND children. Note the ability to put a wildcard * at the end of child to search for child, children.

The Advanced Search results for diarrhea child The Advanced Search results for diarrhea child* has retrieved 451 records from the Cochrane Database of Systematic Reviews. You have the option to Export All Results (save). Note: if the results of your search are too many, you can narrow it by limiting the keyword search to Title instead of Search All Text. Note that we retrieved more than 400 Systematic Reviews and it might be smart to further restrict the search with more terms, realizing that you might miss some good articles. For our purposes, though, let’s look at the record about oral zinc (note that variations of the spelling of diarrhoea are accounted for).

The screen displays the Abstract of the first systematic review listed in the search - Oral zinc for treating diarrhoea in children. To access the full-text review, click on the Full PDF hypertext link in the left column. Other options are Summary and Standard. Also note the hypertext links to specific sections of the systematic review. This is the information about who did the systematic review and when it was last updated. If we click on Summary, we’ll see the following .

We have displayed the Abstract of the systematic review that includes the Background, Objectives, Search strategy, Selection criteria, Data collection and analysis and Main Results. Summary gives a good overview of purpose, methodology, results, conclusions and a plane language summary (next slide).

The final section of the Abstract is titled Plain language summary The final section of the Abstract is titled Plain language summary. This section is useful for disseminating the results to groups of health workers and patients. Also note the Main results and author’s conclusions (the ‘bottom line’) as these sections discuss the review’s results and how they should be used.

We have displayed the PDF Full version of the Oral zinc for treating diarrhoea in children systematic review. Other options include Summary and Standard files. Note: The url that contains http://hinari- gw.who.int/whalecom... shows that we have logged in to HINARI properly and will have access to the full-text version of this review.

From the Advanced Search page of the Cochrane Library, we have clicked on the Cochrane Reviews: By Topic hyperlink. This has displayed the Topics for Cochrane Reviews. From this extensive list, you have another option for locating subject- specific material. Note that there are other search lists including an A-Z list, Updated Reviews and New Reviews.

For more training material, you can click on The Cochrane Library Help hyperlink. We have opened the Search Manual. Another option is a listing of Web Updates.

If your institution does not have access to Cochrane… If your institution does not have access to Cochrane…. Access to the Abstracts is free from a link at: http://www.cochrane.org/

After accessing the Cochrane Collaboration (http://www. cochrane After accessing the Cochrane Collaboration (http://www.cochrane.org/), click on the Cochrane Library link. This will give you access to the Library’s search options and the abstracts but not the full-text articles. On this site, click on The Cochrane Library. Click here

We now access the third Reference Sources option for evidence-based health information - EBM Guidelines. Let’s look at another resource, EBM Guidelines.

This is the initial page of EBM Guidelines Evidence-Based Medicine This is the initial page of EBM Guidelines Evidence-Based Medicine. Also published by John Wiley, this resource is a collection of clinical guidelines for primary care combined with evidence-based research. You can Search by keyword or Browse database contents by EBM Guidelines, Evidence summaries, Pictures, Audio samples, Videos and Programs.

We have completed a keyword search for Influenza We have completed a keyword search for Influenza. The results page includes summaries of the key issues including Related resources and References and links to important websites. Also included are links to the Evidence summaries.

We have displayed the first Evidence summary We have displayed the first Evidence summary. Each link contains a brief review of the study and notes the reference(s).

We now access the fourth Reference Sources option for evidence-based health information – BMJ’s BestPractice – a combination of research evidence, guidelines and expert opinion.

We have completed a keyword search for diabetes We have completed a keyword search for diabetes. Note the drop down menu with the broad category results of the search.

The results for the diabetes search are displayed in broad subject categories. Note that each category contains full-text documents on the Highlights, Basics, Prevention, Diagnosis, Treatment, Followup and Resources.

HINARI Evidence-Based Journals (other journals may have EBM articles) We have browsed the ‘E’ in the HINARI Find journals by title list and it notes several journals for evidence-based practice.

Table of Contents – Part C Other (Internet) Resources: HINARI/PubMed’s Clinical Queries (Clinical Study Categories & Systematic Reviews citations) and ‘Type of Article’ Limits (Meta-Analysis, Randomized Control Trial & Clinical Practice) 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 Summary

We now search for evidence-based articles using PubMed We now search for evidence-based articles using PubMed. From the main HINARI webpage, go to PubMed by clicking on Search HINARI journal articles through PubMed (Medline). Remember you must login to HINARI to have access to the full-text articles.

Open the Clinical Queries box Open the Clinical Queries box. This search tool assigns filters to keyword searches - to locate articles on Clinical Studies, Systematic Reviews and Medical Genetics. Note: for these PubMed applications, all individuals will have access to the free full text articles. The examples are from HINARI/PubMed searches and, for those properly logged in, will also include access to articles from HINARI participating publishers.

To use the Search by Clinical Study Categories, you would type a disease or procedure in the Search box and select one Category and Scope per search. We have displayed the options for Category and clicked on Therapy from the drop down menu. Note the definition of the Filters on the bottom of the page. Note: you can go directly to PubMed Clinical Queries The direct link to PubMed Clinical Queries is http://www.ncbi.nlm.nih.gov/pubmed/clinical

For the Scope option, we will enter Narrow and also enter type 2 diabetes AND developing countries in the search box.

The Therapy (Category) and Narrow (Scope) type 2 diabetes AND developing countries search has resulted in 8 citations. We now will click on the See all option. Note that the results for Systematic Reviews and Medical Genetics also are displayed.

We have displayed all 8 articles for this search including 7 HINARI and 3 Free Full Text articles. Remember - you can access the full-text articles by clicking on these Filters or changing the display from Summary to Abstract. Note that the specific search is listed in the Search box including the AND (Therapy/Narrow[filter]) for systematic reviews.

We have clicked on the See all option for the systematic reviews results. The type 2 diabetes AND developing countries AND systematic [sb] search resulted in 13 articles.

If you have a MY NCBI account, you can add Meta-analysis and Systematic Reviews to your Filters. Go to Manage Filters, click on Properties option and put each term in the Search with terms box. When you save a PubMed search, you will be sent an email listing new articles on the specific topic. Remember that you will need to go to HINARI to get the full-text articles. In this example, Free Full Text, HINARI, Meta-analysis and Systematic Reviews are listed in Filters.

Another tools from PubMed is using the Limits option Another tools from PubMed is using the Limits option. In this example, we have opened Limits. We will check the Meta-Analysis box in the Type of Article section and enter hypertension in the PubMed Search box. Note: From the initial PubMed search page, click on Limits to activate this option.

The results of this search are 1177 citations including 286 Free Full text articles. Note the Limits Activated: Meta-Analysis line. Remember that you must Remove this Limit if you want to complete another PubMed Search.

We have added AND developing countries to the previous search and now 4 citations.

Now displayed are the results of a hypertension search with two evidence-based medicine Type of Article boxes checked (Meta-Analysis and Randomized Controlled Trial). The citations for this search include 3104 Free Full text articles. Note the Limits Activated: Meta-Analysis, Randomized Controlled Trial line.

Definition Clinical Practice Guidelines "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" (Institute of Medicine, 1990) Clinical Practice Guidelines is a related tool that has been developed using the evidence based medicine studies. We will discuss this in the following four slides.

Overview of Guidelines Describe a range of generally accepted approaches for the diagnosis, management, or prevention of specific diseases or conditions Define practices that meet the needs of most patients in most circumstances Are recommendations that are based on evidence from a rigorous systematic review and synthesis of the published medical literature Primarily for use by clinicians--physicians, nurses, and other health professionals in clinical practice

Using the Limits option, we now will check the Practice Guideline box in the Type of Article section and enter malaria treatment in the PubMed Search box. Note you can click on more than 1 box in the Type of Article section.

The results of this search are 31 citations including 13 Free Full text articles. Note the Limits Activated: Practice Guideline line. Again… you must Remove this limit if you want to complete another PubMed Search.

Additional CPG resources National Guideline Clearinghouse (USA) http://www.guideline.gov/ Open Clinical: Clinical Practice Guidelines http://www.openclinical.org/guidelines.html About Clinical Practice Guidelines http://www.nhlbi.nih.gov/guidelines/about.htm#what

PubMed Health specializes in reviews of clinical effective research – which finds answers to ‘What Works’ in medicine and health care. It is based on systematic reviews of clinical trials. PubMed Health is a service provided by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).

From the Contents drop down menu, you can access PubMed Health’s information in the following categories: For consumers, Executive summaries, Clinical guides and Full text reviews. We will open the Executive summaries option. Note also that PubMed Health contains a Medical encyclopedia.

The Executive Summaries Results is organized via an A-Z alphabetical listing. This format also is used for the other options in the Contents drop down menu. We have entered HIV AND pregnancy in the keyword search box.

For the HIV AND pregnancy search, there are 368 Results displayed in PubMed Health. The initial display is in the Summary format. By clicking on the title, the Abstract will be displayed. The Refine your search option organizes the results by the categories in Contents drop down menu. Also note the Medical Encyclopedia links to key concepts in the search results.

When available, PubMed Health contains links to full-text documents When available, PubMed Health contains links to full-text documents. Displayed in this slide are the titles from the H listing for the Full Text Reviews. We will open the HIV in Pregnant Women document.

The Full Text Review contains a Structured Abstract and then links to the various sections of the Review (next slide).

We have displayed the AIDS (Acquired immune deficiency syndrome) definition from the A.D.A.M. Medical Encyclopedia.

Trip Database is a clinical search tool for health professionals to identify quality clinical evidence for clinical practice. It allows simultaneous searching of multiple sites which speeds up the question answering process. Registration is required but free and gives the users additional resources.

We have completed a search for malaria AND bednets We have completed a search for malaria AND bednets. The results are displayed with, in some cases, links to Full Text.

Preview goes to source – in this case PubMed… We have completed a search for malaria AND bednets. The results are displayed with, in some cases, links to Full Text.

Fulltext goes to journal – The Lancet Infectious Diseases and will be asked to pay for the article. Need to copy citation and go to HINARI A-Z journals list… We have completed a search for malaria AND bednets. The results are displayed with, in some cases, links to Full Text.

For this search, we checked 4 boxes and now will Export selected links as a CVS file.

The report is displayed as an Excel spreadsheet with the title, url, publication and date of each checked citation. Access to full-text journal articles will depend on whether they are free full text articles or if your institution is eligible for HINARI or has a subscription.

We have displayed the Advanced Search for the trip database.

EvidenceUPDATES contain a searchable database, an email alerting system and links to selected evidence-based resources. Registration is required but free.

We have entered chloroquine resistance in the tool’s search box.

For this search there are 14 matches that note the citation information plus type of article (e.g. Review, Original). Access to the full-text article again will be if it is a free full text one or your institution has access via HINARI or a subscription.

EvidenceUPDATES contain options to Download Citations including to several commercial reference manager softwares. We will download to the Text File option.

In the Text File option, the abstracts for the checked results are listed in a Notepad file.

EvidenceUPDATES also contains an Advanced Search option that initially is based on disciplines, categories and populations. From the drop down menu, subcategories for each broad discipline will be displayed.

The Canadian Institutes of Health Research web site contains four Knowledge Translation Learning Modules. Several of these online courses are relevant for evidence based practice and use of knowledge to make informed health decisions.

The Essential Health Links gateway contains annotated links to numerous Evidence-Based Medicine resources available on the Internet.

Additional Evidence-based Health Resources Bandolier Knowledge: Oxford University http://www.medicine.ox.ac.uk/bandolier/knowledge.html The Campbell Library http://www.campbellcollaboration.org/library.php DARE: Database of Abstracts of Reviews of Effects http://www.crd.york.ac.uk/crdweb/ Duke University Medical Center Library: EBM http://www.mclibrary.duke.edu/subject/ebm?tab=contents Listed here are some freely available websites that are useful resources for finding clinical and public health evidence.

EBM Librarian https://sites.google.com/site/ebmlibrarian/ McMaster PLUS collection http://hiru.mcmaster.ca/hiru/HIRU_McMaster_PLUS_projects.aspx National Guidelines Clearinghouse http://www.guideline.gov/ Nesbit Guide Evidence-Based Resources http://www.urmc.rochester.edu/hslt/miner/digital_library/evidence_based_resources.cfm

Review/Summary Evidence-based practice depends on knowing the most recent, valid scientific knowledge. This involves finding the ‘best’ studies. Sometimes others have evaluated the quality of the studies, including methodology; many new evidence-based tools mentioned in this tutorial provide evaluation. Here are some general comments to remember about evidence-based practice. We hope that this tutorial has led to a better understanding of what evidence-based practice is and how to efficiently find good evidence using HINARI resources.

When there is no evaluation available, it is essential to evaluate the validity of the study. Tools for evaluating studies can be found in the Evaluating the Evidence section in the EBM tutorial mentioned earlier and found at: http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm

It is always important to consider studies in terms of applicability to and values of the local patient/situation. Evidence-based practice is a developing field and new, useful resources are continuously being developed.

Appendix 1 Appendix 1 – Contains four case studies for developing Evidence-Based Practice curriculum: experimental cancer research, EBP curriculum for pharmacy students, health literacy for pharmacy students and outreach activity for early intervention providers Developed by: Irena Bond, Library Manager Associate Professor of Library and Learning Resources Massachusetts College of Pharmacy and Health Sciences

Research Evidence Practitioner’s Experience Local Conditions Patient/Community Preferences & Values This is the end of the Evidence-based Medicine for HINARI Users module. The material initially was developed by: Gale G. Hannigan, PhD, MLS, MPH; Professor & Medical Informatics Education Librarian, Texas A&M University. Material revised and enhanced by Irena Bond, Library Manager, Associate Professor of Library and Learning Resources, Massachusetts College of Pharmacy and Health Sciences. There is a workbook that accompanies this module. The workbook will take you through a live session covering the topics included in this demonstration with working examples. Updated 2012 02