Best Evidence Resources Whats fast, free and efficient Melanie Browne BHSc, MLIS Information Specialist, Mount Sinai Hospital, Toronto, Canada Sandra Kendall MLS Director of Library Services, Mount Sinai Hospital, Toronto, Canada Copyright © All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.

What we will be discussing today The strengths and weaknesses of Google and Google Scholar Introduction to medical librarianship and our arena of information overload Clinical queries and best evidence resources including consumer health resources

With an emphasis on Fast, Free and Efficient

The Evidence Issue Medical libraries support evidence-based decision-making. What is evidence? Evidence is information that comes closest to the facts of a matter. The findings of high quality, methodologically appropriate research are the most accurate evidence. Canadian Health Services Research Foundation 2005

Googles Mission accessibleuseful To organize the world's information and make it universally accessible and useful ( ) Google Newsletter for Librarians:

Enter search term / phrase Click Advanced Search

Use the advanced screen to narrow your search further Specify how many results you want displayed

Limit Results Limit by Language File Format Last updated Location on page

Statistics Bar Page Title URL of Result Interpreting Your Google Results

Google Search Tips Google Guide Gary Price Google tips Gadgetopia's -

Google Services

Google Scholar Tool in its beta development stage (introduced in November 2004) Gets its information directly from publishers and crawling the web Seems to focus mainly on science and technology (22% coverage) It has an algorithm that tries to provide only scholarly results

Google Scholar: Content Types Peer-reviewed papers – journal articles Theses Books Pre-prints - collections, personal websites Abstracts from PubMed etc. Technical reports Conference papers

Google Scholar: Relevance Ranking Takes into account: Full text of the article Author Publication in which the article appeared How often it has been cited in Google Scholars scholarly literature

Some are Not that Scholarly

Cited By Link Indicates the number of times this document was cited by other works that are indexed in Google Scholar.

Links The links across the bottom indicate where Google Scholar found this document on the internet. Ingenta is a fee based link.

Google Scholar: Concerns Indexes a subset of scholarly literature in all fields. Search result content varies. –Full text is often available, but sometimes links lead only to abstracts or citations. –Some duplicate and fragmentary entries appear, as well as variant editions of works (e.g. search results may include a preprint and post print of a work, as well as the version published in a journal).

It is unclear what Google Scholar is saying about their content and relevancy Nodular Regenerative hyperplasia Publication where two different articles are transposed into this one Pancreatic cancer

Google Scholar: Search Features Boolean – AND is the default; OR Phrase Date Title Publication Author

Google Scholar: Search Strategies Prefixes. Use prefixes to limit your terms to a particular field. author: pawson t To find articles on a given topic, add relevant keywords to the search. author:pawson cell

Listing of the author is random

Versus

Google Scholar: Search features needed for medical librarians Controlled indexing Truncation Limits (especially publication type such as RCT)

How does Google Scholar fit into the medical librarians toolkit? Everyone knows Google On Google Scholar.

Google Scholar: Conclusions Improvements and better features are expected Valuable resources, a great supplement but NOT a substitute for subject specific databases At least this offering could be working towards universal access to medical and scientific literature

Strengths and Weaknesses of Google Scholar StrengthsWeaknesses Easy to use Simple & familiar interface with ability to do keyword searches Ability to search over a number of databases at one time Searches a variety of material types including books, journals, websites Limited search capabilities No medical subject headings (MeSH) or Boolean operators You dont know which databases you are searching Cant specify which material type you would like, for example, journals only No ability to sort by author, title, date, publication Provides links to full text of both free articles and those in journals to which McMaster subscribes No information about how frequently Google Scholar is updated Google Scholar Adapted from: A resource for health sciences research at McMaster

Strengths and Weaknesses of Google Scholar StrengthsWeaknesses Searches for scholarly materialsNot sure how scholarly is defined, some materials are questionable Good for an overview of materials on a subject area Difficult to perform a specific search with precise results Displays number of citations for each article and links to list of those citing Questionable reliability of the number of citations compared with Science Citation Index Brings the most relevant materials (according to Google Scholar) to the top of the list Relevance is based partially on times cited, therefore older articles may come up first Adapted from: A resource for health sciences research at McMaster

Beaton, James, and Smith, Cheri Google versus PubMed. Ann R Coll Surg Engl 87:

Clinical Queries Occupational safety and needle injuries among nurses Application of competitive polymerase chain reaction (PCR) Comparison of midwifery services between Canada and the UK Total # of hip/knee replacements in Ontario and costs associated

Clinical Scenarios Interactions between Acute colonic pseudoobstruction (Ogilvies syndrome) and morphine Histomorphometry of the orbital zygomatic bone arch on the face of a rabbit

Clinical question In patients with an open tibial fracture, is it appropriate to substitute an external fixator with an intramedullary nail, taking into account the risk of infection and consolidation rate?

One ICU patient generates up to 236 variable categories Morris, Crit Care Clin 1999, 15:523 Humans capable of managing 5 to 9 variables adequately Miller, Psychol Rev 1956, 63:81 Data overload - patient information

Textbooks Journal articles Review articles Association guidelines Hospital protocols Pharmaceutical company information Electronic medical literature Data overload - reference information

Do we use this information ? Studied 4 month periods before and after publication of the landmark ARDSNet trial Rubenfeld GD et al. ATS 2001

Do we use this information ? Studied 4 month periods before and after publication of the landmark ARDSNet trial Percentage of patients receiving ventilation according to study protocol: Day 0 Day 3 Day 7 Day 0 Day 3 Day 7 before afterbefore afterbefore after 3% 6% 9% 3% 6% 9% Rubenfeld GD et al. ATS 2001

Do we use this information ? Studied 4 month periods before and after publication of the landmark ARDSNet trial Percentage of patients receiving ventilation according to study protocol: Day 0 Day 3 Day 7 Day 0 Day 3 Day 7 before afterbefore afterbefore after 3% 1% 6% 3% 9% 7% 3% 1% 6% 3% 9% 7% Rubenfeld GD et al. ATS 2001

Evidence Based Resources: TIER 1

Evidence Based Medical Resources Systematic Literature Searches Cochrane Library Clinical Evidence Systematic Literature Surveillance ACP Journal Club

Clinical Questions Four fundamental types of clinical questions: 1.Therapy Question - Concerns the effectiveness of a treatment ( drugs, surgical procedures, hospitalization) or preventative measure (immunizations etc.) - determining the effect of different treatments on improving patient function or avoiding adverse events. – RCT (randomized controlled trial)

Clinical Question 2.Prognosis Question – Deals with outcome of a patient with a particular condition i.e. how likely is a child with febrile seizures to actually develop a seizure disorder? – observational study assessing prognosis, cohort

Clinical Question 3.Diagnosis Question – Deals with the ability of a test to predict the likelihood of a disease i.e. usefulness of a (diagnostic peritoneal lavage) DPL in predicting operable abdominal injuries - compare against the gold-standard - case-control, cross-sectional

Clinical Question 4.Harm Question – Deals with the likelihood of a therapeutic intervention to cause harm. Exposure could be to medicine, drugs, foods, environmental agents, or medical procedures. i.e. – Development of cancer after radiation exposure – observation study, case-control

PICO Model Population: Who is the patient or what problem is being addressed? Intervention: What is the intervention / exposure? Comparison: What is the comparison group? Outcome: What is the outcome / endpoint? Richardson et al The well-built clinical question: A key to evidence-based decision. ACP Journal Club. A-12.

Where do we Start? Provide information based on the best evidence at the time In medicine, our best single source is a Randomized Controlled Trial –Patients are randomly sorted into a control group and a treatment group –Neither the patient, nor treatment provider, nor researcher knows sorting

Whats Even Better? A Systematic Review Summaries of RCTs evaluating similar interventions Care is taken to ensure that only quality studies are included –Well-designed study –Unbiased allocation of participants –Proper training given to researchers –Reasonable attrition rates

Whats Better than That? A Meta-analysis – A series of methods for systematically combining information from more than one investigation to draw a conclusion which could not be drawn solely on the basis of the single investigations. A systematic review that goes one step further…. Combines results of similar studies to form a single conclusion

What is the Best? A Cochrane Review Rigorous peer review process Highly structured Graphic display of information Consumer abstract Takes advantage of online environment Commitment to maintain currency

Systematic Reviews Comprehensive search Use only high quality studies Summary of the results

Sources of Systematic Reviews Cochrane DARE – Database of Abstracts of Reviews of Effects

The Cochrane Collaboration

Cochrane's Mission The Cochrane Collaboration is an international network of individuals and institutions committed to preparing, maintaining, and disseminating systematic reviews of the effects of health care. Not-for- profit charity registered in the UK

Subject Scope: The effects of healthcare

Cochrane Library - Limitations Only addresses questions that can be in randomized controlled trials Doesnt address all subject matter Only available through subscription

Clinical Evidence A database of questions (summaries) covering the effects of treatments and interventions. Online Update Frequency: Monthly PDA format: Yes Publisher: BMJ Publishing Group

You get information on …

Synopses Published in secondary journals –Appraise for validity –Use only high quality original studies and review articles –Provide a bottom line –Succinct, accurate, and authoritative

ACP Journal Club Resource Information Surveys over 150 peer-reviewed medical journals to produce summaries of original studies and systematic reviews For the internist or sub-specialist physician Online Update Frequency: Bi-monthly Publisher: American College of Physicians (ACP)

PubMed Central U.S. National Institutes of Health (NIH) Free digital archive of biomedical and life sciences journal literature A platform for enriched linking, analysis, and use of research reports and data Indexes over 4600 peer reviewed journals Contains over 13.5 million citations from 1951-

15388 results Need to narrow this to a manageable number

Standard Boolean Logic

545 citations, displayed 20 at a time Select limit to focus the results

Limits

The yellow bar at the top shows that limits have been applied.

PubMed: Conclusions Fast Free! Efficient…with some training

Case Greenwald, Robert And a Diagnostic Test Was Performed N Engl J Med 353:

Scenario Population: Infant with diarrhea an unusual rash ("alligator skin") multiple immunologic abnormalities including low T-cell function tissue eosinophilia (of the gastric mucosa) as well as peripheral eosinophilia an apparent X-linked genetic pattern (several male relatives died in infancy). What is the diagnosis?

Consumer Health Growing demand everywhere 55% of internet users use the internet to find health information Very different needs than the health care professional –Obstacles Got to be free!

What does the Healthcare Consumer Look Like? 40-44% function at the lowest level of literacy 55% of internet users use it to find health information Strongly favours community filtered info Strongly rely on search engines –12% first turn to Google

New Role for U.S. Public Libraries NCLIS has called on President Bush to support public libraries as health information distribution centers Key role as consumer health information provider Building on what they already do well! No Canadian equivalent

How do Consumers Search? Rely on search engines 65% use single word searches 71% select from first 5 results Site usefulness is key factor in assessing credibility

What are they Finding? Consumers using the Internet may have difficulty in finding complete and accurate information on a health problem (Berland et al.) Reading level is between 10 th and 12 grade Disconnect between information seekers and application of information

What are they Searching For? 93% searching for info on specific illnesses or conditions 65% looking for info on drugs; wellness; and weight control 40% for info on mental health conditions 50% for info on complementary therapies/alternative medicine

Evaluating Consumer Health Information Resources Consider the source Focus on quality Be a cyberskeptic Look for the evidence Check for currency Beware of bias Protect your privacy Consult with a health professional From MedlinePlus Guide to Healthy Web Surfing:

Cochrane Consumer Available via Informed Health Online (Health Research and Education Foundation Ltd. in Melbourne, Australia) Promotes the accessibility of health information from the Cochrane Collaboration

Consumer Health Resources NLM Gateway –MEDLINEplus –ClinicalTrials.gov –DIRLINE – Directory of Health Organizations –Genetics Home Reference –HEALTHINFOQUEST

MEDLINEplus Brings together authoritative information from NLM, the National Institutes of Health (NIH), and other government agencies and health-related organizations.

MEDLINEplus Includes: –Pre-formulated MEDLINE searches to give easy access to medical journal articles. –Information about drugs –An illustrated medical encyclopedia –Interactive patient tutorials –latest health news

MEDLINEplus Also includes: Over 700 Health Topics pages in English (over 650 of these are also available in Spanish) Information from over 1,250 organizations Over 17,000 links to authoritative health information

MedlinePlus Drug Information

MedlinePlus Medical Encyclopedia

MEDLINEplus: Strengths User driven topics User driven design Authoritative information Topics are reviewed at least every six months and new links are added every day Selective comprehensive resource

ClinicalTrials.gov Offers up-to-date information for locating federally and privately supported clinical trials for a wide range of diseases and conditions Currently contains approximately 22,000 clinical studies

If you want to see if there are clinical trials in your area

Lab Tests Online Designed to help consumers and caregivers better understand the many clinical lab tests that are part of routine care Covers diagnosis and treatment of a broad range of conditions and diseases Product of a unique collaboration among professional societies representing the clinical laboratory community

HEALTHINFOQUEST Pathfinders are designed for public librarians and health information specialists.

Canadian Health Network Canadas answer to Medline Plus Focus is on Health Prevention, rather than disease –It is a wealth of information to help you prevent disease and make healthy choices for yourself and your community Coverage is not as extensive

Canadian Health Network Works with partner organizations across Canada and provides direct links Alphabetically arranged? Can be overwhelming for users Not our 1 st choice!

In Conclusion: Not all evidence is created equal

Suggested Reading National commission seeks expanded health information role for libraries: NCLIS recommends private-public partnership for conducting study Public libraries 44 (4): 216. Alpi, KM Expert searching in public health. Journal of the Medical Library Association 93 (1): Baker, GR, Norton, P Making patients safer! reducing error in canadian healthcare. HealthcarePapers 2 (1): Beaton J, Smith C Google versus PubMed. Ann R Coll Surg Engl. 87(6): Butler D Google makes data free for all. Nature. 438(7067): Butler D Science searches shift up a gear as Google starts Scholar engine. Nature. 432(7016): 423. Copyright © All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.

Suggested Reading Crespo, Javier Training the health information seeker: Quality issues in health information web sites. Library trends 53, no. 2: Ellis-Danquah, La V Addressing health disparities: African american consumer information resources on the web. Medical reference services quarterly 23, no. 4: Eysenbach, G., Kohler, C How do consumers search for and appraise health information on the world. BMJ 324, no. 7337: Kiley R Finding health information on the Internet: health professionals. Hosp Med. 61(10): Fricke, M., Fallis, D., Jones, M., Luszko, GM Consumer health information on the internet about carpal tunnel syndrome: The American journal of medicine 118, no. 2: Copyright © All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.

Suggested Reading Glanville J, Haines M, Auston I Finding information on clinical effectiveness. BMJ. 317(7152): Gillaspy, Mary L Factors affecting the provision of consumer health information in public libraries: The last five years. Library trends 53 (3): Giustini, D., Barsky, E A look at Google Scholar, PubMed, and Scirus : comparisons and recommendations. Journal of the Canadian Health Libraries Association 26: Golderman, Gail Staying healthy. Library journal 18-20, 22-4, 26. Henderson, J Google scholar: A source for clinicians? CMAJ 172 (12): On Google Scholar. Copyright © All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.

Suggested Reading Google Newsletter for Librarians: Schloman BF Google extends its reach. Online J Issues Nurs. 10(2):8. Su KC, Waldren SE, Patrick TB. Differences in the effects of filters on health information retrieval from the Internet in three languages from three countries: a comparative study. Medinfo. 2004;11(Pt 2): Steinbrook R. Searching for the right search--reaching the medical literature. N Engl J Med Jan 5;354(1):4-7. Younger P. Using the Internet to conduct a literature search. Nurs Stand Oct 20-26;19(6):45-51; quiz 52. Copyright © All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.