1. Evidence-Based Practice Finding the evidence Ben Skinner (ben.skinner@bsuh.nhs.uk)ben.skinner@bsuh.nhs.uk

2. You have just moved to a new town and need to register with a GP. You find that two are accepting patients:- Claire completed her GP training two years ago. She won the Fraser Rose medal for scoring the highest marks out of 2000 MRCGP candidates. Jo has had 10 years post-qualification experience as a GP. She passed her MRCGP with Distinction (top 25% in the country) Who do you choose as your doctor?

3. Choudhry NK, et al. Systematic review: the relationship between clinical experience and quality of health care. Annals of Internal Medicine 2005;142:260–273.

4. Individual Clinical Expertise Best External Evidence Patients’ Values & Expectations Evidence- Based Practice Peer review process extremely flawed Tiny percentage of clinical research is good quality Need skills to find ALL relevant research and judge its quality Best External Evidence

5. Peer Review The Centre for Evidence-Based Medicine regularly read, appraise and digest clinical research published in c150 peer-reviewed medical journals They find that: –Approximately 5% are methodologically valid and reliable –Of those 5%, approximately 5% are clinically relevant As a rule of thumb, 0.25% of peer- reviewed research is worth your time

6. Essentials of evidence-based searching Understanding of: Well structured clinical question Appraised / Non-appraised resources –Reviews –Guidelines –Digests –Primary research Critical appraisal

7. Appraised vs Non-appraised resources Tertiary evidence –Clinical guidelines, Systematic Reviews Secondary evidence –Critically appraised digests of primary research Primary evidence –Original studies or trials

8. Guideline sites National Library for Health Guidelines: www.library.nhs.uk/guidelinesfinder www.library.nhs.uk/guidelinesfinder National Guideline Clearinghouse: www.guideline.gov www.guideline.gov OMNI: www.omni.ac.uk www.omni.ac.uk (For guidelines - click advanced search and specify: “Practice guidelines” in Resource type)

9. Enter as many terms into the search box as you wish - It retrieves the guidelines in which all the terms occur Search for a phrase by using quotes – E.g. “prenatal diagnosis” You can use brackets and logical operators – E.g. (prenatal OR antenatal) AND screening You can truncate words with the * symbol – E.g. infertil* would find infertile or infertility Basic search techniques

10. National Library for Health Guidelines Finder http://www.library.nhs.uk/guidelinesfinder/ http://www.library.nhs.uk/guidelinesfinder/

11. Search for ‘pre-eclampsia’ on NLH

12. National Guidelines Clearinghouse http://www.guideline.gov http://www.guideline.gov

13. Search for ‘pre-eclampsia’ on NGCH

14. Cochrane Library for systematic reviews A set of databases that contains reliable evidence about the effectiveness of interventions: –Treatment –Diagnosis and screening –Health promotion –Organisation of care Be critical –Check date of last update –Check scope of review

15. Cochrane Database of Systematic Reviews –Full text of systematic reviews published by Cochrane –Each review is updated at least every two years Database of Abstracts of Reviews of Effects (DARE) –Critically appraised summaries of other systematic reviews Cochrane Central Register of Controlled Trials –Bibliographic references to randomised controlled trials –Not critically appraised NHS Economic Evaluation Database –Critically appraised summaries of economic evaluations The Cochrane Library contains…

16. Cochrane Library http://www.thecochranelibrary.com http://www.thecochranelibrary.com

17. Search for ‘rupture AND membrane’

18. Viewing a record Navigate using contents panel Print using PDF

19. Pre-appraised resources Evidence-Based Medicine - http://ebm.bmjjournals.com/http://ebm.bmjjournals.com/ Produced by the Centre for Evidence-Based Medicine Searches over 100 journals Finds the 5% of trials that are methodologically sound and presents only those that are clinically important

20. Pre-appraised resources Bandolier - www.jr2.ox.ac.uk/bandolier/www.jr2.ox.ac.uk/bandolier/

21. Searching across multiple resources Women’s Health Specialist Library: www.library.nhs.uk/womenshealth www.library.nhs.uk/womenshealth OMNI: www.omni.ac.ukwww.omni.ac.uk (For guidelines - click advanced search and specify: “Practice guidelines” in Resource type) Turning Research into Practice (TRIP): www.tripdatabase.comwww.tripdatabase.com Google: www.google.co.ukwww.google.co.uk

22. Women’s Health Specialist Library www.library.nhs.uk/womenshealth/ www.library.nhs.uk/womenshealth/

23. Google Google should be one of the last places you look because the ratio of useful to non- useful resources is so tiny To make a Google search more effective add site:nhs.uk to your search, e.g. pre-eclampsia aspirin site:nhs.uk

24. Primary research databases Medline is accessible in two ways: Pubmed: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi http://www.ncbi.nlm.nih.gov/entrez/query.fcgi –Links to full text are misleading – not always free! Dialog: http://nhs.dialog.comhttp://nhs.dialog.com –Requires an ATHENS password –Direct access to full text articles where available –Additional databases can be search simultaneously NOTE: Dialog also gives access to Embase (only 35% overlap with Medline)

25. Accessing Dialog http://nhs.dialog.com Click on Search Databases. On the next page enter your NHS Athens Username and Password. To apply for a password go to: www.athens.nhs.uk

26. 8 Bibliographic Databases AMED Complementary Medicine BNI Nursing (UK bias) CINAHL International Nursing & Allied Health KINGS FUND Health and Social Care Management DH DATA Health Management EMBASE Medicine (strong on pharmaceuticals; European bias) MEDLINE Medicine (US bias) PSYCINFO Psychology & Psychiatry Note: Only a 35% overlap between Medline and Embase

27. Evidence-Based Filters These have been designed and trialled to retrieve high-quality articles with maximum sensitivity and specificity There are filters for studies of: aetiology, diagnostic tests, therapy and prognosis Details can be found at: www.ncbi.nlm.nih.gov/entrez/query/static/clinicaltable.html www.ncbi.nlm.nih.gov/entrez/query/static/clinicaltable.html

28. Saving Results Click “Show Titles” on the search page Tick the articles you are interested in Select “Display” Click “Save” (you can choose whether to save as PDF, Word, etc)

29. Critical Appraisal Far fewer than 1% of published trials are conducted well enough and clinically relevant enough to be worth implementing Critical appraisal is aided by the use of checklists that outline all of the questions that should be asked about a paper. See: http://www.phru.nhs.uk/casp/critical_appraisal_tools.htm http://www.phru.nhs.uk/casp/critical_appraisal_tools.htm

30. Resources NHS Library services –Searches done for you on demand –Over 1500 full-text electronic journals –KnowledgeShare (ben.skinner@bsuh.nhs.uk)ben.skinner@bsuh.nhs.uk Personalised current awareness Further advice and support