1. Evidence-based Practice for HINARI Users (Module 6)

2. Table of Contents EBM definition 5 step EBM process HINARI Resources Cochrane Library Evidence-based Medicine Guidelines Essential Evidence Plus EBM Journals PubMed/Clinical Queries PubMed Health Other Resources

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

4. Why EBP? Improve care To bridge the gap between research & practice “Kill as few patients as possible” (O. London) new treatment fewer side effects cheaper or less invasive resistance to existing therapies, etc. Keep knowledge and skills current (continuing education) To save time to find the best information

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

6. 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, 2 nd. ed. BMJ Books, 2007.

7. The 5 Step EBP Process AskAccessAppraiseApplyAssess 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

8. Background Questions General questions - disorder – What is the disorder? – What causes it? – How does it manifest? – Treatment options? Information Resources – books – narrative reviews general overview of a topic Foreground Questions Specific questions - patient – INTERVENTION/PREVENTION – ETIOLOGY, RISK – DIAGNOSIS – PROGNOSIS Information Resources – journal articles – synopses of articles – systematic reviews answer specific questions Step 1: ASK (questions, PICO) a focused (answerable) clinical question Ask

9. 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 - treat, diagnose, observe)? C = Comparison intervention (What is the alternative to the intervention - placebo, different drug, nothing?) O = Outcome (What are the relevant outcomes - morbidity, mortality, death, complications)? Step 1: ASK PICO Format Ask

10. Why should I use PICO? define problem - clarify it in your own mind identify concepts/terms for searching ask patient centered questions; treatment of pneumococcal pneumonia SHOULD be different for – elderly, severely demented patient – terminal cancer Patient – young, mother of 2 children

11. Example: Intervention Questions A 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. Identify the 4 PICO components

12. Formulate the Clinical Question PICO P (patient) - 54 year old male with intermediate grade prostate cancer I (intervention) - radical prostatectomy C (comparison intervention) - radiation treatment O (outcome) - 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?

13. 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?

14. 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?

15. 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.

16. Access EBP Step 2: ACCESS (studies, hierarchies) Track Down the Best Evidence Start “hunting” from the best resource: match your question to the best medical information resource for this question.

17. Hierarchy of Evidence Research Studies experimental observational synthesis

19. Appraise EBP Step 3: Appraise (validity, impact) Appraisal principles (primary and secondary research) – Does PICO of the study match my PICO question? – validity internal validity – methods – How well was the study done? Is it biased? external validity – generalizability – impact Does it matter to your patient? University of Oxford’s Center of EBM: http://www.cebm.net/index.aspx?o=1157http://www.cebm.net/index.aspx?o=1157 Evaluating the Evidence section in the EBM tutorial at: http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm

20. EBP Step 4: APPLY (patient, setting) Integrate the results with your clinical expertise and your patient values Patient Is my patient similar enough that the results of the study apply? Will the potential benefits outweigh the potential harms of treatment ? What does my patient think? What are his cultural beliefs? – Setting Is the intervention feasible in my settings? What alternatives are available? Apply

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

22. HINARI Resources Cochrane Library – filtered PubMed – unfiltered Clinical Queries Filters PubMed Health HINARI EBM Journals

23. Cochrane Database of Systematic Reviews The Cochrane Library (John Wiley) high-quality, filtered, critically appraised Systematic Reviews from all over the world minimum bias: evidence is included/excluded on the basis of explicit quality criteria abstracts searchable for free on the Internet; complete database is available via HINARI

24. From the Reference Sources 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.

25. The initial page of this site has a title, abstract or keyword option Search engine. You also have various options to Browse by Topic and Browse by Review Group Open the Advanced Search.

26. We have opened the Advanced Search option and will complete a search diarrhea child* using the Title, Abstract, Keywords option with the wildcard (*) used to locate the terms child and children. Note the Medical Terms (MeSH) optionSearch Manager – to view search history.

27. The Advanced Search for diarrhea child* Title, Abstracts and Keyword has retrieved 95 records that are Cochrane Reviews Reviews plus Other Reviews, Methods Studies and other options for a total of 2250 results. You have the option to Export All Results (save).

28. The Advanced Search for diarrhea child* Title, Search All Text has retrieved 882 records that are Cochrane Reviews, a significantly higher number.

29. The screen displays the Abstract of the first systematic review listed in the search - Probiotics for treating acute infectious diarrhoea. Note the options for View Full Article (HTML), Summary (PDF) and Full (PDF).

30. Displayed is the Abstract of the systematic review that includes the Background, Objectives, Search methods, Selection criteria, Data collection and analysis, Main Results and Authors conclusions.

31. 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 Resume in French.

32. Now displayed is the PDF Full version of the Probiotics for treating acute infections diarrhoea systematic review. Other options include Summary and Standard files.

33. From the Cochrane Library initial page, we have clicked on the Browse by Topic hyperlink.. From this extensive list, you have another option for locating subject- specific material. Note the links to a list of Cochrane Reviews and also Trials.

34. From the Reference Sources list, we have opened 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.

35. 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. PRIMARY and SECONDARY HITS Also included are links to the Evidence summaries.

36. We have displayed the 2nd Evidence summary. Each link contains a brief review of the study and notes the reference(s).

37. From the Reference Sources list, we have opened the initial page of Essential Evidence Plus. Also published by John Wiley, it includes access to Cochrane Library and also a series of databases and tools to access the EBM material. By keyword, you can Search all or some of the databases.

38. We have opened the EBMG evidence summaries database that, via broad subject categories, has access to 4440 articles.

39. We have opened the initial page of EBMG evidence summaries listing for Infectious disease. Material is listed by either a summary view or expanded view that includes a sentence describing each entry.

40. We have opened Decision Support Tools that has 406 tools and calculators that assist in clinical decision making.

41. 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.