1. Search for Evidence; Evidence Based Medicine
Prepared By: Nadia Masoud
The Medical Librarian

2. Physicians “NEED” EBM, WHY?
In order to take a proper clinical decisions, physicians should keep up-to-date with the Medical Literature.
To keep themselves updated, physicians need to read at least 6-8 hours daily. These hours will be added to the busy schedule and work load they have daily.

3. Physicians “NEED” EBM, WHY?
Need for valid information daily on Diagnosis, treatment, prognosis and prevention
Inadequate traditional sources:
Outdated, too voluminous to be practical” (Textbooks)
Frequently wrong (Expert opinions)
Ineffective (Didactics/CME)
Too overwhelming in volume and variable in validity (Medical Journals)

4. EBM Founding Father
Prof. Archibald Cochrane a British medical epidemiologist is the Founding Father of the Evidence Based Medicine Concept.
“The Cochrane Collaboration”, the main source for EBM, was named after him.

5. Evidence Based Medicine (EBM)
Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values
Sackett DL, Straus SE, Richardson WS, Rosenberg W, and Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd Ed, Churchill Livingstone, London, 2000

6. Evidence Based Medicine
Basis of Evidence-based care involves the integration of the best research evidence with clinical expertise and patient values.          
Best Clinical Evidence
Clinical Experience
Patient’s Needs/ Preferences

7. The Evidence Based Cycle
Identify and define the problem
Formulate a focused clinical question
Identify the appropriate resources
Search for valid and relevant information
Critical appraisal
Implement in practice

8. Types of Clinical Questions
Background Questions ask for general knowledge about a disease, disease process or clinical circumstances.
Background Questions are those questions which have been answered in the past and are now part of the “fiber of medicine”
Ask They generally ask "who, what, when, why, where or how" about a single disease, drug, intervention or concept.
You can find a helpful background information particular subject by searching Encyclopedias, dictionaries, textbooks, thesauri, ..etc. Bibliographies at the end of articles lead you to other books and articles on your topic, which might be very helpful.

9. Types of Clinical Questions
Foreground Questions The foreground questions are the base of the EBM Search. They are more difficult to answer than background questions because they require sources that provide a wide range of knowledge and look for specific patient cases or problems.

10. Searching the Online Databases
Choose the appropriate database
Consult at least two databases to prevent missing a significant piece of work on the subject
When using a new database, familiarize yourself with its language by using the online help

11. Develop a Search Strategy
There are seven steps to be considered for applying the EBM principles and responding to the clinical inquiries.
Receive and analyze the clinical question by using the PICO method
Expand your background, gather pertinent background information
Classify the clinical question into a category (therapy, diagnosis, etiology, prognosis)
Search for the information in the best resources
Evaluate literature for accuracy and relevance
Formulate a response
Communicate information and follow up(1)

12. The EBM Process Assess your patient Ask clinical questions
Acquire the best evidence
Appraise the evidence
Apply the evidence to patient care

13. ASK A Clinical Question
Formulate a well-built clinical questions.
In practice, well-built clinical questions usually contain four elements abbreviated in PICO Format
P - Patient / problem : Identify the problem of the patient
I - Intervention of Interest (such as a drug or test)
C – Comparison / the Comparison Intervention
O – Outcome / the Intended Outcome

14. Patient / Population – who and what?
Intervention – how?
Comparison (if appropriate) – what is the main alternative?
Outcome – what are you hoping to accomplish, measure, improve, affect?

15. P = Patient/Problem/Population: Ask “how would I describe a group of patients similar to mine?” Balance precision with brevity
I = Intervention: Ask “which main intervention am I considering?” (cause, prognostic factor, treatment, etc..)
C = Comparison/Control: Ask “which is the main alternative to compare with the intervention?” again, be specific
O = Outcome: Ask “what can I hope to accomplish?” or “what could this exposure really affect?” again, be specific.

16. Types of Research Studies
1-Randomized controlled trial:  (answers therapy, prevention questions) Randomization avoids selection bias. Clinical trials that involve one test treatment and one control treatment, concurrent enrollment and follow up of the test-and control treated groups, and in which the treatments to be administered are selected by a random process.

17. Types of Research Studies
2-Cohort study:  (answers prognosis, etiology, prevention questions) Cohorts are defined populations that, as a whole, are followed in an attempt to determine distinguishing subgroup characteristics.   Researchers identify and compare two groups over a period of time.  At the start of the study, one of the groups has a particular condition or receives a particular treatment, and the other does not.  At the end of a certain amount of time, researchers compare the two groups to see how they did. 

18. Types of Research Studies
3-Case control study: (answers prognosis, etiology, prevention questions) Case control studies are studies that identifies patients who already have the outcome of interest and control patients without that outcome, and look back to see if they had the exposure of interest or not.  
4-Case series and case reports:  (answers prognosis, etiology, prevention questions) Consist either of collections of reports on the treatment of individual patients, or of reports on a single patient.

19. Search for the Best Study
Type of Question
Best Type of Study to Search For
Therapy
RCT>cohort > case control > case series
Diagnosis
Prospective, blind comparison to a gold standard
Etiology/Harm
RCT > cohort > case control > case series
Prognosis
Cohort study > case control > case series
Prevention
RCT>cohort study > case control > case series
Clinical Exam
Prospective, blind comparison to gold standard
Cost
Economic analysis

20. Acquire the Best Evidence
Online databases are the most important sources for evidence retrieval.
The best method to search for evidence is by using the “4S’ hierarchical structure of Evidence Databases, which consist
Systems; Online resources provide summary reviews of the relevant medical information on specific clinical cases.
Synopses; which are evidence based summaries prepared from original research
Synthesis; Systematic Reviews can be found through the Cochrane Library
Studies; Research published in non-filtered databases

21. “4S’ Hierarchical Structure of the Online Databases to be Searched for EBM

22. EBM Search Protocol Pyramid
Navigating the Maze: Information Mastery: How to lower the work of Your Information Searches: An Overview, Health Sciences Library, University of Virginia

23. Searching Tips, to Recall Relevant Evidence
Search Strategy to build the Inquiry Strings should be implemented.
They include;
Defining appropriate Keywords from the clinical question, Use Medical Subject Headings (MeSH) if required;
Considering Synonyms and related terms;
Selecting the most relevant databases;
Combining keywords with Boolean Operators;
Considering the “Phrase Searching” and Truncations.

24. Boolean Searching Use Boolean Operators to combine search terms.
These are the most common connectors:
“And” : To narrow your search. All terms must appear in results
“OR” : To broaden your search. Either term should appear in results
“Not” : To narrow your search by excluding specific terms.
“Adj” : Search for terms that appear together
Using AND, OR, NOT, and ADJ to create logical search statements is also known as Boolean searching , Boolean Operators.

25. “Evidence Based Medicine” “Point of Care Testing”
Phrase Searching
You can narrow your search by using a “Phrase Search” instead of keywords.
Put your phrase between Quotations (“ “)
Examples
“Evidence Based Medicine”
“Point of Care Testing”
“Physical Therapy”

26. Truncation
To obtain more results and broaden your search, Truncate / Stem the word to its root.
Truncation means shortening a search term by adding a symbol to the root of a word, to retrieve its variant endings
Examples
Search for “child*” retrieves documents for child, children, childhood, childbirth, …etc.
The most used Truncation Symbol is the Asterisk (*)

27. Tips for Smart Searching
Always be as precise as possible when selecting keywords that describe your topic
Check your spelling
Use acronyms if available
(WHO – World Health Organization )
Consider differences between American and British spelling
(Hematology / Haematology – Pediatrics / Paediatrics)

28. Clinical Case
Jeff, a smoker of more than 30 years, has talked about giving up smoking. He has tried unsuccessfully to quit in the past. He has heard through a friend that acupuncture was successful. Should he try it? Other interventions that you know of include nicotine replacement therapy and antidepressants.
Clinical question
In people who smoke is acupuncture compared to nicotine replacement therapy or antidepressants effective treatment for smoking cessation.

29. PICO Population Smoker Intervention Acupuncture
Comparison Nicotine replacement therapy OR antidepressants
Outcome Smoking cessation

32. Question Analysis / PICO Format
Clinical Question
Question Analysis / PICO Format
Patient / Population : Patients with chronic
heart failure
Intervention : Chocolate intake
Comparison : No chocolate intake
Outcome : blood pressure

33. Cochrane Library
Search #1 : "heart failure" or "cardiovascular disease*“ Search #2 : "high blood pressure" or hypertension Search #3 : chocolate or cocoa Search #4 : 1 and 2 and 3

35. Question Analysis / PICO Format
Clinical Question
Is the land-based therapeutic exercise beneficial for people with knee OA in terms of reduced joint pain or improved physical function. ?
Question Analysis / PICO Format
Patient / Population : Adults, Knee Osteoarthritis
Intervention : Land-Based Therapeutic Exercise
Comparison : Drug Therapy
Outcome : Reduce Pain / Improved Physical Function
Search String
knee$ and (osteoarthritis or OA) and (exercise or physiotherapy or "physical therapy") and ("reduc$ pain" or comfort$)

36. Appraise the Evidence
Critical Appraisal is the process of carefully and systematically examining research evidence to judge its trustworthiness, its value and relevance in a particular context.
The purpose of the critical appraisal is to determine whether;
Research evidence is accurate and free of known or unknown bias,
Evidence results are acceptable and provide the answer to the question raised
How confidently can the evidence be applied to the practice

37. Critical Appraisal Process Assess the Validity
Are the results valid?
A crucial question in the critical appraisal process. The recalled / retrieved evidence should be examined for;
Well Built PICO Question
Randomization for selecting participating patients to eliminate Bias
Research study should be blinded, or double-blinded when possible.
Study groups must be treated equally
ensure that patients who started the trial are accounted for until the end.

38. Critical Appraisal Process What are the Results?
What are the Results? Once the validity of the study is ensured, statistical analysis should be performed on the retrieved study results to check the Values .
Each study type, either Therapy or Diagnosis, etc. has its measures to calculate.
The findings / Calculation Results should fall within the range of True Values.

39. Apply on the Patient
Decision should be taken whether to apply the evidence on the patient or not.
Physician should ask the following questions before Applying the evidence;
Is my patient so different from those in the study?
Is the treatment available in my setting OR Is the healthcare system willing to fund it
What are the alternatives available?
What are the side effects of the intervention?
Are the outcomes appropriate to my patient?

58. Cochrane Group Lists

75. New Example
In post-menopausal women, does hormone replacement treatment therapy prevent osteoporosis
Terms
Osteoporosis / Bone Density / Bone Mass
Post-menopaus$ / menopaus$ / women
Hormone Replacement Therapy / HRT
Search String
Osteoporosis and menopaus$ and (“hormone treatment therapy” or hrt)

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