1. Evidence Based Resources in Miner Library Online Psychiatry Residents 2007Marilyn_Rosen@urmc.rochester.edu

3. What is EBM? The judicious and systematic use of the best current evidence in making decisions about the care of the individual patient. EBM is meant to integrate clinical expertise with the best available research evidence, and with patient values.

4. EBM Your Clinical Expertise Patient’s Values & Expectations Best Available Research Evidence

5. The Five Steps of EBM 1. Convert information needs into answerable questions 2. Find in the medical literature the best evidence with which to answer them 3. Critically appraise that evidence for its validity and usefulness 4. Apply the results of this appraisal in your practice 5. Evaluate your performance

6. PICO Method P = Patient or Problem I = Intervention or Exposure C = Comparative Intervention or Exposure O = Outcome

7. Types of Clinical Questions Diagnosis (What medical condition or disease does the patient have?) Diagnosis (What medical condition or disease does the patient have?) Etiology/Harm (What causes the condition: what increases or decreases the risk for the disease or condition?) Etiology/Harm (What causes the condition: what increases or decreases the risk for the disease or condition?) Prognosis (What are possible outcomes of the disease & the probability with which they can be expected to occur?) Prognosis (What are possible outcomes of the disease & the probability with which they can be expected to occur?) Therapy (How effective or risky is treatment of the disease or condition?) Therapy (How effective or risky is treatment of the disease or condition?)

8. Clinical Question: Are SSRIs or Tricyclic antidepressants more effective in treating patients with depression?

9. P: patients with depression I: SSRI’s C:Tricyclic antidepressants O: alleviate depression search concepts: patients with depression,SSRIs, Tricyclics type of question: therapy

10. Tools to help find valid answers to specific clinical questions Ideally, contain structured collections of clinical evidence Ideally, contain structured collections of clinical evidence The “perfect” system would integrate and concisely summarize all evidence about a clinical problem and automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information. The “perfect” system would integrate and concisely summarize all evidence about a clinical problem and automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information. Clinician and patient could always have the benefit of current best evidence. Clinician and patient could always have the benefit of current best evidence.

11. Hershey Kisses Fannie Farmer Sampler Nestle’s Quik Godiva Truffles Stever’s chocolates ( Park Ave., Rochester ) Ghirardelli Chocolate Bars D ecadence Levels of … Chocolate

12. Studies Syntheses Synopses Summaries Systems Computerized decision support EB topic reviews, Practice guidelines Appraisals of single study or systematic review Systematic reviews Original studies 5 S’s of Evidence Based Medicine (Levels of Evidence) (Haynes. ACP Journal Club. 2006:145(3), A-8-A-9) One aspect of management, or one inter- vention Full range of evidence for a given condition

13. Organizational Model for EBM Resources [Zynx Health, Clin-eguide] Clinical Evidence, UpToDate, PIER, Nat’l Guidelines,APA Guidelines,NELMH ACP Journal Club, InfoPOEMS CochranePubMed,Medline,PsycINFO Studies Syntheses Synopses Summaries Systems One aspect of management, or one intervention Full range of evidence for a given condition

14. Organizational Model for EBM Resources [Zynx Health, Clin-eguide] Clinical Evidence, UpToDate, PIER, Nat’l Guidelines ACP Journal Club, InfoPOEMS Cochrane PubMed, PsycINFO, Medline Studies Syntheses Synopses Summaries Systems

15. Systems: Computerized Decision Support Not widely used. Are often homegrown or “in-process.” Not widely used. Are often homegrown or “in-process.” Some vendors are working to develop knowledge-based sources that can be integrated with the medical record. Still some question about just how well they integrate Some vendors are working to develop knowledge-based sources that can be integrated with the medical record. Still some question about just how well they integrate –Zynx Health Zynx HealthZynx Health –Problem-Knowledge Couplers –First Consult; iConsult –Clin-eguide

16. Organizational Model for EBM Resources [Zynx Health, Clin-eguide] Clinical Evidence, UpToDate, PIER, Nat’l Guidelines, APA Guidelines, NELMH ACP Journal Club, InfoPOEMS Cochrane PubMed,PsycINFO, Medline Studies Syntheses Synopses Summaries Systems

17. Summaries: Evidence-Based Textbooks Concise, easily digestible, and covering the range of evidence available on a given condition Concise, easily digestible, and covering the range of evidence available on a given condition “Exactly enough information to support a clinical action” “Exactly enough information to support a clinical action”Examples: Clinical Evidence Clinical Evidence UpToDate (not yet entirely evidence-based) UpToDate (not yet entirely evidence-based) PIER PIER Clinical Guidelines Clinical Guidelines

18. Clinical Evidence Clinical Evidence summarizes the current state of evidence covering the benefits and harms of common preventative or therapeutic interventions with an emphasis on the outcomes that matter to patients. Contributors look for good systematic reviews and RCTs. Sometimes they will use observational studies, if that is all that is available, and they will tell you if there is no good evidence.

19. http://bmjupdates.mcmaster.ca/index.asp

20. PIER Peer-reviewed, evidence-based tool (all recommendations have evidence ratings) Peer-reviewed, evidence-based tool (all recommendations have evidence ratings) Designed as clinician’s manual of standards of care Designed as clinician’s manual of standards of care From American College of Physicians From American College of Physicians Reviews cover diseases, screening, prevention, alternative and complementary medicine, procedures, etc. Reviews cover diseases, screening, prevention, alternative and complementary medicine, procedures, etc.

21. Guidelines National Guideline Clearinghouse – a collection of evidence-based clinical practice guidelines sponsored by the Agency for Healthcare Research and Quality, the AMA, and the American Association of Health Plans. http://www.guideline.govNational Guideline Clearinghouse – a collection of evidence-based clinical practice guidelines sponsored by the Agency for Healthcare Research and Quality, the AMA, and the American Association of Health Plans. http://www.guideline.gov http://www.guideline.gov PsychiatryOnline – APA GuidelinesPsychiatryOnline – APA Guidelines

22. http://www.library.nhs.uk/mentalhealth/

23. Organizational Model for EBM Resources [Zynx Health, Clin-eguide] Clinical Evidence, UpToDate, PIER, Nat’l Guidelines, APA Guidelines, NELMH ACP Journal Club, InfoPOEMS Cochrane PubMed, PsycINFO, Medline Studies Syntheses Synopses Summaries Systems

24. Synopses: of individual studies and reviews Abstract and commentary of clinical trial, research study, or systematic review Abstract and commentary of clinical trial, research study, or systematic review Short, concise, but very specific Short, concise, but very specificExamples: ACP Journal Club ACP Journal Club InfoPOEMS InfoPOEMS

25. ACP Journal Club Structured abstracts and commentary on recently published, methodologically sound, and clinically relevant research.

27. Organizational Model for EBM Resources [Zynx Health, Clin-eguide] Clinical Evidence, UpToDate, PIER, Nat’l Guidelines,APA Guidelines, NELMH ACP Journal Club, InfoPOEMS Cochrane PubMed, PsycINFO, Medline Studies Syntheses Synopses Summaries Systems

28. Syntheses: Systematic Reviews Cochrane Database of Systematic Reviews Cochrane Database of Systematic Reviews –“Gold standard” of systematic reviews –Explicit procedures for retrieval, selection, analysis of evidence The Database of Abstracts of Reviews of Effectiveness (DARE) The Database of Abstracts of Reviews of Effectiveness (DARE) - Essentially, DARE contains all the systematic reviews found outside of Cochrane - Essentially, DARE contains all the systematic reviews found outside of Cochrane

30. Search Tips Your terms are NOT mapped to Medical Subject Headings, so: Use truncation ($): cancer$ for cancer, cancers, etc. Use truncation ($): cancer$ for cancer, cancers, etc. Use synonyms: tumor$ or cancer$ or neoplasm$ Use synonyms: tumor$ or cancer$ or neoplasm$ Limit search to SEARCH FIELDS of title, abstract Limit search to SEARCH FIELDS of title, abstract Full text : Ovid PDFs for Cochrane Ovid PDFs for Cochrane Article review for DARE & ACP Journal Club (full text of the review, not the article) Article review for DARE & ACP Journal Club (full text of the review, not the article)Cochrane: “Protocols” describes unfinished reviews (you can limit your search to Systematic Reviews to avoid protocols) “Protocols” describes unfinished reviews (you can limit your search to Systematic Reviews to avoid protocols)

31. [Zynx Health, Clin-eguide] Clinical Evidence, UpToDate, PIER, Nat’l Guidelines, APA Guidelines, NELMH ACP Journal Club, InfoPOEMS Cochrane, other Systematic Reviews PubMed, PsycINFO, Medline Studies Syntheses Synopses Summaries Systems Organizational Model for EBM Resources

32. Limit : clinical queries or publication types

33. PsycINFO – Limit to clinical queries

34. Medline & PsycINFO Tips: Click on “more Limits”, and then use Clinical Queries to find clinically sound studies. Click on “more Limits”, and then use Clinical Queries to find clinically sound studies. “..pg” allows you to delete search statements “..pg” allows you to delete search statements “*” restrict to focus “*” restrict to focus “$”- truncation or wildcard “$”- truncation or wildcard “More Limits” – publication types can limit to better evidence in Medline: clinical trials (check off all phases), practice guideline, reviews, meta-analysis, multi-center study, RCT, validation studies, evualation studies. “More Limits” – publication types can limit to better evidence in Medline: clinical trials (check off all phases), practice guideline, reviews, meta-analysis, multi-center study, RCT, validation studies, evualation studies. Search: 3050533.ui. Search: 3050533.ui. PsycINFO matching terms are different from MESH headings. PsycINFO matching terms are different from MESH headings.

35. PubMed Search

36. PubMed - Tips Left sidebar,under Clinical Queries - search by clinical studies or for systematic reviews Left sidebar,under Clinical Queries - search by clinical studies or for systematic reviews Limit to publication types: Clinical trials, Meta-analysis, Practice guidelines, Evaluation Studies, Review, Validation studies Limit to publication types: Clinical trials, Meta-analysis, Practice guidelines, Evaluation Studies, Review, Validation studies Left sidebar, MESH database Left sidebar, MESH database “History” shows your search statements “History” shows your search statements “Details” shows terms searched when you enter words in search box. “Details” shows terms searched when you enter words in search box.

38. Limitations of the Resources and Model Higher on the pyramid, scarcer the resources become Higher on the pyramid, scarcer the resources become Number of EB summary publications is growing, but number of disease conditions covered by any of them is only in the hundreds Number of EB summary publications is growing, but number of disease conditions covered by any of them is only in the hundreds Synopses take months after publication to be written and published Synopses take months after publication to be written and published

39. Word of Caution Be aware – make sure the publisher of an EBM resource is using sound methods when developing “evidence-based” information tools Be aware – make sure the publisher of an EBM resource is using sound methods when developing “evidence-based” information tools Summaries Summaries –Include details of retrieval, appraisal process, currency, references Synopses Synopses –Defined procedures for retrieving and appraising –Include quantitative evidence