1. Internet Resources for Evidence-Based Practice Ben Skinner KnowledgeShare

2. Individual Clinical Expertise Best External Evidence Patients’ Values & Expectations Evidence- Based Practice

3. Essentials of evidence-based searching Understanding of Well structured clinical question Appraised / Non-appraised resources Reviews Guidelines Digests Hierarchy of evidence Critical appraisal

4. Clinical questions Patient / Population: Includes demographics and condition / disease Intervention / Indicator: Which intervention, treatment or approach should be used? Comparison: What is the main alternative to compare with the intervention? Outcome: What are the important outcomes for the patient?

5. Example of PICO Patients:In a middle-aged man with high blood-pressure… Intervention: … does supplementing the diet with fish oil… Comparison: … in comparison with doing nothing… Outcome: … reduce the risk of cardiovascular disease?

6. 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

7. The problems of peer review Fails to identify flawed literature reviews Fails to detect statistical problems and bias Open to abuse by rival researchers Positive publication bias may overestimate the benefits of treatments by up to 1/3

8. Clinical guidelines Be critical Well structured questions Transparent methodology Multidisciplinary groups Evidence and recommendation grading Open peer review process Easy to navigate

9. 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)

10. 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. “myocardial infarction” You can use brackets and logical operators E.g. (“myocardial infarction” OR MI) AND thrombolysis You can truncate words with the * symbol E.g. thrombo* would find thrombolytic, thrombolysis etc Basic search techniques

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

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

13. 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

14. 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…

15. Cochrane – What is it good for? What research has been carried out on self-esteem among doctors working in psychiatric community hospitals? Is health education effective in improving compliance with HRT? How useful is Prostate Specific Antigen for detecting cancer of the prostate? Are there any studies on incidence and prevalence of irritable bowel syndrome?    

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

17. Gathers good quality evidence on healthcare interventions Presents a digested summary of the evidence Online edition updated and expanded monthly Browse the sections or the A-Z topic list to find the disease or condition before using the search feature Pre-appraised resources Clinical Evidence - http://www.clinicalevidence.comhttp://www.clinicalevidence.com

18. 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

19. Pre-appraised resources Bandolier - www.jr2.ox.ac.uk/bandolier/index.htmlwww.jr2.ox.ac.uk/bandolier/index.html Identifies a handful of studies that answer a question, and reports on their quality More of a primary care focus – unusual questions posed by clinicians Light-hearted tone - easy to read and digest

20. Searching across multiple resources National Library for Health: www.library.nhs.uk www.library.nhs.uk Google: www.google.co.ukwww.google.co.uk Google Scholar: http://scholar.google.com http://scholar.google.com

21. National Library for Health http://www.library.nhs.uk http://www.library.nhs.uk

22. 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. Google Scholar restricts to academic resources but it is better to use medical databases epilepsy lorazepam site:nhs.uk

23. Primary research databases Dialog: http://nhs.dialog.comhttp://nhs.dialog.com Requires an ATHENS password Direct access to full text articles where available NOTE: Dialog gives access to Medline, CINAHL, Embase, PsycInfo and more…

24. Remember… Evidence-based medicine is not about finding a study that looks like it might be useful… … it is about making sure you haven’t missed another study that might be better. If you do go to the primary literature you should initially choose articles based on study design

25. Hierarchy of evidence (for studies of therapy) Systematic Reviews Randomised Control Trials Cohort Studies Case-Control Studies Cross Sectional Surveys Case StudiesSTRONG WEAK

26. Critical appraisal Not just title, author and journal dependant! A tiny percentage of studies are methodologically sound and clinically relevant Need the skills to evaluate what you read Different criteria for all types of research www.phru.nhs.uk/casp/casp.htm www.agreecollaboration.org (for guidelines) www.agreecollaboration.org Training available from the Library Services