Embase - supporting Evidence Based

Medicine

Your host: Ann-Marie Roche Your presenter: Ian Crowlesmith

Welcome to our Embase webinar!

Registering in Embase

2

• Medicine without evidence• EBM: what it is and what it isn’t• Using EBM in practice: PICO (with case study)• EBM in Embase - working with Cochrane

- unique content in Embase (RCTs)

- check tags and publication types

• EBM: finding clinical evidence (with case studies)• Other approaches - practice guidelines

- comparative effectiveness- systematic reviews

Agenda

4

Johns Hopkins’ Tragedy: Could Librarians Have Prevented a Death?

Source: http://newsbreaks.infotoday.com/nbreader.asp?ArticleID=17534

Medicine without evidence

David L. Sackett, William M.C. Rosenberg, J.A. Muir Gray, R. Brian Haynes & W. Scott Richardson

David L. Sackett et al.

The practice of evidence based medicine means integrating individual clinical expertise with the best available external evidence from systematic research.

…

By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

EBM worldwide

Levels of evidence

Source: Robin Harbour & Juliet Miller (SIGN), BMJ 2001;323:334.1

Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness has not been proved with randomised controlled trials

Source: Gordon Smith & Jill Pell, BMJ 2003;327:1459

Ref: Nursetopia.netOxford Centre for Evidence-based Medicine - Levels of Evidence (Mar 2009)

Formulate a clinical question

Use EBM to systematically look for relevant evidence

Evaluate the evidence and integrate with clinical expertise

Apply the results to the patient

Information specialist

Clinician

Using EBM in practice

P = Patient

I = Intervention

C = Comparison / Control

O = Outcome

Using EBM to systematically look for relevant evidence

Case study

Imagine yourself as a medical intern or librarian who has been asked to advise a senior clinician about any risks that might be associated with the treatment of a patient under his care.

http://www.youtube.com/watch?v=QzZbYMS1tQ4

(Source: see http://www.embase.com/info)

Clinical question

Are there any risks associated with the administration of antibiotics together with digoxin in a patient with congestive heart failure who has contracted pneumonia?

One possible solution is in this paper ...

Using PICO in Embase

P = patient with congestive heart failure and pneumonia

I = digoxin and antibiotics

C = clinical trials or other levels of evidence?

O = risks (e.g. interactions or side effects)

Searching for subheadings

EBM: the Embase advantageExtensive coverage: > 7,500 journals

> 800,000 conference abstractsIndexed AiPs + In-process recordsWorldwide coverage (languages)

Over 65 years: 25m records, 1947 – 2012All MEDLINE records(Embase Classic abstracts)

In depth indexing: > 30,000 drugs> 1,500 device terms (2012)

EBM terminology: RCTs, CCTs, DTA studiesComparative effectivenessSystematic reviews

Collaboration with Cochrane

Year Embase enhancement1993 Randomized controlled trial added to Emtree

1997 UK Cochrane Centre project to identify RCTs in Embase

• 100,000 RCTs & CCTs from 1980 identified and updated in both Embase & the Cochrane database (CENTRAL)

• Unique Embase coverage of non-English RCTs vs MEDLINE 2004 Systematic Review added to Emtree2007 Controlled Clinical Trial added to Emtree2011 Topic terms differentiated from study types for RCTs and 9

other terms in Emtree

1993- present

• ‘Embase is a rich source of reports of randomized trials that are either not included in MEDLINE or not indexed as trials in MEDLINE, especially reports in some languages other than English’.

• ‘In addition to searching CENTRAL, people looking for reports of randomized trials should search Embase, as well as MEDLINE, for reports published in recent years that have not yet been considered for inclusion in CENTRAL’.

Carol Lefebvre MLA 2010

Unique content in Embase

Ref: Lefebvre et al. Emerging Themes in Epidemiology 2008 5:13

1) All data from 2005

PubMed 1) Embase ‘unique’ 1)

Chinese 257 320Dutch 3 13Italian 11 15Persian (Farsi) 0 6Turkish 12 50

Carol Lefebvre MLA 2010

Randomized trials in Embase

Ref: Lefebvre et al. Emerging Themes in Epidemiology 2008 5:13

Randomized trials in EmbaseUpdate 2011 – 2012 data

Language Embase PubMed Embase PubMed Embase PubMed

German 95 56 28 19 9152 6267

French 41 22 26 12 4525 2780

Italian 19 11 7 5 1973 1341

Turkish 58 8 36 - 756 84

Chinese 550 364 167 86 7381 5057

Year 2011 2012 All years

Example searches: Embase: ‘randomized controlled trial’/de AND french:la PubMed: "randomized controlled trial"[Publication Type] AND french[language]

Search date: 22 October 2012

Publication types and topics

• 10 EBM-related “topic terms” in Emtree

• Introduced in 2011

Check tags for EBM in Embase

Check tag Year Scope noteSystematic review

2004 Used for studies that systematically summarize all relevant evidence pertaining to a defined health question, and including items identified as such by the author

Meta analysis

1987 Used for original reports evaluating medical interventions by the statistical analysis of a large collection of analysis results from individual studies, for the purpose of integrating the findings; not limited to clinical trials

Clinical trial 1974 Used for original reports of prospective clinical studies in which the (comparative) efficacy of one or more medical interventions in humans is evaluated; also used for prospective clinical veterinary trials in which the (comparative) efficacy of one or more medical interventions in animals is evaluated

Human 1974 Used for all items where humans are a feature, including studies on human tissue, cells or cell components

Sources: Emtree browser in Embase.comEmbase Indexing Guide 2012 (via Embase.com/info)

EBM terms in Embase / Emtree

• via Advanced Limits in Advanced Search

• via Emtree

2004 2005 2006 2007 2008 2009 2010 2011 20120

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000PubMed

Embase

Systematic reviews

Search strategies: PubMed: systematic[sb]Embase: [systematic review]/lim

0

5000

10000

15000

20000

Systematic reviews

Search strategy decoded: Embasesystematic review/de

(see check tag list for scope note)

Search strategy decoded: PubMed(systematic review [ti] OR meta-analysis [pt] OR meta-analysis [ti] OR systematic literature review [ti] OR (systematic review [tiab] AND review [pt]) OR consensus development conference [pt] OR practice guideline [pt] OR cochrane database syst rev [ta] OR acp journal club [ta] OR health technol assess [ta] OR evid rep technol assess summ [ta]) OR ((evidence based[ti] OR evidence-based medicine [mh] OR best practice* [ti] OR evidence synthesis [tiab]) AND (review [pt] OR diseases category[mh] OR behavior and behavior mechanisms [mh] OR therapeutics [mh] OR evaluation studies[pt] OR validation studies[pt] OR guideline [pt])) OR ((systematic [tw] OR systematically [tw] OR critical [tiab] OR (study selection [tw]) OR (predetermined [tw] OR inclusion [tw] AND criteri* [tw]) OR exclusion criteri* [tw] OR main outcome measures [tw] OR standard of care [tw] OR standards of care [tw]) AND (survey [tiab] OR surveys [tiab] OR overview* [tw] OR review [tiab] OR reviews [tiab] OR search* [tw] OR handsearch [tw] OR analysis [tiab] OR critique [tiab] OR appraisal [tw] OR (reduction [tw]AND (risk [mh] OR risk [tw]) AND (death OR recurrence))) AND (literature [tiab] OR articles [tiab] OR publications [tiab] OR publication [tiab] OR bibliography [tiab] OR bibliographies [tiab] OR published [tiab] OR unpublished [tw] OR citation [tw] OR citations [tw] OR database [tiab] OR internet [tiab] OR textbooks [tiab] OR references [tw] OR scales [tw] OR papers [tw] OR datasets [tw] OR trials [tiab] OR meta-analy* [tw] OR (clinical [tiab] AND studies [tiab]) OR treatment outcome [mh] OR treatment outcome [tw])) NOT (letter [pt] OR newspaper article [pt] OR comment [pt])

David L. Sackett et al.

The practice of evidence based medicine means integrating individual clinical expertise with the best available external evidence from systematic research.…

By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

EBM: finding clinical evidence (1)Diagnosis

• Diagnosis : disease subheading‘celiac disease’/dm_di

• Diagnostic test accuracy study (2011)Used for original studies or systematic reviews which assess how accurately a test distinguishes humans or animals having a condition or disease from those who do not. Typically, the test under evaluation is called the index test and its results are compared to the results of the best available standard test (reference standard), which defines the condition or disease

Case study: devices used in DTA studies for celiac disease

Searching for DTA studies

EBM: finding clinical evidence (2)Prognosis

• Prognosis as Emtree term

• Filters based on HIRU hedges (McMaster Univ.) *

Max. specificity: prognos* OR survivalBest balance: prognos* OR epidemiology:lnk OR follow-up

Case study: prognosis for Parkinson’s disease* Ref: http://hiru.mcmaster.ca/hiru/HIRU_Hedges_EMBASE_Strategies.aspx

Searching for prognoses

EBM: finding clinical evidence (3)Therapy• Drug subheading : drug therapy• Disease subheadings : drug therapy

radiotherapytherapysurgery

Safety• Drug subheadings : adverse drug reaction

drug interaction• Disease subheadings : side effect

complication

Case study: complications arising following deep brain stimulation for Parkinson’s disease

Searching for complications

Article on complications

EBM: finding clinical evidence (4)Rehabilitation

• Disease subheading: rehabilitation‘parkinson disease’/mj/dm_rh 529 results

Prevention

• Disease subheading: prevention1. ‘myocardial infarction’/mj/dm_pc4,359 results

2. aspirin/de 147,770 results

3. #1 AND #2 1,113 results

EBM: levels of evidence

systematic review meta-analysis

case report case control study cohort analysis case study randomized controlled study editorial

EBM: finding guidelines

Emtree.. . . . . . . . .

Searching for guidelines

Articles on guidelines

EBM: other approaches

Comparative Effectiveness Research (CER)

• Emtree term: comparative effectivenessAdded in 2010; approx. 2000 results/year from 2011

Cochrane Database of Systematic Reviews

• Advanced limit: [cochrane review]/limOver 11,000 reviews included in Embase since 2000

Embase - supporting Evidence Based Medicine

Summary

• A Q&A will be sent by email.• For more information and questions please contact

bdtraining@elsevier.com• Our next Embase webinar is scheduled for Oct 25th,

looking at drug safety and we will go deep into indexing and Nov 21st.

• Go to http://www.embase.com/info/embase-webinars for all Embase webinars and archives.

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