Literature Searching: Asking

Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MemAcadMEd MSc MBBSChairman, Knowledge Translation Committee

Department of Medicine, KAMC,KSA

2

Why Evidence-based Practice? Improves the quality of patient care Standardizes the delivery of healthcare Reduces the expense of healthcare Incorporates patient values into healthcare

decisions

Bridging the Gaps

Knowledge Practice

Resources Expenditure

What is Evidence-based Medicine “ Evidence-based medicine is the integration of:

best available research evidence with clinical expertise and patient values”

Sackett, et al 2001

EBP! The Patient

ClinicalExpertis

e

BestEvidence

4

Evidence: Clinically relevant research, the literature

Expertise: Practitioner’s knowledge& experience

Expectations: Patient’s characteristics, preferences & values

Three Pronged Approach

4

Integrates Evidence With

Clinical expertise

Experience

Judgment

Patient values and preferences

Quality of life

Costs

Other important factors

EVIDENCE-BASED MEDICINE

What is Evidence-based Practice

EBP is about asking questions and searching for answers in the body of medical research, and having found a

likely source of information appraising the

paper for its scientific validity and then

applying the result to your problem.

Evidence-based Practice

Ask clinical Questions

Acquire the best evidence

Appraise the evidence

Applyevidence to your patient

5A’s !!Assess

effectiveness, efficiency of EBM

process

Evidence-based Practice

Ask clinical Questions: PICO

Acquire the best evidence:

Literature Searching

Appraise the evidence:

Critical Appraisal

Applyevidence to your patient:

Knowledge Translation(Implementation)

5A’s !!Assess

effectiveness, efficiency of EBM

process

Self-Education & Training in EBM EBM Resources: 

http://guides.mclibrary.duke.edu/content.php?pid=274373&sid=2262393

http://www.med.yale.edu/library/education/guides/feature/finditfast

 CEBM Website:  http://www.youtube.com/user/cebmed, http://www.cebm.net/index.aspx?o=1965

YouTube: http://www.youtube.com/watch?v=odfo9CQGi0c

Clinical Query: EBM Approach

Ask clinical questions

Acquire the best evidence

Appraise the evidence

Applyevidence to Your patient

5A’s !!Assess

effectiveness, efficiency of

EBM process

EVIDENCE-BASED MEDICINE

Ask clinical question Background /Foreground questions

• Background Question

• Asks for general knowledge about a disorder. Textbooks

are good for answering background questions

• Foreground Question

Asks for specific knowledge about managing patients

with a disorder; consists of three or four components

(PICO): Diagnosis, Therapy, Prognosis etc

Journal articles are good for answering foreground questions.

Ask clinical question

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.

Ask Clinical Questions: PICO

Patient/Population OutcomeIntervention/

Exposure Comparison

Components of Clinical Questions

In patients withacute MI

In post-menopausal

women

In women withsuspected

coronary disease

does early treat-ment with a statin

what is the accuracy of

exercise ECHO

does hormonereplacement

therapy

compared to placebo

compared to exercise

ECG

compared to noHRT

decrease cardio-vascular mortality?

for diagnosingsignificant

CAD?increase the

risk of breast cancer?

Study designs

Descriptive

Observational Intervention

Analytic

cross-sectional case-

controlcohort

prospective

naturalexperiment quasi-

experiment

RCT

retrospective

•Case report• Case series• Survey

Decide on the best type of study design for your question: For each type of question there is a

hierarchy of evidence

Therapy/PreventionWhat should I do about this problem?

RCT>cohort > case control > case series

DiagnosisDoes this person have the problem?

Cross-sectional study with blind comparison to a gold standard

Etiology/HarmWhat causes the problem?

RCT > cohort > case control > case series

Prognosis/PredictionWho will get the problem?

RCT >cohort study > case control > case series

Frequency and RateHow common is the problem?

cohort study > cross-sectional study

NOTE: A well designed systematic review of RCTS (randomized controlled trials) is best as it is least biased therefore more valid.

Finding the Evidence

“Finding Evidence”: Sources

Primary: PubMed, EmBase, Cinahl, Pyschlit Secondary: Systematic Reviews: Cochrane Library, PubMed Guidelines websites: Guidelines Clearinghouse, Guidelines

International Network CATS: BestBets, ACP ournal Club Point of Care: Clinical Evidence, EvidencePlus, UpToDate etc Tertiary resources (meta search engines, databases of

databases): TRIP+ (Translating Research Into Practice), PrimeEvidence

Ask clinical question:

Expanded PICO=PICOT3 P   Population/Patient/

ProblemHow would I describe a group of patient's similar

to mine

 I   Intervention/Indicator

Which main intervention, exposure, prognostic factor am I considering?

 C   Comparator/Control

What is the main alternative to compare with the intervention?

 O   Outcome What can I hope to accomplish, measure, improve, affect?

T   Type of Study Question you are asking

How would I categorize this question? e.g. Diagnostic, Therapeutic etc.

T   Type of Study Design you would want to find

What would be the best study design in order to answer this question? e.g. Randomized Controlled

Study, Cohort study etc.

 T   Time you got How much time you got to answer your question? Point-of Care Resources versus the others!

Example:A 28-year-old male presents with recurrent furunculosis (skin boils) for past 8 months; these episodes have been treated with drainage and several courses of antibiotics but keep recurring. He asks if recurrences can be prevented. To convert this to an answerable question, use the P I C O method as follow:

Question:‘In patients with recurrent furunculosis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate?’

 P   Population/Patient/ Problem  =   patients with

recurrent furunculosis

 I   Intervention/Indicator  =   prophylactic

antibiotics C   Comparator/

Control  =   no treatment

 O   Outcome  =   reduction in recurrence rate of

furunculosis

Expanded PICO=PICOT3 P   Population/Patient/

ProblemHow would I describe a group of patient's similar

to mine: patients with recurrent furunculosis

 I   Intervention/Indicator

Which main intervention, exposure, prognostic factor am I considering? prophylactic

antibiotics C   Comparator/

Control What is the main alternative to compare with the intervention? no treatment

 O   Outcome What can I hope to accomplish, measure, improve, affect? reduction in recurrence rate

of furunculosisT   Type of Question you

are asking How would I categorize this question? Prevention

T   Type of Study you would want to find

What would be the best study design in order to answer this question? Randomized

Controlled Study T   Time you got How much time you got to answer your question?

Point-of Care Resources POCR versus the others! e.g.no time! Check it in POCR e.g.

UpToDate, Dynamed, Cochrane etc.

Example:Mr. X wants to discuss the possibility of a vasectomy. He says he has heard something about vasectomy causing an increase in testicular cancer later in life. You know that the risk of this is low but want to give him a more precise answer. 

 Question:‘In men, does having a vasectomy (compared to not having one) increase the risk of getting testicular cancer in the future?’

 P   Population/patient

 =   adult males

 I   Intervention/indicator

 =   vasectomy

 C   Comparator/control

 =   no vasectomy

 O   Outcome  =   testicular cancer

Expanded PICO=PICOT3 P   Population/Patient/

Problem How would I describe a group of patient's similar to mine: adult males

 I   Intervention/Indicator Which main intervention, exposure, prognostic

factor am I considering? vasectomy

 C   Comparator/Control What is the main alternative to compare with the

intervention? no vasectomy

 O   Outcome What can I hope to accomplish, measure, improve, affect? testicular cancer

T   Type of Question you are asking How would I categorize this question? Harm

T   Type of Study you would want to find

What would be the best study design in order to answer this question? Randomized

Controlled Study or Cohort study  T   Time you got How much time you got to answer your question?

Point-of Care Resources POCR versus the others! e.g.no time! Check it in POCR e.g.

UpToDate, Dynamed, Cochrane etc.