Evidence-based Practice
for HINARI Users
(Module 6)
Table of Contents
• Evidence & EBM definitions
• 5 step EBM process
• HINARI Resources
• Cochrane Library
• Evidence-based Medicine Guidelines
• Essential Evidence Plus
• EBM Journals
• PubMed/Clinical Queries
• PubMed Health
• Other Resources
What is Evidence?
Context-free
Evidence concerns facts
scientific evidence
intended for use to support
(medical
effectiveness or
a conclusion
biomedical research)
• A fact is something known
Evidence
by experience or
Context sensitive
Tacit evidence
scientific evidence
observation
(views and
(putting evidence into
realities of doctors
a particular
• Evidence is used to
and patients)
operational setting)
support a conclusion; it is
not the conclusion itself
Source: Lomas J et al. Conceptualizing and combining evidence for health system
guidance. Canadian Health Services Research Foundation, 2005.
What is EBP?
The integration of best
evidence* from current
research, patient
preferences and values, and
clinical expertise to clinical
questions in a timely
fashion (Sackett, 2000).
Best Evidence
EBP
Patient
Values/Local
Conditions
Clinical
Expertise
*Best available evidence is: consistent research evidence with
high quality and quantity
Why EBP?
• Improve care
• To bridge the gap between research & practice
• “Kill as few patients as possible” (O. London)
• new treatment
• fewer side effects
• cheaper or less invasive
• resistance to existing therapies, etc.
• Keep knowledge and skills current (continuing
education)
• To save time to find the best information
What are some Barriers for EBP?
•
•
•
•
•
•
Time, effort & skills needed
Access to evidence
Overuse, underuse, misuse of evidence
Poor decision making
Environment not supportive of EBP
Intimidation by senior clinicians
How does EBP help?
A patient comes to a clinic with a fresh dog bite. It looks clean
and the nurse and patient wonder if prophylactic antibiotics are
necessary. The nurse searches PubMed and found a meta
analysis indicating that the average infection rate for dog bites
was 14% and that antibiotics halved this risk to 7%.
• For every 100 people with dog bites, treatment with antibiotics will
save 7 from infection
• Treating 14 (NNT) people with dog bites will prevent 1 infection
• You explain these numbers to the patient along with possible
consequences and patient decides not to take antibiotics.
• On a follow up visit you find out that he did not get infected.
Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.
The 5 Step EBP Process
1.
ASK: Formulate an
answerable clinical question
2.
ACCESS: Track down the best
Evidence
3.
APPRAISE: Appraise the
evidence for its validity and
usefulness
4.
APPLY: Integrate the results
with your clinical expertise
and your patient values/local
conditions
5.
ASSESS: Evaluate the
effectiveness of the process
Ask
Assess
Access
Apply
Appraise
Step 1: ASK (questions, PICO)
a focused (answerable) clinical question
Background Questions
• General questions - disorder
–
–
–
–
What is the disorder?
What causes it?
How does it manifest?
Treatment options?
• Information Resources
– books
– narrative reviews
• general overview of a topic
Ask
Foreground Questions
• Specific questions - patient
–
–
–
–
INTERVENTION/PREVENTION
ETIOLOGY, RISK
DIAGNOSIS
PROGNOSIS
• Information Resources
– journal articles
– synopses of articles
– systematic reviews
• answer specific questions
Step 1: ASK
PICO Format
Ask
P = Patient, population or problem (Who are the
patients or populations? What is the disease?)
I = Intervention (What do you want to do with this
patient - treat, diagnose, observe)?
C = Comparison intervention (What is the alternative to
the intervention - placebo, different drug, nothing?)
O = Outcome (What are the relevant outcomes morbidity, mortality, death, complications)?
Why should I use PICO?
•
•
•
define problem - clarify it in your own mind
identify concepts/terms for searching
ask patient centered questions; treatment of
pneumococcal pneumonia SHOULD be
different for
– elderly, severely demented patient
– terminal cancer Patient
– young, mother of 2 children
Example: Intervention Questions
• A 54 year old male patient was diagnosed with
intermediate grade prostate cancer and wants
to know whether to get a radical
prostatectomy or radiation treatment. He is
concerned about death from prostate cancer
and also risks of impotence and incontinence.
• Identify the 4 PICO components
Formulate the Clinical Question
• PICO
P (patient) - 54 year old male with intermediate grade
prostate cancer
I (intervention) - radical prostatectomy
C (comparison intervention) - radiation treatment
O (outcome) - reduce risk of mortality, impotence, and
incontinence
• Focused clinical question
In 54 year old male patients with intermediate grade prostate
cancer, is radical prostatectomy more effective compared to
radiation treatment in reducing the risk of mortality,
impotence, and incontinence?
Etiology and Risk Questions
What causes a disease or health condition?
• The reverse of intervention questions-they deal with
harmful outcomes of an activity or exposure (public
health issues)
• Develop a clinical question for the case:
S. is a smoker and just found out that she is 3
months pregnant. She quit smoking immediately. But
she is worried if her developing baby was harmed
and if the baby is at risk for having developmental
problems. She is asking you if smoking during the
first trimester can harm her baby?
Etiology or Risk Questions
• P-babies of mothers who smoke
I- smoking in first trimester
C-nothing
O-increase risk of developmental problems
• Question: Are babies of mothers who smoke
during their first trimester at an increased risk
of developmental disabilities?
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.
EBP Step 2: ACCESS (studies, hierarchies)
Track Down the Best Evidence
Access
Start “hunting” from the best resource:
match your question to the best medical
information resource for this question.
Hierarchy of Evidence
Research Studies
synthesis
experimental
observational
EBP Step 3: Appraise (validity, impact)
Appraise
• Appraisal principles (primary and secondary research)
– Does PICO of the study match my PICO question?
– validity
• internal validity – methods
–How well was the study done? Is it biased?
• external validity
–generalizability
– impact
• Does it matter to your patient?
•
•
University of Oxford’s Center of EBM: http://www.cebm.net/index.aspx?o=1157
Evaluating the Evidence section in the EBM tutorial at:
http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm
EBP Step 4: APPLY (patient, setting)
Integrate the results with your clinical
expertise and your patient values
Apply
• Patient
• Is my patient similar enough that the results of
the study apply?
• Will the potential benefits outweigh the
potential harms of treatment ?
• What does my patient think? What are his
cultural beliefs?
– Setting
• Is the intervention feasible in my settings?
• What alternatives are available?
EBP Step 5: ASSESS (patient, yourself)
Evaluate the effectiveness of the process.
Assess
• Am I asking questions?
• Am I writing down my information needs?
• How is my searching going? Am I becoming more
efficient?
• What is my success rate in the EBM steps?
• Am I periodically syncing (checking) my skills and
knowledge with new developments?
• Teach others EBP skills
• Keep a record of your questions
HINARI Resources
• Cochrane Library – filtered
• PubMed – unfiltered
• Clinical Queries
• Filters
• PubMed Health
• HINARI EBM Journals
Cochrane Database of Systematic Reviews
The Cochrane Library (John Wiley)
• high-quality, filtered, critically appraised
Systematic Reviews from all over the world
• minimum bias: evidence is included/excluded
on the basis of explicit quality criteria
• abstracts searchable for free on the Internet;
complete database is available via HINARI
From the Reference Sources menu, we now will
click on the Cochrane Library link. The Cochrane
Library contains high-quality, independent
evidence including reliable evidence from
Cochrane and other systematic reviews and
clinical trials. It is published by John Wiley.
The initial page of this site has a
title, abstract or keyword option
Search engine. You also have
various options to Browse by Topic
and Browse by Review Group
Open the Advanced Search.
We have opened the Advanced Search option and
will complete a search diarrhea child* using the
Title, Abstract, Keywords option with the wildcard
(*) used to locate the terms child and children.
Note the Medical Terms (MeSH) optionSearch
Manager – to view search history.
The Advanced Search for diarrhea child* Title,
Abstracts and Keyword has retrieved 95 records
that are Cochrane Reviews Reviews plus Other
Reviews, Methods Studies and other options for
a total of 2250 results.
You have the option to Export All Results (save).
The Advanced Search for diarrhea
child* Title, Search All Text has
retrieved 882 records that are
Cochrane Reviews, a significantly
higher number.
The screen displays the Abstract of
the first systematic review listed in the
search - Probiotics for treating acute
infectious diarrhoea. Note the options
for View Full Article (HTML),
Summary (PDF) and Full (PDF).
Displayed is the Abstract of the systematic
review that includes the Background,
Objectives, Search methods, Selection
criteria, Data collection and analysis, Main
Results and Authors conclusions.
The final section of the Abstract is titled Plain
language summary. This section is useful for
disseminating the results to groups of health
workers and patients.
Also note the Resume in French.
Now displayed is the PDF Full version of the
Probiotics for treating acute infections
diarrhoea systematic review. Other options
include Summary and Standard files.
From the Cochrane Library initial
page, we have clicked on the
Browse by Topic hyperlink.. From this
extensive list, you have another
option for locating subject- specific
material. Note the links to a list of
Cochrane Reviews and also Trials.
From the Reference Sources list, we have
opened the initial page of EBM Guidelines
Evidence-Based Medicine. Also published by
John Wiley, this resource is a collection of
clinical guidelines for primary care combined
with evidence-based research.
You can Search by keyword or Browse
database contents by EBM Guidelines,
Evidence summaries, Pictures, Audio samples,
Videos and Programs.
We have completed a keyword search for Influenza. The
results page includes summaries of the key issues
including Related resources and References and links to
important websites. PRIMARY and SECONDARY HITS
Also included are links to the Evidence summaries.
We have displayed the 2nd Evidence
summary. Each link contains a brief review
of the study and notes the reference(s).
From the Reference Sources list, we
have opened the initial page of Essential
Evidence Plus. Also published by John
Wiley, it includes access to Cochrane
Library and also a series of databases
and tools to access the EBM material.
By keyword, you can Search all or some
of the databases.
We have opened the EBMG
evidence summaries database
that, via broad subject categories,
has access to 4440 articles.
We have opened the initial page of
EBMG evidence summaries listing
for Infectious disease. Material is
listed by either a summary view or
expanded view that includes a
sentence describing each entry.
We have opened
Decision Support Tools
that has 406 tools and
calculators that assist in
clinical decision making.
HINARI Evidence-Based Journals
(other journals may have EBM articles)
We have browsed the ‘E’ in the HINARI Find journals by title
list and it notes several journals for evidence-based practice.