Evidence-based Practice
Resources for HINARI Users
(Module 7.2)
Evidence-based Practice Resources
for HINARI Users
Instructions - This part of the:
course is a PowerPoint demonstration
intended to introduce you to Evidence-based
Practice and related HINARI resources.
module is off-line and is intended as an
information resource for reference use.
Table of Contents
• Evidence-based Medicine (EBM) definition,
background and resources
• Clinical Evidence
• Cochrane Library
• EBM Guidelines
• BMJ Practice
• HINARI EBM Journals
• Searching for EBM articles in HINARI/PubMed’s
Clinical Queries and Limits
• Other Resources
• Summary
Evidence-based Practice (EBP) Definition
"Evidence-Based Practice requires that
decisions about health care are based on
the best available, current, valid and
relevant evidence. These decisions should
be made by those receiving care, informed
by the tacit and explicit knowledge of
those providing care, within the context of
available resources."
Sicily statement on evidence-based practice. BMC
Medical Education, 2005 Jan 5;5(1):1
What is EBP?
• The integration of best
evidence* from
current research,
patient preferences
and values, and clinical
expertise to clinical
questions (Sackett,
2000) in a timely
fashion.
Best Evidence
EBP
Patient
Values/Local
Conditions
Clinical
Expertise
*Best available evidence is: consistent research evidence with
high quality and quantity
Why EBP?
• To improve care
– To bridge the gap between research & practice
– “Kill as few patients as possible” (O. London)
– A new treatment might have fewer side effects.
– A new treatment could be cheaper or less invasive
– A new treatment may be necessary in case people
develop resistance to existing therapies, etc.
• To keep knowledge and skills current (continuing
education)
• To save time to find the best information
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.
What are some Barriers for EBP?
•
•
•
•
•
•
Overuse, underuse, misuse of evidence
Time, effort, & skill needed
Access to evidence
Intimidation by senior clinicians
Environment not supportive of EBP
Poor decision making
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
a focused (answerable) clinical question
Ask
• Background questions (What do I know about this?)
• Foreground (Clinical) Questions
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
(e.g. treat, diagnose, observe)?
C = Comparison intervention (What is the alternative to the
intervention (e.g. placebo, different drug, nothing?)
O = Outcome (What are the relevant outcomes (e.g.
morbidity, mortality, death, complications)?
Why should I use PICO?
•
•
•
To help define problem in clarify it in your own mind
To prepare for searching
To ask patient centered questions. Treatment of
Pneumococcal Pneumonia SHOULD be different for
– Terminal Cancer Patient
– Elderly, Severely Demented Patient
– Young, mother of 2 children
• Developing the question requires:
– Some background knowledge of the condition
– Understanding of the patient and what are the outcomes
and beliefs that matter to this patient
• Death? Disability? Quality of life? Cost? Improvement
of symptoms?
Example: Intervention Questions
• Identify background questions, create a PICO
and a focused clinical question for this case:
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.
Formulate the Clinical Question
• PICO
P - 54 year old male with intermediate grade prostate cancer
I - radical prostatectomy
C- radiation treatment
O- 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?
EBP Step 1a:
Classify the type of the question
• What is the treatment?
Question of INTERVENTION/PREVENTION
• What causes the problem?
Question of ETIOLOGY, RISK
• Does this person have the problem?
Question of DIAGNOSIS
• Who (and how likely) will get the problem?
Question of PROGNOSIS
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?
Diagnosis Questions
• These questions are concerned with how accurate a
diagnostic test is in various groups and in comparison
to other tests or usually to a “gold standard test”.
As part of your clinic assessment of elderly patients,
there is a hearing check. You think that a simple
whispered voice test is very accurate compared to
other methods. You want to do a literature search.
What is your question? (1)
Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.
Example
• P-elderly people
I-whispered voice test
C-no test (or other tests)
O-accurate diagnosis of hearing problems
• Question: In elderly people, does the
whispered voice compared to other tests give
an accurate diagnosis of hearing problems?
Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.
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 Step1b:
Decide on the best type of study for question
For each type of question there is a hierarchy of evidence
Therapy/Prevention
RCT>cohort > case control > case series
What should I do about this
problem?
Diagnosis
Does this person have the
problem?
Etiology/Harm
cross-sectional study with blind comparison
to a gold standard
RCT > cohort > case control > case series
What causes the problem?
Prognosis/Prediction
Who will get the problem?
RCT >cohort study > case control > case
series
Frequency and Rate
cohort study > cross-sectional study
How common is the problem?
NOTE: A well designed systematic review of RCTS (randomized
controlled trials) is best as it is least biased therefore more valid.
Hierarchy of Study Designs for Intervention
Least
• Randomized Controlled Trial
Experimental
• Cohort Studies
Observational
• Case-Controlled Studies
Observational
• Case reports/Clinical Observations
Observational
Bias
Most
Bias
To recognize the type of study ask the questions:
1. Is intervention randomly assigned? Yes-RCT; No-Observational study
2. When were the outcomes determined?
• After the exposure-cohort study (prospective study)
• During the exposure-cross-sectional study
• Before the exposure-case-control study (retrospective study based on recall)
EBP Step 2: ACCESS
Track Down the Best Evidence
Access
1. Start “hunting” from the best resource: Match your question
to the best medical information resource for this question.
•
Well designed Systematic Reviews¹ can be a great place
to start they contain commentary about validity
¹A systematic review involves the application of scientific
strategies, in ways that limit bias, to the assembly, critical
appraisal, and synthesis of all relevant studies that
address a specific clinical question.
Cook DJ, Mulrow CD, Haynes RB. Annals of Internal
Medicine March 1, 1997; 126 (5) 376.
Track Down
Hierarchy of Evidence- Access evidence at
the level that will give you the best evidence
Filtered & Critically Appraised
Expert Opinion and Not Filtered
Background info.
Most clinically relevant (at the top) Least clinically relevant (at the bottom)
Why not get info only from
textbooks and review articles?
• Texts and review articles?
– Dated – perhaps by several years
– Often biased
• Author chooses article that he/she agrees with (or has
written)
• Author chooses articles of his/her friends
• Author does not identify all the relevant literature
• Review’s methods are not explained
• These resources help with background knowledge
(learn about disease) not foreground (answer the
specific clinical question for this patient)
Why not get info only from
guidelines?
• They can assure standards of care but:
– Can be biased
– May not always be developed by experienced
experts
– Are not always evidence-based
– Can work for most patients but not for all
– Can work in some circumstances but not in all
– Can be dated
– There may not be guidelines for everything
Filtered and Critically Appraised
Evidence-Based Resources
• The Cochrane Library by The Cochrane Collaboration
via Wiley
– Independent non-for-profit international collaboration
– Reviews are among the studies of highest scientific evidence
– Minimum Bias: Evidence is included/excluded on the basis of
explicit quality criteria
– Reviews involve exhaustive searches for all RCT, both
published and unpublished, on a particular topic
– Abstracts searchable for free on the Internet; complete
database is available via HINARI for most countries
– 1995-
Benefits for using not-evaluated databases
for EBM research (PubMed, Cinahl)
•
•
•
•
Create comprehensive search strategies
Conduct systematic reviews of the literature
Conduct synonym searching utilizing thesauri
Set up and distribute alerts relating to evidencebased medicine
• Limit to specific populations & publication types
• Utilize EBM built-in filters (search strategies)
EBP Step 3: Appraise:
Appraise
Determine if the results are valid and useful
• Appraisal principles (primary and secondary research)
– What is the PICO of the study? Does it match my
question?
– How well was the study done? Is it biased?
– What do the results mean? Are they real and
relevant?
• More: University of Oxford’s Center of EBM:
http://www.cebm.net/index.aspx?o=1157
• Tools for evaluating studies can be found in the
Evaluating the Evidence section in the EBM tutorial at:
http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm
EBP Step 4: APPLY:
Integrate the results with your clinical
expertise and your patient values
Apply
• Question to ask:
– Is the intervention feasible in my settings?
– What alternatives are available?
– Is my patient so different then those in the study that the
results cannot apply ?
– Will the potential benefits outweigh the potential harms of
treatment ?
– What does my patient think? What are his cultural beliefs?
– Individual decision making/group decision making/choice
– Explaining risks and benefits to patients:
https://docs.google.com/View?id=d7k3gkg_679hnvn54c8
• Visual Rx: http://www.nntonline.net/visualrx/
EBP Step 5: ASSESS
Assess
Evaluate the effectiveness of the process.
How am I doing?
•
•
•
•
Am I asking questions?
Am I writing down my information needs?
What is my success rate in the EBM steps?
How is my searching going? Am I becoming more
efficient?
• Am I periodically syncing (checking) my skills and
knowledge with new developments?
• Teach others EBP skills
• Keep a record of your questions
Limitations of EBP
• Limited scope of evidence-it will never be
complete
• The quality of research available
• Keeping it patient centered, cost effective
• Evidence from Randomized Controlled Trials
for real life patients
• Communicating uncertainties
• Decision making
If you are interested in learning more about EBM, go
to the online tutorial Introduction to Evidence-Based
Medicine from the Health Sciences Library, University
of North Carolina (USA):
http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm
Logging on to HINARI 1
To access the HINARI Evidence-based
Medicine resources, we must Login to
the HINARI website using the URL
http://www.who.int/hinari/
Logging
into
HINARI
We will need to enter
our HINARI
User Name2and Password
in the appropriate boxes, then click on the Login button.
Note: If you do not properly sign on, you will not have access
to Evidence-based Medicine resources that are located in the
Reference Sources drop down menu.
From the HINARI Reference Sources drop
down menu, we also can find tutorials for
learning more about EBM. In this example,
we will link to BMJ Learning.
From the BMJ Learning’s Browse our
modules listing, we have clicked on
Clinical Epidemiology and located
four EBM-related tutorials.
From the Reference Sources drop down
menu, there are four valuable EBMrelated sites. First, we will click on the
Clinical Evidence link, a resource for
informing treatment decisions and
improving patient care. It is published by
the BMJ Publishing group.
In the Clinical Evidence site, you can search by Sections,
Full review list or (keyword) Search this site.
Also note that there is a Clinical Evidence Userguide in
multiple languages and links to the Latest updated reviews.
Using the Search this site option, we have
completed a keyword search for
tuberculosis and identified 73 documents.
The links include clinical evidence
Guidelines, Keypoints, Interventions and
Updates about this topic.
We have further limited this search
by combining tuberculosis and HIV.
This has resulted in 56 documents.
We will click on the link to
Tuberculosis in people with HIV.
The initial page of HIV: treating tuberculosis initially
displays Interventions based on clinical questions.
Note that also you have access to Key points, About
this condition, Updates, Guidelines and References.
We will click on the Guidelines hyperlink.
The Guidelines page contains the
title, name of organization and
hyperlink to 10 documents from key
health agencies. The guidelines
have been sourced from the National
Guidelines Clearinghouse (USA).
We have clicked on the Full review list option and
displayed the topics under the A alphabetical list.
This A-Z subject access contains an extensive list
of topics and clinical evidence material.
From the Reference Sources drop down 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.
Note the full-text reviews are available to Band 1
only while Abstracts can be accessed by all users.
The Cochrane Library
COCHRANE LIBRARY : The Cochrane Collaboration.
Oxford: Update Software;
1996-. Updated quarterly.
• Cochrane Database of Systematic Reviews (CDSR)
– High-quality pre-evaluated systematic reviews from
all over the world
– International, not-for-profit organization
– Complete reviews and protocols (reviews that are
still in progress)
– CDSR abstracts are in Medline but there is no link to
full-text of the review
– Specific topics, explicit evaluation criteria to
minimize bias
The initial page of this site has a title,
abstract or keyword option Search engine.
You also can Browse Cochrane Database
by broad subject heading . The initial page
also highlights New and Updated
Cochrane Reviews. We will go to the
Advanced Search.
Also from the initial page, there is a link to
the Cochrane Journal Club.
We have opened the Advanced Search option where you
can specify search fields and have the ability to combine
terms using AND/OR/NOT operators.
In this text Advanced Search, we have combined
diarrhea child* using the Search All Text option with the
wildcard (*) used to locate the terms child and children.
Note that you also can complete a MeSH Search, look at
your Search History or Saved Searches.
The Advanced Search results for diarrhea child*
has retrieved 451 records from the Cochrane
Database of Systematic Reviews. You have the
option to Export All Results (save).
Note: if the results of your search are too many,
you can narrow it by limiting the keyword search
to Title instead of Search All Text.
The screen displays the Abstract of the first
systematic review listed in the search - Oral
zinc for treating diarrhoea in children.
To access the full-text review, click on the Full
PDF hypertext link in the left column. Other
options are Summary and Standard.
Also note the hypertext links to specific
sections of the systematic review.
We have displayed the Abstract of the
systematic review that includes the
Background, Objectives, Search strategy,
Selection criteria, Data collection and
analysis and Main Results.
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 Main results and author’s
conclusions (the ‘bottom line’) as these
sections discuss the review’s results and how
they should be used.
We have displayed the PDF Full version of
the Oral zinc for treating diarrhoea in children
systematic review. Other options include
Summary and Standard files.
Note: The url that contains http://hinarigw.who.int/whalecom... shows that we have
logged in to HINARI properly and will have
access to the full-text version of this review.
From the Advanced Search page of the Cochrane
Library, we have clicked on the Cochrane Reviews:
By Topic hyperlink. This has displayed the Topics for
Cochrane Reviews. From this extensive list, you have
another option for locating subject- specific material.
Note that there are other search lists including an A-Z
list, Updated Reviews and New Reviews.
For more training material, you can click on
The Cochrane Library Help hyperlink. We
have opened the Search Manual. Another
option is a listing of Web Updates.
If your institution does not have
access to Cochrane….
Access to the Abstracts is free from
a link at:
http://www.cochrane.org/
After accessing the Cochrane Collaboration
(http://www.cochrane.org/), click on the
Cochrane Library link. This will give you
access to the Library’s search options and
the abstracts but not the full-text articles.
Click here
We now access the third Reference
Sources option for evidence-based
health information - EBM Guidelines.
This is 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.
Also included are links to the Evidence summaries.
We have displayed the first Evidence summary.
Each link contains a brief review of the study and
notes the reference(s).
We now access the fourth Reference Sources
option for evidence-based health information –
BMJ’s BestPractice – a combination of research
evidence, guidelines and expert opinion.
We have completed a keyword
search for diabetes. Note the
drop down menu with the broad
category results of the search.
The results for the diabetes search are
displayed in broad subject categories. Note that
each category contains full-text documents on
the Highlights, Basics, Prevention, Diagnosis,
Treatment, Followup and Resources.
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.
We now search for evidence-based articles using
PubMed. From the main HINARI webpage, go to
PubMed by clicking on Search HINARI journal
articles through PubMed (Medline).
Remember you must login to HINARI to have
access to the full-text articles.
Open the Clinical Queries box. This search
tool assigns filters to keyword searches - to
locate articles on Clinical Studies, Systematic
Reviews and Medical Genetics.
In June 2010, these features were revised so
that you can complete a search for Clinical
Studies, Systematic Reviews and Medical
Genetics at the same time.
To use the Search by Clinical Study Categories, you
would type a disease or procedure in the Search box
and select one Category and Scope per search. We
have displayed the options for Category and clicked
on Therapy from the drop down menu. Note the
definition of the Filters on the bottom of the page.
Note: you can go directly to PubMed Clinical Queries
The direct link to PubMed Clinical Queries is
http://www.ncbi.nlm.nih.gov/pubmed/clinical
For the Scope option, we will enter Narrow
and also enter type 2 diabetes AND
developing countries in the search box.
The Therapy (Category) and Narrow (Scope) type 2
diabetes AND developing countries search has resulted
in 8 citations. We now will click on the See all option.
Note that the results for Systematic Reviews and Medical
Genetics also are displayed.
We have displayed all 8 articles for this search
including 7 HINARI and 3 Free Full Text articles.
Remember - you can access the full-text articles by
clicking on these Filters or changing the display from
Summary to Abstract.
Note that the specific search is listed in the Search
box including the AND (Therapy/Narrow[filter]) for
systematic reviews.
We have clicked on the See all option for the
systematic reviews results. The type 2
diabetes AND developing countries AND
systematic [sb] search resulted in 13 articles.
If you have a MY NCBI account, you can add Meta-analysis and Systematic
Reviews to your Filters. Go to Manage Filters, click on Properties option
and put each term in the Search with terms box.
When you save a PubMed search, you will be sent an email listing new
articles on the specific topic. Remember that you will need to go to HINARI
to get the full-text articles.
In this example, Free Full Text, HINARI, Meta-analysis and Systematic
Reviews are listed in Filters.
Additional Evidence-based Health Resources
• National Guidelines Clearinghouse
http://www.guideline.gov/
• DARE: Database of Abstracts of Reviews of Effects
http://www.crd.york.ac.uk/crdweb/
• health-evidence.ca http://health-evidence.ca
• The Campbell Library
http://www.campbellcollaboration.org/library.php
• McMaster PLUS collection
http://hiru.mcmaster.ca/hiru/HIRU_McMaster_PL
US_projects.aspx
• Duke University Medical Center Library: EBM
http://www.mclibrary.duke.edu/subject/ebm?tab=co
ntents
• EBM Librarian
• https://sites.google.com/site/ebmlibrarian/
EvidenceUPDATES contain a searchable
database, an email alerting system and links
to selected evidence-based resources.
Registration is required but free.
Trip Database is a clinical search tool for
health professionals to identify quality
clinical evidence for clinical practice.
Registration is required but free and
gives the users additional resources.
The Essential Health Links gateway
contains annotated links to numerous
Evidence-Based Medicine resources
available on the Internet.
The Canadian Institutes of Health
Research web site contains four
Knowledge Translation Learning
Modules. Several of these online
courses are relevant for evidence
based practice and use of knowledge
to make informed health decisions.
Review/Summary
• Evidence-based practice depends on
knowing the most recent, valid scientific
knowledge.
• This involves finding the ‘best’ studies.
• Sometimes others have evaluated the
quality of the studies, including
methodology; many new evidence-based
tools mentioned in this tutorial provide
evaluation.
• When there is no evaluation available, it is
essential to evaluate the validity of the
study.
• Tools for evaluating studies can be found
in the Evaluating the Evidence section in
the EBM tutorial mentioned earlier and
found at:
http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm
• It is always important to consider studies
in terms of applicability to and values of
the local patient/situation.
• Evidence-based practice is a developing
field and new, useful resources are
continuously being developed.
Appendix 1
Appendix 1 – Contains four case studies for
developing Evidence-Based Practice curriculum:
experimental cancer research, EBP
curriculum for pharmacy students, health
literacy for pharmacy students and
outreach activity for early intervention
providers
Developed by:
Irena Bond, Library Manager
Associate Professor of Library and Learning Resources
Massachusetts College of Pharmacy and Health Sciences
Research Evidence
Practitioner’s Experience
Local Conditions
Patient/Community Preferences
& Values
This is the end of the Evidence-based Medicine for HINARI Users module.
The material initially was developed by: Gale G. Hannigan, PhD, MLS, MPH;
Professor & Medical Informatics Education Librarian, Texas A&M University.
Material revised and enhanced by Irena Bond, Library Manager, Associate
Professor of Library and Learning Resources, Massachusetts College of
Pharmacy and Health Sciences.
There is a workbook that accompanies this module. The workbook will take you
through a live session covering the topics included in this demonstration with
working examples.
Updated 2011 08