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Searching for Evidence Based Medicine Literature

Aug 2012

What is Evidence-Based Medicine?

The goal of (EBM) is to be aware of the evidence on which ones practice is based, the soundness of the evidence, and the strength of inference the evidence permits. The strategy employed requires a clear delineation of the relevant questions(s); a thorough search of the literature relating to the questions; a critical appraisal of the evidence, and its application to the clinical situation; and a balanced application of the conclusions to the clinical problem.a

a
Preface (2002). In Guyatt GH, Rennie D. (Eds.), Users Guides to the Medical Literature (pp. xiv). Chicago: AMA Press.

The Exponential Growth of the Literature

PubMed "indexed journals represent an increasingly smaller portion of the broader universe of medical information. NLM (National Library of Medicine) estimates that currently about 14,000 biomedical journals are published and it selects

only about one-quarter of new submissions for indexing based

on quality and relevance to biomedical topics. These biomedical journals, in turn, represent only a small fraction of the growing array of information sources on the Web."

Druss, BG, et al. Growth and decentralization of the medical literature: implications of evidence-based medicine. JMLA. 2005;93(4):499-501

Steps in the Evidence-Based Process are:

(Citrome, & Ketter, 2009)

Step 1
Formulate the Question

Using PICO to focus the question:

Clinical questions should be directly relevant to the problem. The question can be phrased to facilitate searching for a precise answer by using PICO: the Patient, population or problem being addressed the Intervention being considered the Comparison intervention or exposure, when relevant the clinical Outcomes of interest
(Washington Health Sciences Libraries, 2007)

Clinical questions often arise from central issues:

(Straus, 2005)

Diagnosis
the process of identifying a disease or condition. Making the correct diagnosis is the foundation for making decisions on clinical intervention. What disease or condition does my patient have?

Therapy
an action or intervention that can potentially improve care or prevent diseases or conditions. What is the best treatment for this disease or condition?

Etiology
the cause of a disease, condition or situation. It may also be referred to as harm or causation. What is the cause of my patients disease or condition?

Prognosis
the progression of a treated disease. What outcome can be expected from the treatment/intervention used?
Definitions from McKibbon, 2009

Step 2
Search for the Answers

Professor Archibald Cochrane, CBE FRCP FFCM, (1909 - 1988)

stresses the importance of using evidence from randomized controlled trials because these were likely to provide much more reliable information than other sources of evidence

www.cochrane.org

prepared reviews based on the best available evidence

www.thecochranelibrary.com

Hierarchy of Evidence and Corresponding Databases

Filtered Information
Cochrane Database of Systematic Reviews

Topic Reviews in the Cochrane Database of Systematic Reviewsa

a

Database of Abstracts of Reviews of Effectiveness (DARE) NHS Economic Evaluation Database Cochrane Methodology Register ACP Journal Club

Unfiltered Information
Cochrane Central Register of Controlled Trials PubMed

PubMed National Guideline Clearinghouse Health Technology Assessment PubMed

(TTUHSC Preston Smith Library, 11/21/2008)

Mouse over Databases

and click Ovid

Click All EBM Reviews

Enter

obesity

as the first keyword search.

Enter

surgery

as the

second keyword search.

For better results, enter keywords separately and then combine with Boolean operators.

X X

AND

Click on the boxes next to set 1 and set 2.

Boolean Logic - AND

obesity

and

surgery

Results of AND combination.

(Note that AND narrows results.)

Enter

3 AND obes*.ti.

to narrow to

articles with any suffix of obesity in the title.

By entering obes*, the computer searches for any suffix of the word: obese obesity

This is called truncation.

Enter

4 AND surgery.ti.

to narrow to

articles with surgery as a word in the title.

Results are narrowed to 87 articles.

Other search techniques:

Look for additional terms such as bypass or banded

Use Boolean OR

bypass

or
banded

Search Results

Click Display to view articles

Systematic Reviews assess randomized trials and provide a comprehensive summary of the available evidence. Over 800 international journals are searched to locate articles. a Systematic Reviews contain all known reference to trials on a particular intervention. Evidence is assessed with explicit quality criteria to minimize bias ensure reliability. Trials that meet assessment criteria can be combined to produce a more statistically reliable result. Data from studies are often combined statistically to increase the power of the findings of numerous studies, which on their own may be too small to produce reliable results. Authors appraise, and synthesize evidence from as many relevant scientific studies as possible.

Click EBM Topic Review

EBM Topic Review

Systematic reviews are prepared by Cochrane Collaborative Groups.

PDF link.

Click Search

Click Ovid Resources

Click Cochrane Database of Systematic Reviews

Click Cochrane Database of Systematic Reviews

Click Table of Contents

Additional Articles to Review

Cochrane Groups
Acute Respiratory Infections Airways Group Anesthesia Group Back Group Breast Cancer Colorectal Cancer Consumers & Communication Cystic Fibrosis & Genetic Disorders Dementia & Cognitive Improvement Depression, Anxiety, & Neurosis Developmental, Psychosocial & Learning Problems Drugs & Alcohol Ear, Nose and Throat Disorders Effective Practice & Organization of Care Epilepsy Eyes & Vision Fertility Regulation Gynecological Cancer Hematological Malignancies Heart Group Hepato-Biliary Group HIV/AIDS Hypertension Incontinence Infectious Diseases Inflammatory Bowel Disease Injuries Group Lung Cancer Menstrual Disorders & Sub-Fertility Group Metabolic & Endocrine Disorders Methodology Review Group Movement Disorders Multiple Sclerosis Musculoskeletal Group Musculoskeletal Injuries Group Neonatal Group Neuromuscular Disease Oral Health Pain, Palliative Care & Supportive Care Peripheral Vascular Diseases Pregnancy & Childbirth Prostatic Diseases & Urologic Cancers Renal Group Schizophrenia Group Sexually Transmitted Diseases Group Skin Group Stroke Group Tobacco Addiction Upper Gastrointestinal & Pancreatic Diseases Wounds Group

Click Search

Click Ovid Resources

Click All EBM Reviews

Click Display to view articles

Scroll to article #3

Click EBM Article Review

ACP Journal Club is a joint online journal: ACP Journal Club Evidence-Based Medicine

by the American College of Physicians by the British Medical Journal Group

Over 100 clinical journals are screened for original studies that are methodologically sound & clinically relevant.

Study categories include:

a

Prevention or treatment Diagnosis Prognosis Etiology Economics Clinical prediction guides Differential diagnosis

Information summarized in structured abstracts include:

aA

Methods Design Intervention

ACP Journal Club includes brief commentaries on:a

aa

Context Methods Clinical applications of findings

Click Search Results

GO>

For next article, type 8 and click Go

Click EBM Article Review

Over 3000 abstracts of systematic reviews that have been quality assessed Reviews answer questions about specific interventions

Results of review and critical commentary About overall quality

Click Search

22

GO>

For next article, type in 22 and click Go

Click Complete Reference

3/5ths of the records are from PubMed Relevant records from Embase Other published and unpublished sources Reports from conference proceedings

CCRT does not contain full-text. Access through Gold Rush.

Mouse over eJournals and click Gold Rush

Type in

journal of the american college of surgeons

Go back to Ovid Search.

For the next article

59

GO>

Click Next

A a

Reports on methods used in the conduct of controlled trials

Includes journal articles, books, and conference proceedings Does not contain full text; access through Gold Rusha
a

83

Go to article #83

Completed and ongoing health technology assessments studies of: medical, social, ethical, and economic implications of health care interventions Aim is to improve the quality and cost-effectiveness of health care

Over 5000 abstracts

Systematically identifies
economic evaluations from around the world

Click Search

Click Ovid Resources

Click ACP Journal Club

Click Expand

Click to Select All

Click Remove Selected

Step 3
Appraise the Evidence

Levels of Evidence
* Medical evidence or recommendations can vary in quality

* Sources of evidence range from:

1. small laboratory studies to 2. well-designed large clinical studies with minimized bias

* Is a recommendation is strong or weak? * Can you be confident in the recommendation? * Grading by strength of recommendations is a systematic approach which can minimize bias and aid interpretation * Quality of evidence can be categorized as high, moderate, low, or very low
(The GRADE Working Group, 2005)

Strength of Recommendation
Recommendations to administer, or not administer, an intervention, should be based on the tradeoffs between benefits on the one hand, and risks, burden and, potentially, costs on the other. If benefits outweigh risks and burden, experts will recommend that clinicians offer a treatment to typical patients. The uncertainty associated with the tradeoff between the benefits and risks and burdens will determine the strength of recommendation. (The GRADE Working Group, 2005)

Strength Of Recommendation Taxonomy (SORT)

Code

Definition
Consistent, good-quality patient-oriented evidence * Inconsistent or limited-quality patient-oriented evidence *

A B C

Consensus, disease-oriented evidence *: usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

*Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life. Diseaseoriented evidence measures: immediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (e.g. blood pressure, blood chemistry, physiologic function, pathologic findings).
(Essential Evidence Plus EBM Guidelines Editorial Team, 2010)

Grading of Recommendations, Assessment, Development, and Evaluation GRADE

Code Quality of Evidence Definition

High

Further research is very unlikely to change our confidence in the estimate of effect.

Several high-quality studies with consistent results In special cases: one large, high-quality multicenter trial
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. One high-quality study Several studies with some limitations Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. One or more studies with severe limitations Any estimate of effect and is very uncertain.

Moderate

Low

Very Low

Expert opinion No direct research evidence One or more studies with severe limitations

(Essential Evidence Plus EBM Guidelines Editorial Team, 2010 )

Enter

EBM Toolkit

and click Google Search.

http://www.ebm.med.ualberta.ca/

Mouse over
Domains, Study Category, and select Worksheet. Look at Calculations. Then look at Systematic Review.

Step 4
Apply the Results

Step 5
Assess the Outcome

Step 6
Integrate with clinical expertise and patients values

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The End