Evidence-based Practice for HINARI Users (Advanced Course: Module 6)

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Evidence-based Practice for HINARI
Users(Advanced Course Module 6)
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Table of Contents

• EBM definition
• 5 step EBM process
• HINARI Resources
• Cochrane Library
• Evidence-based Medicine Guidelines
• Essential Evidence Plus
• EBM Journals
• PubMed/Clinical Queries
• PubMed Health
• Other Resources

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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).

EBP
Best available evidence is consistent research
evidence with high quality and quantity
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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

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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

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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.

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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

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Step 1 ASK (questions, PICO) a focused
(answerable) clinical question

• Background Questions

• Foreground Questions

• Specific questions - patient
• INTERVENTION/PREVENTION
• ETIOLOGY, RISK
• DIAGNOSIS
• PROGNOSIS
• Information Resources
• journal articles
• synopses of articles
• systematic reviews
• answer specific 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

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Step 1 ASK PICO Format

• 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)?

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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

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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

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Formulate the Clinical Question

• PICOP - 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 questionIn 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?

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Etiology and Risk QuestionsWhat 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?

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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?

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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.

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EBP Step 2 ACCESS (studies, hierarchies)Track
Down the Best Evidence
Start hunting from the best resource match
your question to the best medical information
resource for this question.
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Hierarchy of EvidenceResearch Studies
synthesis
experimental
observational
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Hierarchy of Evidence Question Type
Therapy/PreventionWhat should I do about this problem? RCTgtcohort gt case control gt case series
DiagnosisDoes this person have the problem? cross-sectional study with blind comparison to a gold standard
Etiology/HarmWhat causes the problem? RCT gt cohort gt case control gt case series
Prognosis/PredictionWho will get the problem? RCT gtcohort study gt case control gt case series
Frequency and Rate How common is the problem? cohort study gt cross-sectional study
A well designed systematic review of RCTS
(randomized controlled trials) is best as it is
least biased therefore more valid. After that,
start with the least biased study type for the
question.
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EBP Step 3 Appraise (validity, impact)

• 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 Oxfords Center of EBM
  http//www.cebm.net/index.aspx?o1157
• Evaluating the Evidence section in the EBM
  tutorial at
• http//www.hsl.unc.edu/Services/Tutorials/ebm/welc
  ome.htm

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EBP Step 4 APPLY (patient, setting)
Integrate the results with your
clinicalexpertise and your patient values

• 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?

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EBP Step 5 ASSESS (patient, yourself)Evaluate
the effectiveness of the process.

• 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

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HINARI Resources

• Cochrane Library filtered
• PubMed unfiltered
• Clinical Queries
• Filters
• PubMed Health
• HINARI EBM Journals

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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

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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.
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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.
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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.
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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.
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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.
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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.
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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 authors conclusions (the bottom line) as
these sections discuss the reviews results and
how they should be used.
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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//hinari-gw.who.int/whalecom... shows that
we have logged in to HINARI properly and will
have access to the full-text version of this
review.
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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.
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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.
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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.
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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.
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We have displayed the 2nd Evidence summary. Each
link contains a brief review of the study and
notes the reference(s).
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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.
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We have opened the EBMG evidence summaries
database that, via broad subject categories, has
access to 4440 articles.
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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.
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We have opened Decision Support Tools that has
406 tools and calculators that assist in clinical
decision making.
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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.