Transcript OB-GYN : Searching the literature for best evidence

EVIDENCE-BASED PSYCHIATRY:
SEARCHING THE LITERATURE AND
APPRAISING THE EVIDENCE
DIANA J. CUNNINGHAM, MLS, MPH, AHIP
ASSOCIATE DEAN AND LILLIAN HETRICK HUBER ENDOWED
DIRECTOR,
HEALTH SCIENCES LIBRARY, NEW YORK MEDICAL COLLEGE
APRIL 9, 2014 METROPOLITAN HOSPITAL
TODAY’S AGENDA
1. Concepts:
Evidence-based medicine
Evidence-based psychiatric practice
Systematic Review
Levels of evidence: hierarchy of methodologies
2. Systematic review process
3. Applying the process & mapping to the literature
4. Finding the evidence: Today’s case
5. So what do we know?
TODAY’S OBJECTIVE:
By the end of this session, participants will be able to assess levels of evidence for a
clinical psychiatric case and discuss examples from the literature
WHAT DOES IT MEAN: ENOUGH EVIDENCE?
In clinical decision-making there is NEVER enough evidence!
Concepts:
Evidence-based medicine:
•
Distinguish stronger evidence from weaker evidence
•
Appraise critically the available evidence and balance the benefits and risks
Evidence-based psychiatric practice:
Focuses on broader care of patients; more complicated patients with less precise
diagnoses, co-morbidities and treatment over time.
Gray, “Psychiatric clinical practice is not always evidence-based.”
Goal: to be aware of the evidence in one’s practice!
SYSTEMATIC REVIEW SAMPLE FLOW CHART
APPARENT LIFE THREATENING EVENTS (ALTE)
ALTE Search Methodology: September 2013
Diana Cunningham
Actual MyNCBI Search:
((alte AND ((infant[MeSH]))) OR (altes AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR
((apparent life threatening events AND ((infant[MeSH]))) OR (apparent life threatening
event AND (infant[MeSH]))) OR (apparent life threatening event* AND ((infant[MeSH])))
AND ((infant[MeSH]))) OR ((life threatening events AND ((infant[MeSH]))) OR (life
threatening event AND ((infant[MeSH]))) OR (life threatening event* AND
((infant[MeSH]))) AND ((infant[MeSH]))) OR ((near miss sids AND ((infant[MeSH]))) OR
(near miss sudden infant death syndrome AND ((infant[MeSH]))) AND ((infant[MeSH])))
OR ((aborted crib death AND ((infant[MeSH]))) OR (aborted sudden infant death
syndrome AND ((infant[MeSH]))) OR (aborted sids AND ((infant[MeSH]))) OR (aborted
cot death AND ((infant[MeSH]))) AND ((infant[MeSH]))) AND ((English[lang]) AND
(infant[MeSH]))
REVIEWING PROCESS
CRITICAL APPRAISAL: IS IT HIGH QUALITY?
Are the results valid?
Did the review explicitly address the clinical question?
Was the search for relevant studies detailed and exhaustive?
Were the primary studies of high methodological quality?
What are the results?
What are the overall results of the review
Selection or inclusion/exclusion criteria
Comparability: randomized or not
Validity of evaluation instrument
Data-analysis
Can I apply the results to my patient?
But must be relevant to your patient or it doesn’t matter!
Relevance
Validity
Feasibility of an intervention
Patient-disease oriented intervention
Realistic generalizability (operational def of
outcome)
Does the study address the question at
hand?
Does the study address my population?
Appropriateness of study design
• Adequacy of blinding
• Allocation concealment
• Randomization of group assignment
• Invalid or biased measurement
("followed own protocol?")
• Importance of comparison or control
group • Intention to treat analysis
• Consideration of appropriate covariates
("were other relevant factors considered?")
• Conclusions consistent with evidence
("do the results make sense?")
• Importance of follow-up of all study
participants
• Appropriate statistical analysis
• Sample size / Power
• Sponsorship
• When study was conducted
• Confirmation with other studies
DRILLING DOWN FOR EVIDENCE
Value = (Relevance + Validity) / Time
Grundage KK, Slawson DC, & Shaughnessy AF. When less Is More: A practical approach to
Searching for evidence answers. J Med Libr Assoc 2002 July; 90(3): 298-304
EVIDENCE PYRAMID: A HIERARCHY OF
METHODOLOGIES
Grades or Levels of Evidence is now included in various resources (e.g. Dynamed)f Evidence for the Purported
Quality of Study Design.L
CONCATO J ET AL. N ENGL J MED 2000;342:1887-1892.
Levels of Evidence
PEER-REVIEWED RESOURCES
BREAD AND BUTTER
PRE-APPRAISED
PubMed (see clinical
queries option)
Cochrane (in PubMed)
PsycINFO
Dynamed
Psychology and
Behavioral Science
Collection
Clinical Evidence
Scopus
UpToDate
National Guidelines
Clearinghouse
(AHRQ)
AND NOW: SEARCH THE LITERATURE
Goal: be aware of the evidence on which one’s practice is based, the soundness of
the evidence, and the strength of interference that the evidence permits:
1. Formulate the relevant (clinical) question
2. Thorough search of the literature for answers pertaining to the question
3. Critically appraising the evidence for validity and importance
4. Apply results to your patient
5. Assess the outcome
NYMC HEALTH SCIENCES LIBRARY
THE LIBRARY BARCODE IS YOUR KEY
TO ACCESS…
Get your barcode at the library as
soon as possible for:
 Remote access to online databases and journals
 Borrowing privileges and access to the library.
To obtain a barcode, complete form on the library’s web page or visit
the Access Services Desk in the Library.
OUR CASE
Patient is a 37 year old Caucasian woman with schizophrenia. She has been a
smoker since she was 9 years old. She currently coughs so badly she can barely
speak and has expressed the desire to quit smoking. You have read something in
the literature about the use of Wellbutrin. You want to look at the evidence in the
literature.
EBM PROCESS
FRESNO TEST MODEL:
Resident PICO Worksheet*
MetropolitanMetropolitan
PsychPsych
Resident
PICO Worksheet*
1 What
is your focused question? (3pts)
POPULATION/PATIENT
INTERVENTION
COMPARISON
OUTCOME
What is your focused question? (3pts)
POPULATION/PATIENT
INTERVENTION
COMPARISON
2 Where would you go to find an answer to questions like this? (8 pts)
OUTCOME
Where would you go to find an answer to questions like this? (8 pts)
1
2
If you were to search PubMed, describe what your search strategy would be. Be as specific about terms, fields, & limits as
possible. (8 pts.)
If you were to search PubMed, describe what your search strategy would be. Be as specific about terms, fields, & limits as possible. (8 pts.)
3
Search terms
1
2
3
3
Search terms
4 What
type of study design would best address your question? (12 pts.)
What type of study design would best address your question? (12 pts.)
5 When
you find a report of original research, what characteristics of the study will you consider to determine it it is relevant, valid, & significant (12 pts.)
When you find a report of original research, what characteristics of the study will you consider to determine it it is relevant, valid, & significant
(12 pts.)
6 What was the best report of original research that addressed your question and why (give cite)? (12 pts)
What was the best report of original research that addressed your question and why (give cite)? (12 pts)
7 What
is the answer to your clinical question? (25 pt)
What is the answer to your clinical question? (25 pt)
*Based upon the Fresno Test of Evidence-based Medicine
*Based upon the Fresno Test of Evidence-based MedicineComplete before Dec 30, 2011 (25 pts.)
Email to [email protected]
PICO
Patient
Intervention
Comparison
Outcome
In (this type of patient), does (therapy A) vs (therapy B or control) (have a certain
desired outcome)?
RESOURCES
WHICH DATABASES:
WHICH RESOURCES
SEARCH ENGINES
WOULD BE MOST USEFUL TO FIND AN ANSWER TO
QUESTIONS LIKE THESE?
SEARCH STRATEGY
Combination of terms/keywords/headings arranged with Boolean operators AND, OR,
and NOT
“use quotes for indexed phrases”
Iterative process:
 Do search – does it need broadening or narrowing?
 To narrow – AND ; To broaden – OR
 Look for MeSH terms and synonyms
PUBMED “CLINICAL QUERIES”
PUBMED CLINICAL QUERY
PUBMED MESH SEARCH
PUBMED MESH AND KEYWORDS
THE EVIDENCE?