Transcript Document 7109621

How can you trust the medical
websites on the Internet? How to
find the best available evidence?
Abdel Hakim Bishawi
Library Manager
Harvard Medical School Dubai
Center-Dubai Health Care City
Email: [email protected]
Mobile: 00971505635194
http://www.hmsdc.hms.harvard.edu/
What is a Medical Librarian?
Medical librarianship is a service profession.
Medical librarians provide health information
about new medical treatments, clinical trials and
standard trials procedures, tests, and equipment
to physicians, allied health professionals,
patients, consumers, and corporations. They
help physicians provide quality care to patients,
help patients find information, answer
consumers’ questions, and provide information
to the health care industries.
Who do they work with?
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doctors
medical students
nurses
pharmacists
researchers
patients
therapists
computers and network gurus
general public and patients’ families
veterinarians
other information specialists
Harvard Medical School Dubai
Center (HMSDC)
HMSDC Institute for Postgraduate Education &
Research has been established to foster the
professional development of physicians, nurses,
research scientists, and allied health
professionals in the Gulf Region.
Launched in 2004 through a joint effort by
(Partners Harvard Medical International) &
Dubai Healthcare City (DHCC), HMSDC is part
of the Government of Dubai’s mission to develop
DHCC into a center of excellence for health care
delivery, medical education, and research.
Academic Medical Center
1- University Hospital
2- HMSDC
3- Dubai Harvard Foundation for
Medical Research
4- Al Maktoum Harvard Medical Library
http://www.hmsdc.hms.harvard.edu/
How do people find information?
Print resources
Electronic resources
The Internet
Ask colleagues
Meetings
Others
Why Google?
Info about people, things, addresses, maps,
images, videos, Google Earth, etc…
Examples
How can I go to Turkuaz shop in Boston?
Google and Medical
information
26,400,000 results
You could find some real gems, but you
could also end up in some strange and
dangerous places!
So how you can tell if a website is reliable?
Evaluating Internet Medical
Information
Who runs the site?
Why have they created the site?
What do they want from you?
Who is paying for the site? Does the site’s
information favor the sponsor?
Evaluating…continued
Is the information reviewed by experts?
Where did the information come from?
Does the site make unbelievable claims?
Is it up-to-date?
Do “they” want your personal information?
What will “they” do with it?
You can find the answers on the main page
or “About us” page of a website.
Websites
End with .com
End with .gov
End with .org
End with .int
End with .edu
Websites you can Trust
Women’s Health.gov
http://4woman.gov
The National Women’s Health Information
Center of the U.S. Department of Health
and Human Services offers statistical
information as well as coverage of
women’s health topics and issues, health
organizations, funding resources, and
publications. It provides information in
Spanish and has a site for girls,
.http://www.4girls.gov
National Women’s Health Resource
Center (NWHRC)
http://www.healthywomen.org
The National Women’s Health Resource
Center is a non-profit, national
clearinghouse for women’s health
information. It develops original health
materials and content for women and
provides links to related news, educational
opportunities, and national organizations.
It also has information about books and
.contacts for local health departments
North American Menopause Society
http://www.menopause.org
The North American Menopause Society
is a nonprofit organization devoted to
research and promoting women’s health
as they age. They study menopause and
its health effects. The site has information
for health care providers and consumers,
including referral lists, educational
materials, research, and participation in
.research studies
Mayo Clinic
/http://www.mayoclinic.com
MayoClinic.com offers a wealth of easy-tounderstand health and medical
information. In addition to diseases and
conditions, the site has a number of
healthy living guides and helpful resources
such as Health Tools, Treatment Decision
Guides, blogs and pod casts, and Ask a
Specialist feature. Mayo Clinic experts
.review web site content for accuracy
The US National Library of Medicine
http://www.nlm.nih.gov/
http://PubMed.gov
The PubMed database comprises more than
19 million citations for biomedical articles
from MEDLINE and life science journals.
Citations may include links to full-text
articles from PubMed Central or publisher
web sites
PubMed
http://preview.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=helppubmed&part=pub
medhelp#pubmedhelp.How_to_Get_the_Journ
PubMed lets you search millions of journal
citations and abstracts in the fields of medicine,
nursing, dentistry, veterinary medicine, the
health care system, and preclinical sciences. It
and to citations ®MEDLINE access to includes
for selected articles in life science journals not
included in MEDLINE. PubMed also provides
access to additional relevant Web sites and links
.to the other NCBI molecular biology resources
Searching PubMed
women healthcare
Click on Limits
Click Go
Check box
Click on Display & select
Abstracts
Send the 4 results to your email
7571 Free Full Text articles
Evidence-Based Practice
(EBP) is a thoughtful integration of the best
available evidence, coupled with clinical
expertise. As such it enables health
practitioners of all varieties to address
healthcare questions with an evaluative
and qualitative approach.
Evidence-Based Practice
EBP allows the practitioner to assess
current and past research, clinical
guidelines, and other information
resources in order to identify relevant
literature while differentiating between
high-quality and low-quality findings.
University of Minnesota
http://www.biomed.lib.umn.edu/l
earn/ebp/mod01/index.html
The 5-Step Process
Step 1: Formulating a well-built question
Step 2: Identifying articles and other
evidence-based resources that answer the
question
Step 3: Critically appraising the evidence
to assess its validity
Step 4: Applying the evidence
Step 5: Re-evaluating the application of
evidence and areas for improvement
Why Evidence-Based Practice
Explosion of literature: 7,827 articles
relevant to family practice published on
monthly basis.
EBP solution: Many Evidence Based review
resources synthesize & critically apprise
current healthcare literature. Clinicians can
make evidence based decisions about
patient care in a focused & time-efficient
manner.
Unmet Information Needs
Practitioner information needs are not being
met. For every three patients seen, two
questions are generated. Only 30% of
those questions are being answered
during patient visits.
Solution: Synthesized EBP resources are
easy to use & help to quickly connect
practitioners with Evidence Based
answers to their clinical questions.
Implementation Delays
Prior to the early 1990’s, it was
recommended that infants sleep on their
stomach despite evidence available in the
1970’s that this contributed to Sudden
Infant Death Syndrome.
Solution: EBP resources take into account
evidence from a wide variety of fields &
provide clinicians with the opportunity for
greater exposure to clinical evidence.
Step 1: Formulating the
Question
• A well-built clinical question includes the
following components:
• The patient’s disorder or disease
• The intervention or finding under review
• A comparison intervention (if applicable—
not always present)
• The outcome
PICO
The acronym PICO assists in remembering
the steps
P: patient or problem;
I: intervention;
C: comparison intervention;
O: outcomes).
Example
“In a 55-year-old man with a 35-year-old
history of chronic smoking, would the
administration of bupropion as compared
to a nicotine replacement therapy (NRT)
be a better therapy in causing long-term
abstinence from smoking?”
PICO
P: Patient ‘s disorder or disease: 55-year old
person with a 35-year old history of
smoking.
I: Intervention or finding under review:
bupropion therapy
C: Comparison Intervention: NRT
O: Outcome: Long term abstinence from
smoking
Framing Good Questions
Describe the subject of the question. It
may be helpful to phrase the question in
this form: “How would I describe a group
of patients similar to this one?”
Framing Good… cont’d
Define which intervention you are
considering for the specific patient or
population; it may be appropriate to name
a second intervention with which to
compare the first. An example of such a
pair would be a traditional x-ray versus an
MRI.
Framing Good … cont’d
Define the type of outcome you wish to
assess. Outcomes may contain several
types. Your question may, for example,
pertain to changes in a physical sign or
prognostic indicator, the outcome of a
diagnostic test, a response to therapy, or
simply, cost effectiveness.
Write a Good Clinical Question
A nine-year-old girl presents in the ER with
diffuse abdominal pain and loss of
appetite. You suspect appendicitis, and
need to decide which imaging modality is
best for making the diagnosis—CT or
ultrasound.
Use PICO
Is ultrasound or CT better for diagnosing
appendicitis in a child?
P: Child with a suspected appendicitis
I: CT
C: Ultrasound
O: reliable diagnosis of appendicitis
Step 2: Database/Resource
Searching
• Resources generally fall into three
categories and are used in sequential
order depending on need and applicability.
The three categories are:
• General information (background)
resources
• Filtered resources
• Unfiltered resources.
General Information (Background)
Resources
Contains resources that provide background
information about various diseases,
conditions, and clinical questions.
Resources include UptoDate and other EBooks such as DeGowin’s Diagnostic
Examination, Current Diagnosis and
Treatment, Harrison’s Online, and Merck
Manual of Diagnosis and Therapy
usually in a textbook format & will not always
integrate the most current research, but
usually include references to journal
literature so you can judge the currency of
the information.
For example: measles has been nearly eradicated, but
there has been a fairly recent outbreak. If you need to
refresh your knowledge of the clinical presentation,
diagnosis, etc. of measles, a background resource would
be the best place to start
Filtered Resources
If you’re trying to decide on a course of
action for a patient (diagnosis, treatment,
etc.) and want to base your decision on
the best available evidence, consult a
filtered resource.
In filtered resources, clinical experts and
subject specialists pose a question and
then synthesize “evidence” to state
conclusions based on the available
research.
Examples
Cochrane Database of Systematic Reviews,
InfoPOEMS, ACP’s Pier (Physician’s INFO
POEMS, Information and Education
Resource), National Guideline
Clearinghouse, Natural Standard, and
Natural Medicines
Unfiltered Resources
Unfiltered resources provide the most recent
information, but it’s up to the clinician to
evaluate each study found to determine its
validity and applicability to the patient.
OVID Medline, PubMed, BIOSIS, PsycINFO,
CINAHL.
Making Search Decisions
are you looking for presentation information,
a differential diagnosis list, or types of
therapies? Try a recent background
resource, such as UpToDate, Stat!Ref, or
MDConsult.
Making… cont’d
Are you trying to decide on the best course
of action (for diagnosis, treatment, etc.)
and want to incorporate recent, reliable
evidence into your decision? Consult a
filtered resource, such as Cochrane,
National Guideline Clearinghouse,
InfoPOEMS, ACP PIER, etc.
Making… cont’d
Were you unable to find an answer to your
question in a filtered resource, or do you
want to continue your research by
checking the journal literature for original
research studies? Try an unfiltered
resource, such as MEDLINE/PubMed,
PsycINFO, BIOSIS, or CINAHL.
Search Example
In children with acute otitis media, should
watchful waiting be considered, instead of
treatment with antibiotics?
PICO
P: child with acute otitis media (AOM)
I: antibiotic therapy
C: observation/watchful waiting
O: resolution of AOM
Step 3: Critical Appraisal
After identifying an article or resource that
seems appropriate to your question (step
2), you must appraise the information
critically. If the study is from a primary
source—one that provides original data on
a topic with no commentary—you should
do a “validity” (closeness-to-truth) check.
To check for validity, ask questions related
to diagnosis, therapy, harm, and prognosis
Diagnosis
Did the patient sample include an
appropriate spectrum of patients similar to
those found in the general practice?
What was the gold standard applied to all
cases?
Therapy
Was the assignment of patients to
treatment
Groups randomized?
Were all enrolled patients accounted for at
the conclusion of the study?
Were the treatment groups similar at the
start of the study?
Harm
Were exposures and outcomes measured
similarly in the groups compared?
Where the comparison groups similar in
outcome in all respects except for the
variable studied?
Was the follow-up adequate?
Prognosis
Was the patient sample representative at a
well-defined point in the course of the
disease or disorder?
Was the length of follow-up adequate ?
Was the follow-up complete?
Try a Critical Appraisal
Consider our question about smoking
cessation: In a 55-year-old man with a 35year-old history of chronic smoking, would
the administration of bupropion as
compared to a nicotine replacement
therapy (NRT) be a better therapy in
causing long-term abstinence from
smoking?
The therapy appraisal
questions
• Was the assignment of patients to
treatment groups randomized?
• Were all enrolled patients accounted for at
the conclusion of the study?
• Were the treatment groups similar at the
start of the study?
Article identified as evidence for
the clinical question
Article Wu, P., Wilson, K., Dimoulas, P.,
Mills, E. J. (2006). Effectiveness of
smoking cessation therapies: A systematic
review and meta-analysis. BMC Public
Health, 6, 300.
Critically appraise the article
using the therapy questions
What did you conclude?
Bupropion, NRT, & varenicline all provide
smoking cessation relief. Their degree of
effectiveness varies by patient & each may
be prescribed individually or as a
combination therapy. Additional studies
are indicated for patients with active
smoking related diseases.
Step 4: Applying the Evidence
Once you have determined that a study is
internally valid (step 3), you must decide
how the study and/or other information
applies to your question. To reach your
conclusion you may consult questions
related to diagnosis, therapy, harm, and
prognosis. Keep in mind that you must
interpret the information based on a
number of criteria and depending on your
skill and experience, you may need to
confer with a peer.
Diagnosis
Is the test affordable, accurate, and available
in my hospital?
Can I estimate the pretest probability of the
disease in question?
Will the posttest probability affect my
management?
Therapy
Is my patient so different from those in the
study group that the results can not be
applied?
According to the study results, how much
would my patient benefit from treatment?
Harm
Can the study results be applied to my
patient?
What is my patient’s risk for adverse
effects?
Are there alternative therapies?
Prognosis
Is my patient similar to the patients in the
study group?
How will the evidence influence my choice of
treatment?
Sample Evidence Application
consider the diagnosis question we
analyzed earlier: A nine year old girl
presents in the ER with abdominal pain
and you suspect appendicitis. Which
imaging modality is best for making the
diagnosis—CT or ultrasound?
Diagnosis questions on applying
the evidence
• Is the test affordable, accurate, and
available in my hospital?
• Can I estimate the pretest probability of
the disease in question?
• Will the posttest probability affect my
management?
an article identified as evidence
for a clinical question.
American College of Radiology (ACR)
(2005). ACR Appropriateness Criteria®:
Right lower quadrant pain. Retrieved
August 1, 2007
Conclusions
Ultrasound, though not inexpensive is more
conclusive than CT. Based on the
Guideline, it tops the list for imaging
children in the right lower quadrant. Since
it most likely an aid in the diagnosis &
management of the patient, ultrasound in
the best choice.
Step 5: Re-evaluating the
Evidence
• Was the diagnosis and treatment
successful?
• Is there new information/data in the
literature?
• How can I improve and/or update my
clinical decisions?
Re-evaluating the Evidence
Case Outcome
In the case of the 9-year girl with lower
right quadrant pain, an ultrasound was
performed and it did indeed indicate acute
appendicitis. An appendectomy was
performed and the child had a full
recovery.
Conclusion
Based on the evidence the diagnosis was
successful. Since guidelines are updated
on a regular basis, and new articles
published, it would be prudent to review
updates regularly. This can be done by
using a variety of resources, alerts, and
routine literature searches.
Using EBP—Case Scenarios:
Introduction
A 52-year-old man, with a history of knee
pain due to osteoarthritis of the joint, visits
your office and mentions that a co-worker
has suggested that electrical nerve
stimulation—also known as TENS
(transcutaneous nerve stimulation)—can
relieve his symptoms. You need to find
some solid evidence that TENS has been
used to relieve knee pain.
More Scenarios
http://www.biomed.lib.umn.edu/learn/eb
p/mod02/case01.html
Questions?