How to find current best evidence

Unit Pengembangan & Evaluasi Pendidikan ( UPEP ) FacultY of MedicinE UniversitY of SriwijayA Palembang

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Introduction
One

solution for the problem of obsolescence of professional education is problem-based learning or learning by inquiry. That is, when confronted by a clinical question for which we are unsure of the current best answer, we need to develop the habit of looking for the current best answer as efficiently as possible

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The success of learning

by inquiry depends heavily on being able to find the current best evidence to manage pressing clinical problems a task that can be either quick and highly rewarding or time-consuming and frustrating.

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ORIENTATION TO EVIDENCE-BASED INFORMATION RESOURCES

Where to

find the best evidence

1. Burn your traditional textbooks 2. Take a 4S approach to evidence-based information access 3. Organize access to evidence-based information services 4. Is it time to change how you seek best evidence?

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1. Burn your traditional textbooks

begin

with textbooks, only to dismiss all but the best of a new breed of them because textbooks are generally well organized for clinical use and much of their content will be current at any one time Unfortunately, in most texts, theres no way to tell what is up-to-date and what is not.

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we

may find some useful information in texts about background questions, such as the pathophysiology of clinical problems. it is best not to use them for seeking the answers to foreground questions, such as the causal (risk) factors, diagnosis, prognosis, prevention or treatment of a disorder if there is an up-to-date, evidence-based alternative.

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2. Take a 4S approach to evidence-based information access

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3. Organize access to evidence-based information services

almost all the resources just reviewed are available on the Internet added value of accessing these services on the Internet is considerable, including links to full-text journal articles, patient information, and complementary texts. you need to be in a location, such as a medical library, hospital or clinic You should ask your university, professional school, hospital, or clinic librarian about what digital library licenses are available and how you can tap into them

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the UK National Health Service provides a broad range of evidence-based and other information to all health professionals and citizens through its National Electronic Library of Health (NeLH, http://www.nelh.nhs.uk/), and Australia and LatinAmerican countries have free access to the Cochrane Library in a country with low resources, The Health Internetwork Access to Research Information program (HINARI, http://www.healthInternetwork.net/) provides institutional access to a wide range of journals and texts at no or low cost.

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. Free access to high-quality evidence-based information abounds on the Internet; beginning with PubMed and its full-text links; open-access journals, such as BioMed Central (http://www.biomedcentral.com/), and the Public Library of Science (http://www.publiclibraryofscience.org/); the many evidence-based resources available through SCHARR (http://www.shef.ac.uk/~scharr/ir/netting/) using free Internet services requires a commitment to finding and appraising information; free, high-quality evidence-based information is in much lower supply and concentration on the Internet than in the specialized resources mentioned above.

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4. Is it time to change how you seek best evidence?

Compare the 4S approach with how you usually seek evidence-based information it surprises that MEDLINE is low on the 4S list of resources for finding current best evidence, then this communication will have served a purpose Resources for finding evidence have evolved in the past few years, and searches can be a lot quicker and more satisfying for answering clinical questions if the features of your quest match those of one of the evolved services

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to

think of organizing your information needs is prompt, pull, push Prompt corresponds to the highest S level systems Pull corresponds to the three lower levels of the 4S approach: you go hunting to pull the evidence you need from available resources Push refers to having evidence sent to you; controlling this is the subject of the next section.

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HOW TO DEAL WITH THE EVIDENCE THAT FINDS YOU: KEEPING UP TO DATE EFFICIENTLY
1.

Cancel your full-text journal subscriptions 2. Invest in evidence-based journals and online services

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1. Cancel your full-text journal subscriptions

Trying to keep up-to-date in your clinical practice by reading full-text journals is a truly hopeless task. From an evidence-based perspective, for a broadbased discipline the number of articles you need to read to find one article that meets basic criteria for quality and relevance ranges from 86 to 107 for the top five full-text general journals

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minutes per article, thats about 3 hours to find one article ready for clinical action; and then the article may cover old ground or provide me-too evidence of yet-another statin, or not be useful to you because of the way you have specialized the scope of your practice You should trade in your (traditional) journal subscriptions. It will save you time but wont necessarily save you money, because you will need to invest in better resources for keeping current

2. Invest in evidence-based journals and online services

A growing number of periodicals summarize the best evidence in traditional journals selections according to explicit criteria for merit, providing structured abstracts of the best studies and expert commentaries about the context of the studies and the clinical applicability of their findings. synoptic journals include ACP Journal Club, Evidence Based Medicine, Evidence Based Mental Health, Evidence Based Nursing, Evidence Based Health Care Policy and Practice, Evidence Based Cardiovascular Medicine, and a number of others.

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Synoptic journals do

what traditional journals wish they could do in selecting the best studies, finding the best articles from all relevant journals and summarizing them in one place Traditional journals cant do this because they can only publish from among the articles that authors choose to send them

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Searching for evidence to solve patient problems

the use of evidence-based information resources is best learned by examples and practice, not by reading Commit yourself to paper on three matters for each of the problems below: 1. The key question to seek an answer for (using the guidelines from Ch. 1). 2. The best answer to the clinical problem that you currently have stored in your brain (being as quantitative as possible). 3. The evidence resources (both traditional and avant garde) that you would consult to find best current answers.

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Carrying out the searching steps

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Problem
Type 2 diabetes and related cardiovascular risk.

Step 1.

Asking answerable questions Step 2A. Selecting an evidence resource Step 2B. Executing the search strategy Step 2C. Examining the evidence

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Step 1. Asking answerable questions

Investigations have shown that Mrs Smothers has an A1c of 8.9%, microproteinuria and hyperlipidemia, with total cholesterol 6.48 mmol/L, LDL 3.4 mmol/L, HDL 0.9 mmol/L, and triglycerides 3.9 mmol/L. With this additional information, we pose the question: In a 56-year-old woman with type 2 diabetes mellitus, microproteinuria, elevated blood pressure, and dyslipidemia, what is the evidence concerning increased risk for cardiovascular complications compared with people with diabetes without these risk factors (and does the risk calculator that Mrs Smothers found provide an evidence-based estimate of risk that fits her circumstances)? In such a patient, does tight control of glucose, blood pressure, cholesterol, and proteinuria reduce subsequent morbidity and mortality?

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Step 2A. Selecting an evidence resource

the focus will be on the best and quickest evidencebased information sources for this clinical discipline, including general and specialized bibliographic databases, in both print and electronic form. electronic media with periodic updates (especially on the Internet, with CD valuable when the Internet is not readily accessible) are rendering paper sources obsolete for looking up evidence

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Electronic media are generally much more accessible, much more thoroughly indexed, and, most importantly, have the potential to be much more up-to-date than paper-based resources. hypertext and the Internet permit unlimited linkages to related and supplementary information a good computer (whether ours or someone elses) with an Internet link (or at least a CD-ROM drive), and a working knowledge of the evidence resources that have been developed for our own clinical discipline, can make an important difference to whether we will be successful in becoming evidence-based practitioners.

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How to deal with the evidence that finds you

The first piece of

information to consider in this case falls into the general category of evidence that finds you patients frequently find information that they want you to comment on you need an efficient approach to evaluating the pedigree and evidence base for claims they encounter on the Internet or other media

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The patient brought along a web page (http://www.betterdiabetescare.org/TOOLBOXrisk.htm) that she had found through Google, so it was easy to examine this source This website has impeccable credentials, with material prepared by the National Diabetes Education Program with sponsorship from the US National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and Centers for Disease Control, and without commercial advertising. This is not to say that the information on the website is necessarily either accurate or up-to-date, but it is more likely to be so than websites that lack these features

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Two

risk calculators for cardiovascular disease are offered on the website, one from Framingham, which can be done with a pencil and paper (http://www.nhlbi.nih.gov/about/framingham/risk wom.pdf), the other from the UK (http://www.dtu.ox.ac.uk/index.html?maindoc=/ri skengine/).

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Where to find the best evidence

Using

the 4S approach, we begin with Ovid, the 4S supermarket, and head for Clinical Evidence, a system that integrates current best evidence for specified clinical questions

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Step 2B. Executing the search strategy

Using our librarys Ovid access from home look up Clinical Evidence, browse the table of contents to Endocrine Disorders, and see five subtopics, two of which are Cardiovascular disease in diabetes and Glycemic control in diabetes. The first of these topics links to a summary of interventions organized in three categories (beneficial, likely to be beneficial, and unknown effectiveness), followed by key messages

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The first of the topics links to a summary of interventions organized in three categories (beneficial, likely to be beneficial, and unknown effectiveness), followed by key messages This section summarizes several recent trials with quantitative results (including number needed to treat, NNT; showing cardiovascular benefits from lowering blood pressure, lipids, and blood sugar as well as from prescribing aspirin bookmark and print the table for reference when you have completed your search

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Step 2C. Examining the evidence

Discounting the side-trip to more traditional textbooks assembled the system, synopsis, and study level information needed to inform an evidence-based decision The Gaede study is summarized in ACP Journal Club, so it has already passed muster for scientific merit and we can skip this critical appraisal step unless we want to look for details that dont appear in the ACP Journal Club abstract The study investigated the benefits of intensive management of type 2 diabetes in a diabetes clinic compared with conventional care by family practitioners with open access to consultation

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