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KEMH Medical Library: Clinical Guidelines & EBP Resources

Evidence Based Practice

Clinical Practice Guidelines "are designed to support the decision-making processes in patient care. The content of a guideline is based on a systematic review of clinical evidence - the main source for evidence-based care".

Open Clinical: Clinical Practice Guidelines


 

O & G, Midwifery and Neonatal / Paediatric Clinical Guidelines

Australian Drug Administration Clinical Guidelines

Australian General Clinical Guidelines

International Clinical Guidelines

EBP Databases & Journals

EBP Organisations

Clinical Trials

EBP Tools & Training

Evidence Based Practice is the integration of clinical expertise, patient values and the best available evidence into the decision making process for patient care. 
(Sackett, D.L., et al. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). Edinburgh: Churchill Livingstone).


 

Hierarchy of Evidence Pyramid
 

 

Some studies that I like to quote by James McCormack.

 

Question type Example Type of study

Therapy

Is this intervention more effective than another?

RCT

Diagnostic Test How accurate is this diagnostic test? Independent, blind comparison to a Gold Standard

Prognosis

What is the likely outcome, progression or survival time for this condition?

Cohort Study > Case Control > Case Series

Harm / Etiology What are the causes of this condition or state of affairs? RCT > Cohort Study > Case Control > Case Series

Prevention

How to reduce the risk of disease RCT > Cohort Study > Case Control > Case Series
Cost-effectiveness Is intervention x more cost-effective than intervention y? Economic Analysis

Quality of Life

What will be the quality of life for the patient with this condition following this intervention etc.? Qualitative Study

 *In each case a systematic review of all the available studies is better than an individual study. A systematic review will compare several RCTs that have studied the same treatment & aggregate results.


More...

Systematic Reviews

An effective systematic review "collates all empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question" (Cochrane Handbook for Systematic Reviews of Interventions  2011).

The Centre for Reviews and Dissemination at York estimates that a  team will take 9-24 months to complete a systematic review. Systematic reviews can be of interventions (i.e. randomised controlled trials) or observations (i.e. case control or cohort studies).

A systematic review should have:

  • clearly stated objectives with pre-defined eligibility criteria for studies
  • explicit, reproducible methodology
  • a systematic search that attempts to identify all studies
  • assessment of the validity of the findings of the included studies (e.g. risk of bias)
  • systematic presentation, and synthesis, of the characteristics and findings of the included studies

“the quality of a systematic review depends on the quality of the studies appraised. It can be difficult to reach meaningful conclusions from reviews of low-level evidence, and thus, systematic reviews are commonly limited to high-level evidence (Level I or II) studies (RCTs)”.

Wright, R.W.,  Brand, R.A., Dunn,W. & Spindler, K.P. (2007). How to Write a Systematic Review. 

Why are systematic reviews necessary?

Problems with systematic reviews

Introduction to systematic reviews by Susan Shenkin)


Steps for conducting a systematic review

Step 1: Scope the literature

Step 2: Form a team

Step 3: Formulate the question, develop and register the protocol

Step 4: Systematically search the literature

Step 5: Data extraction

Step 6: Quality appraisal

Step 7: Data synthesis

Step 8: Interpreting results, presenting the review

 

(References: Higgins, J. & Green, S. (2011). Cochrane Handbook for Systematic Reviews of Interventions Wright, R.W.,  Brand, R.A., Dunn,W. & Spindler, K.P. (2007). How to Write a Systematic Review. Clinical Orthopaedics and Related Research, 455, pp. 23–29; Simons, M. (2011).  Guidelines for writing systematic reviews; Curtin University Systematic Reviews; Duke University: Systematic Reviews: The Process; University of Edinburgh, Systematic reviews and meta-analyses: a step-by-step guide )


Guidance

Cochrane Handbook for Systematic Reviews of Interventions

The Campbell Collaboration: Producing a Review

Institute of Medicine Standards for Systematic Reviews

PRISMA statement, flowchart & checklist

Systematic Reviews: Center for Reviews and Dissemination's guidance for understanding reviews in health care

Curtin University: Systematic Reviews

Duke University: Systematic Reviews: The Process

University of Edinburgh: Systematic Reviews and Meta-analyses

National Collaborating Centre for Methods and Tools. (2014). Anatomy of a Systematic Review [fact sheet].


Systematic Review verses Literature Review

  

      Criteria           

 

    Systematic Reviews          

            

  Literature Reviews

Question

Focused on a single question (often PICO based)

Not necessarily focused on a single question - may describe an overview

Protocol

A peer reviewed protocol or plan is included

No protocol included

Background

Summarises the available literature

Summarises the available literature

Objectives

Clear objectives are identified

Objectives may or may not be identified

Inclusion/Exclusion Criteria

Criteria stated before the review is conducted

Criteria not stated

Search Strategy

Comprehensive and systematic (stated in the document)

Strategy not explicitly stated (not always comprehensive or systematic)

Process of Selecting Articles

Usually clear and explicit

Not described in a literature review

Process of Evaluating Articles

Comprehensive evaluation of study quality

Evaluation of study quality may or may not be included

Process of Extracting Information

Usually clear and specific

Not clear or explicit

Results & Data Synthesis

Clear summaries of studies based on high quality evidence

Summary based on studies where the quality of the articles may not be specified. May also be influenced by the reviewer's theories, needs and beliefs.

Discussion

Written by an expert or group of experts with a detailed and well grounded knowledge of the issues

Written by an expert or group of experts with a detailed and well grounded knowledge of the issues

(from Curtin University Library's Systematic Review guide)

 

 

 

The first step in finding the evidence is to ask the right question!

There is an art to constructing a clinical question in such a way that you maximise your chances of finding meaningful information in an efficient manner.

For example, imagine the following scenario:

Your patient is a thirty year old woman, 14 weeks pregnant with her first child.  On an initial antenatal visit she is found to have a BMI of 32, putting her in the obese range.  You are concerned about the risk of adverse outcomes for the woman and her baby, especially if she gains a lot of weight during her pregnancy.  You wonder whether dietary or lifestyle interventions could help your patient limit her weight gain during the remainder of her pregnancy.

 

One approach to turn our scenario into a clinical question is to use the PICOT formula. This helps us to pick out the key point from our scenario.

 

P = Patient or Population or Problem

"thirty year old woman, 14 weeks pregnant with her first child.....BMI of 32"

I = Intervention

"dietary or lifestyle interventions"

C = Comparison

usual care

O = Outcome

"limit her weight gain during pregnancy"

T = Type of study

Question = therapy; study type = RCT or systematic review

 

 

The next step is to translate the key points we have identified into keywords. 

When considering keywords, it is important to choose terms which will help us find the information we need, without narrowing down our search too much.  For example "BMI of 32" is too specific; "obese" would be a better term. 

We also need to consider synonyms, or alternative terms, for our keywords, in order to capture as many relevant articles as possible.  For example, alternative terms for "lifestyle intervention" could include "exercise" or "diet".

Next we need to consider dropping some terms which may be redundant.  For example, if we include the term "pregnant" or "antenatal" we don't need the term "woman".  If the comparison is "usual care", we don't need to specify this in our keywords.

Finally, we need to think how to form our terms into an effective search strategy.  We combine alternative terms with OR and terms for different concepts with AND.

We could end up with something like this:

obese OR overweight

AND

pregnant OR pregnancy OR antenatal OR prenatal

AND

lifestyle OR diet OR exercise

AND

weight gain OR excessive weight

limit to Systematic Reviews or RCTs.


More...

Formulate a Clinical Question UWA Faculty of Medicine, Dentistry & Health Science

Find the best evidence UWA Faculty of Medicine, Dentistry & Health Science

The well-built clinical question: a key to evidence-based decisions. Richardson, WS. et al. ACP Journal Club, v123:A12, Nov-Dec, 1995.

Where do I find the evidence?

There are a host of medical databases, and it can be difficult to know where to begin.  The most efficient method is to start at the top of the 'hierarchy of evidence' pyramid  (see About EBP tab) and work down.  This way you start by searching the most highly filtered resources, which may be able to give you a quick answer to your query.  Only after checking these do you work your way down to the unfiltered resources containing single studies which will take you time to appraise.  

 

Clinical decision-making tools, such as Best Practice and Dynamed, have already synthesised and summarised the evidence on many topics for you.  You may also find it useful to look at local and international guidelines, including the KEMH and RANZCOG guidelines as well as those from the Australian Clinical Guidelines Portal , the National Guideline Clearinghouse (US) and the NICE Pathways (UK). Also see the Clinical Guidelnes & EBP Resources tab above.

 

If you do not find the answer to your query in the guidelines or clinical decision-making tools, you may be able to find a relevant systematic review.  The Cochrane Library provides access to systematic reviews, as does TRIP and the PubMed clinical queries search.

 

If your query relates to a less common topic, the evidence may not yet have been synthesised.  In this case you will need to use unfiltered resources to look for original studies, and then appraise them yourself.  You will also need to find original studies if you are involved in research, or in producing or updating guidelines, since filtered resources will often not include the very latest, cutting-edge research.  Databases in which you can find quality single studies include: MedlinePubMedCinahlPsycInfo; Embase.  For a complete list of relevant databases, consult the subject guide for your area of interest.

 

Alternatively, this table gives examples of clinical questions matched with selected databases.   

Appraising the Evidence

"Critical appraisal is the process of carefully and systematically examining research to judge its trustworthiness, and its value and relevance in a particular context."

CASP http://www.healthknowledge.org.uk/interactive-learning/fae/overall-intro-to-critical-appraisal

The following resources will help you:

  • Decide whether specific studies have been undertaken in a way that makes their findings reliable.
  • Make sense of the results.
  • Know what these results mean in the context of the decision that needs to be made.

 

Critically Appraising Evidence for Healthcare JBI eBook

Synthesizing Quantitative Evidence JBI eBook

 

Practice Guidelines

Practice Guideline Critical Appraisal Worksheet - Duke University

 

Systematic Reviews

Inclusion Criteria  McMaster University guide to inclusion criteria for systematic reviews.

Anatomy of a Systematic Review National Collaborating Centre for Methods and Tools (Canada)

CASP critical appraisal of Systematic Reviews

Systematic Review (of Therapy) worksheet  CEBM Toronto

Systematic Review Critical Appraisal   Duke University

 

Randomised Controlled Trials

CASP critical appraisal of RCTs

 

Therapy

FRISBE for critical appraisal of therapy studies. Duke University

Therapy worksheet  CEBM Toronto

Therapy Critical Appraisal Worksheet  Duke University

 

Diagnosis

Evidence-based Medicine: Answering questions of diagnosis  Clin Med Res 2004. 2(1):63-9. 

An introduction to critical appraisal of articles of diagnosis  J Am Osteopath Assoc 2007. 107(8):304-9. 

Diagnosis Critical Appraisal Worksheet  Duke University

Diagnosis worksheet  CEBM Toronto

Stats Calculator  CEBM Toronto

How to calculate Likelihood Ratios CEBM Toronto

Diagnostic Test Calculator  Alan Schwartz, University of Illinois, Chicago.

Synthesizing Evidence of Diagnostic Accuracy JBI eBook

 

Prognosis

Prognosis Critical Appraisal Worksheet  Duke University

Prognosis worksheet  CEBM University of Toronto

 

Harm

Harm worksheet  CEBM University of Toronto

Harm Critical Appraisal Worksheet  Duke University

Synthesizing Evidence of Risk JBI eBook

 

Differential Diagnosis

Differential Diagnosis Critical Appraisal Worksheet Duke University

 

Economic Evaluation

CASP critical appraisal of economic evaluations

Synthesizing Economic Evidence JBI eBook

 

Qualitative Studies

Qualitative Study Critical Appraisal Worksheet Duke University

Qualitative Research in Health Care A. Are the Results of the Study Valid? JAMA. 2000 Jul 19;284(3):357-362.

Qualitative Research in Health Care B. What Are the Results and How Do They Help Me Care for My Patients? JAMA. 2000 Jul 26;284(4):478-482.

Synthesizing Qualitative Evidence JBI eBook

Synthesizing Evidence from Narrative, Text and Opinion JBI eBook

 

Quality Improvement

How to Use an Article About Quality Improvement. JAMA 2010;304 2279-2287

 

More...

Appraise the evidence UWA Faculty of Medicine, Dentistry & Health Sciences

Apply the evidence UWA Faculty of Medicine, Dentistry & Health Sciences

Knowledge Translation in Healthcare JBI eBook

Public Engagement in Translating Knowledge to Action JBI eBook

Translation Science and the JBI Model of Evidence Based Healthcare JBI eBook

 

Videos, articles & tools to help you calculate results.

Number Needed to Treat

How to calculate the number-needed-to-treat  Terry Shaneyfelt.  video 3 min

The NNT Tutorial  Grahm Walker video 4 min

Number needed to treat Phillip Sedgewick.  BMJ 2010;341:c5614

Number Needed to Treat (Dr. Cates)

 

Absolute Risk Reduction, Relative Risk Reduction, Relative Risk

How to calculate a relative risk  Terry Shaneyfelt.  video 3 min

Basic Statistics for Clinicians: Assessing the effects of treatment: measures of association   CMAJ. 1995 Feb 1;152(3):351-7. Erratum in: Can Med Assoc J 1995 Mar 15;152(6):813.

 

Odds Ratios

Gordon Guyatt explaining odds ratios video 21 min

How to calculate an odds ratio  Terry Shaneyfelt.  video 3 min

Odds ratios.  Philip Sedgwick.  BMJ 2010;341:c4414 

 

Intention-to-Treat

Intention-to-treat analysis - What it is and why is it important?  Terry Shaneyfelt  video 5min

What is intention-to-treat analysis? Allan Shaughnessy video 1 min

What is the intention-to-treat analysis?  Philip Sedgewick   BMJ 2013;346:f3662

 

Forest Plots

How to interpret a forest plot.  Terry Shaneyfelt video 5 min 

Interpreting and understanding meta-analysis graphs--a practical guide. Aust Fam Physician. 2006 Aug;35(8):635-8. PubMed PMID: 16894442

 

Confidence Intervals

Confidence intervals.  Terry Shaneyfelt video 5 min

Basic Statistics for Clinicians: Interpreting study results: confidence intervals  CMAJ. 1995 Jan 15;152(2):169-73.

 

Sensitivity, Specificity and Likelihood ratios

Sensitivity & specificity  H. Gilbert Welch video 8 min

How to calculate sensitivity  Terry Shaneyfelt video 4 min

How to calculate specificity  Terry Shaneyfelt video 3 min

What are likelihood ratios and how are they used  Terry Shaneyfelt video 10 min

Table of Examples of LR (scroll down to table)

More...

more videos by Allan Shaughnessy

Stating the meaning of effect size measures in plain English  

These links courtesy of Duke University

Qualitative Research

"studying the behaviour of individuals in all the complexity of their real-life situations"   Bawden, D. (1990). User-oriented evaluation of information systems and services. England: Gower. p.27

"Not everything that counts can be counted, and not everything that can be counted counts" Albert Einstein


While there is great variation in qualitative research approaches, the following two features emerge across approaches:

  • interpretive - qualitative research focuses on understanding the way people interpret and make sense of their experiences and the world in which they live
  • naturalistic - qualitative research studies social phenomena in their natural settings

From Qualitative Research Guidelines Project

 

Advantages of Qualitative Data Analysis

Disadvantages of Qualitative Data Analysis

From Analyse This!!! Learning to analyse qualitative data


  Quantitative Research Qualitative Research

General Framework

  • Seeks  to confirm hypotheses
  • Postivist paradigm
  • Seeks to explore phenomena
  • Naturalistic paradigm
Objectives
  • To predict & control
  • To understand (what, how & why)

Tools

  • Highly structured methods: questionnaires, surveys & structured observation
  • Use semi-structured methods: in-depth interviews, focus groups & participant observation
Design
  • Rigid design
  • Controlled & experimental
  • Emergent design

Focus

  • Prediction
  • Outcomes
  • Generalisability
  • Rich description
  • Similarities & contrasts
  • Process & context
Data analysis
  • Statistical
  • Non-statistical

Sampling

  • Relatively large samples often using random sampling
  • Small samples using purposive, convenient or snow ball sampling

Table from Qualitative Research in Nursing


Finding Qualitative Research

Formulate your question using:

Population AND Situation

or PICo

Population 

phenomena of Interest

Context

See PICO or PICo from Systematic Reviews Guide Curtin University


Search 

Integrative Approaches to Qualitative and Quantitative Evidence, National Institute for Health and Clinical Excellence (NICE), UK. Add qualitative as a keyword.

Campbell Collaboration Systematic reviews on the effects of interventions within the areas of education, crime & justice, social welfare & international development

Note: Try adding qualitative or qualitative research as a concept in other databases.

Qualitative research filter for PubMed

PubMed includes saved search strategies (queries) that may help in the identification of literature relavent to health services research, including qualitative research.

  1. Connect to PubMed
  2. Under PubMed Tools choose Topic-Specific Queries .
  3. Choose Health Services Research (HSR) Queries.
  4. Select category Qualitative Research and choose narrow (usually preferable) or broad scope.  [Note:  To see what this actually searches, click on filter table.]
  5. Type topic terms in search box and click Go.

A modification of this strategy is linked below. Click on the strategy to run the search in PubMed, using the KEMH-specific URL.  You may then add other concepts to the search

qualitative research [MeSH] OR qualitative[tiab] OR themes[tiab]

Adapted from Duke University


Guidance 


More...

Qualitative Study Critical Appraisal Worksheet Duke University

Appraising qualitative research articles in medicine and medical education Cote, L. & Turgeon, J. (2005). Medical Teacher. 27(1): 71-75.

Appraising qualitative research in health education: guidelines for public health educators Jeanfreau, SG & Jack, L. (2010) Health Promot Pract. 11(5): 612-617.

Qualitative Research in Health Care A. Are the Results of the Study Valid? JAMA. 2000 Jul 19;284(3):357-362.

Qualitative Research in Health Care B. What Are the Results and How Do They Help Me Care for My Patients? JAMA. 2000 Jul 26;284(4):478-482.

Qualitative research and its uses in health care  Al-Busaidi ZQ. Sultan Qaboos University Medical Journal. 2008;8(1):11-19.

The art and science of clinical knowledge: Evidence beyond measures and numbers. Malterud, K. (2001).  The Lancet. 358: 397-400.

 

Synthesizing Qualitative Evidence JBI eBook

Synthesizing Evidence from Narrative, Text and Opinion JBI eBook

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