Agenzia sanitaria e sociale regionale Literature search in

Agenzia sanitaria e sociale regionale Literature search in neurology: an evidence-based approach Luca Vignatelli and Chiara Bassi http: //asr. regione. emilia-romagna. it International Course of Neuroepidemiology Chișinău, Moldova September 24 -28, 2012

Agenzia sanitaria e sociale regionale We will cover … 1. Basic principles to organize the search for Evidence-Based literature 2. Main websites of Evidence-Based literature Focus on - neurology - free websites

Agenzia sanitaria e sociale regionale 1 Medical literature: resource or problem?

Agenzia sanitaria e sociale regionale 2010 … AND NOW?

Hierarchy of evidence: the pyramid model Agenzia sanitaria e sociale regionale (Di. Censo et al. 2009)

Agenzia sanitaria e sociale regionale Production of medical literature: bottom-up process Guidelines / HTA Systematic Reviews Primary Literature

Agenzia sanitaria e sociale regionale 2 How to organize your search strategy TIPS

Agenzia sanitaria e sociale regionale 1 st TIP Clarify yourself what kind of information you need

Agenzia sanitaria e sociale regionale Are you looking for … 1) Information on clinical background … ? 2) New ideas, innovations, emerging technologies or drugs (horizon scanning) … ? 3) A prompt answer on specific clinical questions (focused search) … ? 4) An exhaustive analysis of literature on a specific argument (systematic search) … ?

Agenzia sanitaria e sociale regionale I will focus on … • evidence for clinical background: clinical practice guidelines • evidence for a specific clinical question (focused search) – systematic reviews – health technology assessment documents – … but also primary studies

Agenzia sanitaria e sociale regionale 2 nd TIP Formulate an answerable clinical question: PICO model

Agenzia sanitaria e sociale regionale Clinical question: PICO model Population Intervention one patient, or a group of patients with a particular condition or a health problem Comparator Outcome a standard intervention, a placebo or no intervention the intervention of interest, which can be therapeutic (e. g. a drug), preventive (e. g. vaccination), diagnostic (e. g. blood pressure measure), prognostic (e. g. a risk factor), etc… Expected clinical result (death risk, quality of life, adverse events)

Agenzia sanitaria e sociale regionale Example: Diagnostic accuracy Subject with mild memory impairment. You wonder if PET is useful for diagnosis of Alzheimer’s disease. Population Intervention People with mild memory impairment Comparator Outcome Standard practice Positron Emission Tomography Sensitivity and specificity compared to reference standard of Alzheimer’s disease

Agenzia sanitaria e sociale regionale Example: Therapeutic effectiveness Subject with drug-resistant mesial temporal lobe epilepsy. You wonder if surgery (anteromesial temporal resection) is effective in obtaining freedom from disabling seizure. Population Intervention People with drug-resistant mesial temporal lobe epilepsy Comparator Outcome Standard practice Anteromesial temporal resection freedom from disabling seizures during year 2 of follow-up

Agenzia sanitaria e sociale regionale Example: Prognosis Asymptomatic subject with incidental MRI abnormalities suggestive of demyelinating disease. You wonder what is the 2 -year risk of clinical progression. Population Intervention Asymptomatic subject Comparator Outcome Standard practice Incidental MRI abnormalities suggestive of demyelinating disease = risk or predictive factor clinical progression at 2 years of follow-up

Agenzia sanitaria e sociale regionale 2 nd TIP … then, choose 1 or more keywords from the PICO to search databases

Agenzia sanitaria e sociale regionale 3 rd TIP Which database? … apply a hierarchical approach … from high-quality summary/synthesis documents to single studies

Agenzia sanitaria e sociale regionale Search for evidence: top-down approach Guidelines / HTA Systematic Reviews Primary Literature

Agenzia sanitaria e sociale regionale 4 th TIP Searching a “large“ database is different from searching a “small” database

Agenzia sanitaria e sociale regionale 4 th TIP Small database: use few words Large database: use more words

Agenzia sanitaria e sociale regionale 3 Searching in practice

Agenzia sanitaria e sociale regionale Your perspective: general clinical background Guidelines Why should we need clinical practice guidelines? • to define the clinical pathway of a disease • to assist decisions about appropriate health care for a specific disease • to choose relevant clinical questions

Agenzia sanitaria e sociale regionale Clinical Practice Guidelines What are they? • "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances“ • Essential features: • identification and assessment of the evidence: systematic review • judgment of the strength of the evidence: grading • review and critique of all these elements by methodologists, clinicians, and other relevant parties: multidisciplinary Field and Lohr, Institute of Medicine, 1992

Agenzia sanitaria e sociale regionale Who produces clinical practice guidelines? • • INTERNATIONAL HEALTH AGENCIES • guidelines published on their websites SCIENTIFIC SOCIETIES • guidelines published in medical journals or on their websites

Agenzia sanitaria e sociale regionale The search method Main websites • a guidelines database: NGC • some guidelines websites: • national health agencies: NICE, SIGN • scientific societies: AAN, EFNS*, ILAE

Agenzia sanitaria e sociale regionale National Guideline Clearinghouse™ • an initiative of the Agency for Healthcare Research and Quality (AHRQ), U. S. Department of Health and Human Services • database: 2421 guidelines (access 6 th June 2012) • “search” engine and index by argument • you can find – summary of single guidelines and link to full text – comparitve documents (guidelines syntheses) • free access: www. guideline. gov

- National Institute for Health and Clinical Excellence Agenzia sanitaria e sociale regionale NICE http: //www. nice. org. uk/

– Scottish Intercollegiate Guidelines Network Agenzia sanitaria e sociale regionale SIGN http: //www. sign. ac. uk/guidelines/published/index. html

Agenzia sanitaria e sociale regionale Scientific societies Clinical Practice Guidelines in Neurology • American Academy of Neurology (AAN) www. aan. com/go/practice/guidelines • Practice Parameters and Assessments • • X European Federation of Neurological Societies (EFNS) www. efns. org • • • Free full text More than 70 guidelines since 2000 Very recently: access restricted only to EFNS members International League Against Epilepsy (ILAE) www. ilae. org • • Few documents Free full text

Agenzia sanitaria e sociale regionale EXAMPLE How thrombolysis should be provided in subjects with major ischemic stroke? P Ischemic stroke I Thrombolysis C O

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Agenzia sanitaria e sociale regionale EXAMPLE How healthy lifestyles recommendations should be provided in subjects with vascular risk factors? P I C O Healthy Lifestyles

Agenzia sanitaria e sociale regionale Your perspective: utility of a single technology Health Technology Assessment Why should we need HTA documents? • to assist decisions on acquiring, buying or applying a technology • Technology = any intervention used to promote health, to prevent, diagnose or treat acute or chronic disease, or for rehabilitation

Agenzia sanitaria e sociale regionale Health Technology Assessment What is it? • The systematic evaluation of properties, effects, and impacts of health care technology • Its main purpose is to inform technology-related policymaking in health care • HTA is conducted by interdisciplinary groups using explicit analytical frameworks drawing from a variety of methods from HTA glossary - www. htaglossary. net

Agenzia sanitaria e sociale regionale Who produces HTA reports? • INTERNATIONAL HEALTH AGENCIES • HTA reports published on their websites − AHRQ (US) − NICE (UK) − HTA – NETSCC (UK) − CADTH (CAN)

Agenzia sanitaria e sociale regionale The search method Main websites • one database: HTA database included in the Centre for Reviews and Dissemination website, University of York, UK • national health agencies websites: • AHRQ, NICE, HTA – NETSCC, CATDH

Agenzia sanitaria e sociale regionale Centre for Reviews and Dissemination • 3 databases: DARE, HTA database, ECON • Centre for Reviews and Dissemination, University of York, funded by National Institute of Health Research, (National Health System, UK) • focused on systematic reviews and HTA reports that evaluate the effects of health care interventions and the delivery and organization of health services • Free access: abstracts and critical appraisal of 9, 000 systematic reviews, and 10, 000 HTA documents www. crd. york. ac. uk/crdweb/

Agenzia sanitaria e sociale regionale EXAMPLE Is Da. TSCAN (123 I-Ioflupane; GE Healthcare) useful to diagnose central neurodegerative disorders? P I C O Da. Tscan

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Agenzia sanitaria e sociale regionale Your perspective: focused clinical question Systematic Reviews

Agenzia sanitaria e sociale regionale Systematic Reviews What are they? • a review that has been prepared using a systematic approach to minimising biases and random errors which is documented in a materials and methods section • A systematic review may, or may not, include a meta-analysis: a statistical analysis of the results from independent studies, which generally aims to produce a single estimate of a treatment effect Chalmers and Altman 1995

Agenzia sanitaria e sociale regionale Who produces Systematic Reviews? • International health agencies • Cochrane Collaboration • Scientific societies • Single researchers

The search method Agenzia sanitaria e sociale regionale Main websites • two databases: • Cochrane Database of Systematic Reviews, included in the Cochrane Library • DARE, included in the Centre for Reviews and Dissemination website, University of York, UK

Agenzia sanitaria e sociale regionale Cochrane Database of Systematic Reviews • Best reliable source for information on the effectiveness of healthcare interventions • Electronic publication updated monthly • 5102 systematic reviews (access June 2012) • Since 2008: you can find also few Diagnostic Test Accuracy systematic reviews • Published by Wiley Interscience (www. thecochranelibrary. com) • Free access: abstracts of systematic reviews • With fee: full-text of systematic reviews

Agenzia sanitaria e sociale regionale Cochrane Neurological Field • A source of useful information for people around the world who are involved with or interested in the practice of evidence-based neurology • The primary aims and activities – Facilitate the production of systematic reviews in neurology and neurosurgery – Serve as liaison for neurological Cochrane Review Groups – Facilitate access to Cochrane reviews and disseminate reviews to a worldwide neurological audience – Promote an evidence-based approach to healthcare in the field of neurology http: //neuronet. cochrane. org/

Agenzia sanitaria e sociale regionale EXAMPLE Are interferon or glatiramer effective in delaying conversion of the first demyelinating event to multiple sclerosis? P I C O first demyelinating event

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Agenzia sanitaria e sociale regionale Your perspective: focused clinical question Primary Literature

Agenzia sanitaria e sociale regionale Pub. Med • U. S. National Library of Medicine's® (NLM) premier bibliographic database Over 19 million references to journal articles in life sciences with a concentration on biomedicine • • Citations from 5. 394 biomedical journals published in 70 countries • Goes back to 1950 • Access free (from 1997): http//www. pubmed. gov

Agenzia sanitaria e sociale regionale Pub. Med: some tips An electronic search strategy should generally have different sets of terms: 1) terms to search for the health condition of interest [P] 2) terms to search for the intervention(s) evaluated [I] 3) terms to search for the types of study design to be included filters from the CLINICAL QUERIES function

Agenzia sanitaria e sociale regionale EXAMPLE Are interferon or glatiramer effective in delaying conversion of the first demyelinating event to multiple sclerosis? P first demyelinating event I interferon / glatiramer C O

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Agenzia sanitaria e sociale regionale Too much information, too little time

Guidelines/HTA Systematic reviews Primary Literature Sistemi di Monitoraggio Meta-engines Agenzia sanitaria e sociale regionale Meta-engines

Agenzia sanitaria e sociale regionale TRIPdatabase • … is not a database but • … a search engine designed to allow clinicians to quickly find answers to their clinical questions using the best available evidence • It permits the simultaneous searching of multiple websites (mainly EBM) • Free access: http: //www. tripdatabase. com/

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Agenzia sanitaria e sociale regionale P. S. … 2 final suggestions

Agenzia sanitaria e sociale regionale … when You need … … a reporting guideline, i. e. recommendations on how to write your clinical research papers … … search EQUATOR Network http: //www. equator-network. org/home/

Agenzia sanitaria e sociale regionale

Agenzia sanitaria e sociale regionale … when You need… … FREE tools for practice and teaching of evidence-based medicine … … go to the Centre for Evidence-based Medicine (CEBM), University of Oxford http: //www. cebm. net/

Agenzia sanitaria e sociale regionale

Agenzia sanitaria e sociale regionale vigna@interfree. it lvignatelli@regione. emilia-romagna. it