SPH1904 Data Literacy: Evidence-Based Practice

• SPH1904 Data Literacy for Healthcare is presented by NUS Libraries

Course Outline

• What is Evidence-Based Practice
• Frame a clinical question using PICO
• Learn the basic search techniques in PubMed
• Evaluate the sources of information

Evidence-Based Practice (EBP)

• EBP is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient
• EBP integrates individual clinical expertise with the best available external clinical evidence from systematic research
• EBP involves best research evidence, clinical expertise and patient values & preferences

The EBP Process

• The 5 steps of evidence-based practice based upon the Sackett et al model are:
• Assess the patient
• Ask a clinical question
• Acquire best evidence
• Appraise the evidence
• Apply the evidence, incorporate values

Frame a Clinical Question Using PICO

• To use evidence-based practice, a clear idea of the question you would like to answer is needed
• PICO helps formulate a clinical question and guide your search for evidence
• PICO stands for:
• Patient or Problem
• Intervention
• Comparison
• Outcome

Case Scenario

• Mrs Tan is 65 years old and visited the polyclinic for a routine check-up.
• She has undergone mechanical heart valve replacement 2 years ago.
• She is currently on warfarin therapy and has a painful tooth
• Her dentist advised a simple extraction.
• The anticoagulation nurse or pharmacist has monitored her target INR level (2.5 to 3.5).
• They have advised her to present the INR test results when visiting the dentist.
• She is concerned about the risk of bleeding because she wants to know if she should continue or discontinue warfarin before her tooth extraction?

Definitions

• Warfarin is a medication known as an anticoagulant or "blood thinner".
• Warfarin works by inhibiting the function of vitamin K-dependent coagulation factors to stop harmful blood clots from forming
• Warfarin is also known as Vitamin K antagonist.
• INR stands for 'international normalised ratio'.
• It is a blood test to measure how long it takes for your blood to clot in people taking warfarin.
• Based on your INR results, your doctor will work out the suitable dosage of warfarin you should take.

Framing a Clinical Question

• Based on this scenario and the PICO framework,
• P would be patient with mechanical valve replacement taking warfarin who is going for tooth extraction
• C would be to discontinue or interrupt warfarin
• An appropriate research question based on the scenario and PICO is, in patients with mechanical heart valves on warfarin therapy undergoing dental extraction, does continuing warfarin compared to discontinuing it reduce the risk of thromboembolic events

Learn Basic Search Techniques in PubMed

• Decisions on patient care require the most relevant, valid and reliable research
• Evidence-based practice is a method of using the best research evidence to strive for optimal patient health outcomes
• Accurately and precisely describing the clinical question is important for developing a clinical question as a first step
• High-quality resources must be searched to find the best information to address the research question

Why Search in PubMed?

• PubMed is a free and important database for health & medical sciences
• PubMed supports retrieval of filtered and unfiltered information
• TRIP Database searches these simultaneously
• For more details on other databases, visit NUS Libraries Subject Guide
• The quality of evidence can be shown as a pyramid, from the bottom includes background information / expert opinion, then case-controlled studies and case series / reports, then cohort studies, then randomized controlled trials (RCTs), then critically-appraised individual articles, then critically-appraised topics, then top of the pyramid- systematic reviews

Search Techniques

• Boolean Operators (AND, OR, NOT)
• OR combines similar concepts or synonyms, helping to broaden search results, such as therapy OR treatment
• AND combines different concepts to narrow down search results, such as cat AND dementia
• NOT excludes search terms that are not relevant to the topic such as cat NOT p-cat
• Truncation is represented by an asterisk (*), shows different ways of retrieving a word or to search spelling variants of a root word like therapy, therapies, and therapeutic.
• The Boolean operator OR combines keywords belonging to the SAME concept

Perform A Basic Search in PubMed

• To perform a basic search in PubMed, do not need to use punctuation and tags
• In the search box, enter warfarin dental extraction
• To build a more comprehensive search, synonyms should be considered with the OR operator
• The truncation symbol (*) may be used to search spelling variants as appropriate
• Terms within the same concept may be grouped with parentheses and different concepts may be combined with the AND operator.

Broaden Search

• A more comprehensive search strategy would include the main concepts of:
• warfarin: Warfarin* OR Coumadin*
• dental extraction: dental extract* OR tooth extract* OR molar extract*
• The final search would be: (warfarin* OR coumadin*) AND (dental extract* OR tooth extract* OR molar extract*)
• Adding more synonyms to widen the search concepts results in a broader set of results retrieved compared to searching warfarin alone

Filter and Sort Search Results

• Results may be filtered based on the publication date. i.e. you can limit to the last 10 years' publications
• Results are sorted by 'Best Match', with the most relevant studies come on top

Find Full Text

• Proxy bookmarklets can be used to find the full text

Evaluate the sources of information

• Use the CRAAP Method:
• Currency
• Relevance
• Authority
• Accuracy
• Purpose
• In the article titled, "Squeezing Fact from Fiction About 100% Fruit Juice", there is a conflict of interest because analysis was supported by the Juice Products Association, making it biased