EBM I - Exam 1 PDF

Information search and Retrieval: Review of DI Resources 1. Stepwise approach to answering DI questions? a. Define clinical question b. Retrieve pertinent literature c. Evaluate critical literature d. Categorize quality of evidence e. Develop...

Information search and Retrieval: Review of DI Resources 1. Stepwise approach to answering DI questions? a. Define clinical question b. Retrieve pertinent literature c. Evaluate critical literature d. Categorize quality of evidence e. Develop conclusion and recommendation 2. Tertiary resources a. Starting point! b. Background i. Disease ii. Prevalence iii. Mechanism iv. PK/PD v. Etc. c. References 3. Secondary resources a. Tools to find primary literature i. Ovid ii. PubMed iii. Embase 4. Primary resources a. Original or new research b. Foundation of formulating recommendations 5. Tips for all questions and queries: a. At least 2 resources to verify the information b. If you find any discrepancies between the 2, find another reputable resource 6. Tertiary resources: a. Electronic tertiary resources i. Lexi-comp ii. Clinical pharmacology iii. Facts & comparisons – eAnswers iv. Micromedex v. Natural standard/natural medicines vi. American Hospital formulary service (AHFS) – part of Lexi vii. E-Textbooks: AccessPharmacy & AccessMedicine viii. Others: 1. UpToDate 2. DynaMed 3. Cochrane database of systemic reviews 4. MDConsult 5. NIH o_ice of dietary supplements 6. Pharmacist’s letter 7. Medscape  8. Food and drug administration (FDA) a. Center for drug evaluation and research (CDER) 9. Center for disease control and prevention (CDC) 10. ClincialTrials.gov b. About clinical pharmacology: i. Available: HSL ii. Reports for… 1. Drug interaction 2. IV compatibility 3. Product comparison 4. Adverse reactions 5. Etc. iii. Monographs iv. International brand names v. Do not crush list vi. Tablet identification vii. Clinical calculators viii. Manufacturer contact information c. About Micromedex: i. Available: HSL ii. Similar to clinical pharmacology: 1. Monographs for supplements (AltMedDex) 2. Drug comparison tool 3. Calculators 4. Comparative tablets a. Dosages b. By class iii. Neofax iv. Red Book pricing information d. About natural medicines: i. Available: HSL ii. Most thoroughly evidence-based resource for dietary supplements and natural products iii. Natural standard + natural medicine = natural medicines iv. Likely/possibly/insu_icient evidence scale v. Monographs vi. Interactions vii. Nutrition depletion viii. Pregnancy and lactation ix. ADRs e. Tips for dietary supplement information i. There is not really a “gold standard” reference ii. Safety is the primary concern iii. Sometimes e_icacy is only theoretical  iv. Review a patient’s entire medication list v. Natural products usually are not FDA approved with supporting clinical trials f. About Lexi-Comp i. Similar to clinical pharmacology and Micromedex 1. Monographs for brand and generic 2. Tablet identification (with images) 3. Toxicology (LexiTox) 4. Interactions 5. IV compatibility ii. Abbreviated international drug monographs iii. “Every patient is unique. We o_er drug referential content solutions that embrace those di_erences and empower you to make the best possible evidence-based decision for each specific patient.” g. About facts and comparison i. Class reviews ii. Includes: 1. Monographs (Rx and OTC) 2. Interactions 3. Tablet identification (with images) 4. Manufacturer index 5. Black box warnings iii. “A drug referential resource geared toward retail pharmacists, delivering evidence-based content and drug comparative tools and tables in an easy-to-use interface.” h. About access pharmacy i. Available: HSL ii. 80 key pharmacy reference texts iii. Blog iv. Quick reference (including herbs and supplements info) v. Drug information (including dosages, trade names, and pricing) vi. Drug therapy cases with practice questions vii. Study tools viii. NAPLEX review help ix. Patient education information i. About access medicine i. Available: HSL ii. Textbooks available by di_erent topics and disease states iii. Patient education handouts on disease and medicines iv. Drug monographs: international names, pricing, patient handouts (English and Spanish) v. Di_erential diagnoses vi. Guidelines vii. Algorithims  viii. Calculators j. The colored books: i. Orange book 1. “approved drug products with therapeutic equivalence evaluations” 2. Brand = generic ii. Pink book 1. Vaccine information 2. Found on cdc.gov iii. Purple book 1. Online database for biological products iv. Red book 1. Latest drug product pricing and packaging information on prescription and over-the-counter drug products a. Drug pricing data (AWP) 2. Found in Micromedex v. Yellow book 1. Health information for international travel k. About UpToDate i. Unavailable at UMKC ii. Great background information, disease states, treatment options, and guidelines iii. Monographs pulled from Lex-Comp iv. Excellent reference to use when starting a class review or other project with an unfamiliar dx state or treatment l. About DynaMed i. Unavailable at UMKC ii. Similar to UpToDate iii. Clinical tools (including stats calculators) iv. News (recent updates, E-newsletter) v. Disease states vi. Guidelines vii. Monographs viii. Patient counseling m. About Cochrane Database of Systematic Reviews i. Available: HSL ii. Up-to-date evidence-based review of topics n. About Pharmacist’s Letter i. Great resource after you graduate ii. If you need a chart or list for something this is usually where you’ll find it iii. Features include: 1. Articles 2. Rumor vs truth  3. Patient handouts 4. Guidelines 5. Charts 6. Journal clubs 7. Continuing education o. About ConsumerLab.com i. Testing of natural products and herbals ii. Have to pay for this! p. About Medscape i. Free ii. A lot of CE q. Abut food and drug administration i. Tons of di_erent topics covered by FDA include: 1. Food, drugs, medical devices, biologics, cosmetics, animal and veterinary, etc. ii. Site contains information regarding: 1. New drug approvals and updates 2. MedWatch and FAERS (report adverse events) 3. Drug information for consumers/healthcare professionals 4. Regulations, recalls, etc. iii. Others: 1. Orang book 2. Label information (package inserts) 3. Approval information for drugs 4. Prescription and OTC drug information 5. Drug safety and side e_ects 6. Adverse event reporting r. About center for disease control and prevention i. Federal agency responsible for supporting public health in the US ii. Publishes the morbidity and mortality weekly report (MMWR) iii. Vaccine adverse event reporting system (VAERS) iv. Includes a variety of public health information on: 1. Traveler’s health 2. Diseases and conditions (ADHD, cancer, HIV, STD’s) 3. Immunizations 4. Bioterrorism s. About national institutes of health (NIH) i. O_ice of dietary supplements ii. TOXNET 1. Household products database 2. LactMed 3. TOXLINE 4. Etc. t. About LactMed  i. Contains information on drugs and other chemicals to which breastfeeding mothers may be exposed ii. Information on levels of such substances in breast milk and infant blood, and the possible adverse e_ects in the nursing infant iii. Suggested therapeutic alternatives to those drugs are provided, where appropriate u. About daily med i. The national library of medicine (a NIH institute) provides DailyMed to the public ii. Contains labeling/package insert information submitted by the FDA by companies iii. Website is user-friendly and easy to navigate iv. NDC, ingredient, recall, and lactation provided v. Other guideline resources – association webpages: i. American association of clinical endocrinologists ii. American diabetes association iii. American heart association iv. Infectious diseases society of America v. American psychiatric association vi. Etc. w. ClinicalTrials.gov i. Shows current/ongoing trials x. Print tertiary resources: i. American Hospital formulary service (AHFS) ii. Cecil’s iii. DeVIta’s iv. Drugs in pregnancy and Lactation v. DSM V vi. Handbook of injectable drugs vii. The Harriet lane handbook viii. Harrison’s ix. Kings guide to parenteral admixtures x. Managing contraceptive pill patients xi. Mandell’s xii. Medications and mother’s milk xiii. The Sanford guide to antimicrobial therapy y. About American Hospital Formulary Service (AHFS) i. Major evidence-based hospital resource ii. Organized by therapeutic categories 1. Alphabetical by generic within the therapeutic categories 2. Index in back very helpful iii. Information in narrative format 1. Includes both labeled and unlabeled indications 2. Dosing and administration  3. Cautions/drug interactions/toxicities 4. Pharmacokinetics/chemistry/stability 5. Available preparations z. About Drugs in pregnancy and lactation: i. Also known as Brigg’s ii. Most comprehensive resource for pregnancy AND lactation information, well referenced iii. Organized alphabetically by generic name iv. Recommendations that indicate the level of risk to the fetus and nursing infant v. Includes FDA risk factors vi. Animal and human pregnancy data aa. About Diagnostic and structural manual of mental disorders (DSM V) i. Universal authority for psychiatric diagnosis and treatment (American Psychiatric Association) ii. Aims to improve diagnoses, treatment, and research iii. Criteria and concise and explicit, intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings bb. About the handbook of injectable drugs i. Also know as Trissel’s ii. Comprehensive information on stability and compatibility of injectable drug products iii. Organized alphabetically by generic name iv. Monographs are divided up into four subheadings: 1. Products 2. Administration 3. Stability 4. Compatibility v. No dosing information cc. About Harriet Lane Handbook i. Written by residents and review by faculty at the John Hopkins Hospital ii. "#1 source of pediatric point-of-care clinical information” iii. Covers drugs on John Hopkins Formulary iv. Everything you need to know in terms of pediatric diagnosis and treatment dd. Kings guide to parenteral admixtures i. The other BIG injectable drug resource ii. Information is a bit more current than Trissel’s ee. Managing contraceptive pill patients i. Provides accurate, comparative analysis of oral contraceptive (both brand and generic) ii. Many helpful tables throughout  iii. Succinct presentation of pertinent information about all important aspects of oral contraceptives 1. Side e_ects 2. Missed doses 3. Hormones 4. Di_erent methods of birth control (oral, implant, IUDs, injection, patch) _. Hale’s medications and mother’s milk i. Current, complete, and evidence-based information on the transmission of maternal drugs into human milk ii. Includes over 1300 drugs, diseases, vaccines, and syndromes iii. Addresses the use of radiopharmaceuticals, chemotherapeutic agents, and vaccines in breastfeeding mothers iv. Covers adult concerns, adult dose, pediatric concerns, infant monitoring, alternatives, and methods of reducing risk to infants gg. Meyler’s side e_ects of drugs i. Includes six volumes and encyclopedic in nature (organized alphabetically) ii. Two indexes in last volume that make Meyler’s easily accessible: 1. Index of drug names 2. Index of adverse reactions a. Drugs that potentially cause each reaction listed iii. Includes: 1. General information about each drug 2. Organs/systems a_ected 3. Drug-drug interactions hh. The Sanford guide i. Covers a wide array of antibiotics and the infections they treat ii. Widely used by practitioners with many considering it a ‘must-have’ iii. Can be cumbersome and di_icult to use at first iv. HIV version also available ii. Top ‘discipline’ textbook resources: i. Cecil’s – general medicine ii. DeVita’s – oncology iii. Harrison’s – internal medicine iv. Mandell’s – infectious disease 7. Primary resources a. Literature evaluation i. Critical evaluation of primary literature will be taught throughout the remainder of this course ii. This will be important for developing evidence-based recommendations Evidence Based Medicine – Library 1. Background questions – what are they and how do I answer them?  a. Background information – general clinical information (examples) i. What does the spleen do? ii. What are carbapenems? iii. What are the side e_ects of Furosemide? 2. Access medicine a. What is this?: Access medicine is a collection of online books that can be found under “Clinical Resources” on the Health Sciences Library Website. b. What kind of books?: AccessPharmacy, books, flash cards, NAPLEX resources c. What’s new? Reviews of clinical trials, studies, and guidelines that examine the validity of approach, methodology, results, and recommendations, and make recommendations that can a_ect decision making d. There’s more! i. Quick reference concise overview of disease states, their diagnosis and treatment ii. Just click on the “Quick Reference” tab > Quick answers & type in a disease estate into the search box. To read more iii. You can also find information about non-prescription meds by clicking on “Herbs and supplements” here and trying in the search bar e. Images for presentations – download the image onto a slide. It includes a citation! 3. Clinical pharmacology a. Search by indication or adverse e_ect b. Drug class overviews: drug class overviews tool in clinical pharmacology can help you compare the side e_ects, contraindications or indications for specific drugs or an entire class of drugs c. Clinical comparisons: compare the side e_ects, contraindications or indications for specific drugs or an entire class of drugs 4. Micromedex a. Mobile app 5. Foreground questions a. What is a foreground question? i. Hint: think specific cases ii. Which drug is better for this condition? iii. Which drug has the least chance of an undesired side e_ect? iv. Which drug has better outcomes for patients with a particular comorbidity? 6. PICO  a. 7. PubMed a. What is PubMed exactly? i. NLM’s premier biomedical database ii. Indexes article-not all full text iii. Freely available online iv. Use it through the Library Website b. PubMed Tips i. Go to the library homepage to access PubMed ii. Use additional filters > article type iii. Narrow results with “results by year” option iv. Look at “similar articles” and “cited by” results v. Use AND OR NOT in searches 8. EMBASE a. What is EMBASE? i. Embase (often styles EMBASE for Excerpta Medica database) is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug. ii. Compared with PubMed it has an additional focus on drugs and pharmacology, medical devices, clinical medicine, and basic science relevant to clinical medicine b. EMBASE search steps i. Browse *Emtree for your term 1. Emtree is EMBASE’s controlled vocabulary tool. It allows you to consolidate like synonyms together under one, preferred term. ii. Take query to drug or disease search iii. Add limits, search, revise 9. PubMed vs EMBASE  a. 10. Evaluating information – Is this CRAAP? a. i. All information you use/find should be evaluated, especially for currency and accuracy Citations and Defining Clinical Questions 1. What’s plagiarism? a. Presenting the words or ideas of someone else as your own without proper acknowledgment of the source b. It’s okay to use the ideas of other people, but you do need to correctly credit them c. It is plagiarism when you: i. Buy or use a term paper written by someone else ii. Cut and paste passages from the Web, a book, or an article and insert them into your paper without citing them iii. Use the words or ideas of another person without citing them iv. Paraphrase that person’s words without citing them 2. When do I cite my sources? a. Anytime factual information or data is used from a source you found b. When you need to quote verbatim  c. Instances where “you summarize, paraphrase, or otherwise use ideas, opinions, interpretations, or conclusions written by another person” d. When you need to utilize a “source’s distinctive structure, organizing strategy, or method” e. When discussing in passing an aspect of someone else’s work 3. What formatting do we use? a. American Medical Association (AMA) manual of style 4. You must use the correct abbreviation for journals within your citation… a. National library of medicine (NLM) journal of abbreviations 5. Sentence case a. A capitalization style that dictates when lowercase and uppercase letters should be used b. Most citations require this formatting for titles, headings, and subheadings c. How to use: i. Capitalize first letter of the first word of your title/subheading/heading ii. Should also capitalize proper nouns iii. Everything else should be in lowercase d. Example: i. Perioperative nivolumab in resectable lung cancer 6. Scholarly article – print a. Author’s name and first and middle initials (as applicable) i. If more than 6 authors, just include the first 3 followed by “et al” b. Title of article and subtitle (as applicable) c. Abbreviated name of journal (needs to be the proper abbreviation) d. Year of publication e. Volume number f. Part of supplement number, when pertinent g. Inclusive page numbers h. Examples: i. ii. 7. Book – print a. Author’s last name and first and middle initials (as applicable) i. If more than 6 authors, just include the first 3 followed by “et al” b. Italicized title  i. Capitalize all words other than: articles, and conjunctions 1. Prepositions (as, of, between, through) 2. Articles (a, the, and, an) 3. Conjunctions (but, and, or, however) – capitalize them if they begin title or subtitle c. City and state of publication d. Publisher e. Year of publication/creation f. Examples: i. 8. Book chapter – print a. Chapter author’s last name and first and middle initials (as applicable) b. Chapter title c. Book author’s last name and first and middle initials d. Book title e. Publisher f. Year of publication g. Page range h. Example: i. 9. Package insert – print a. Drug b. Package insert c. Pharmaceutical company d. Year (should reference most recent package insert) e. Example: i. 10. Scholarly article – electronic a. Author’s last name and first and middle initial (as applicable) b. Title of article c. Abbreviated name of journal (needs to be the proper abbreviation) d. Year e. Volume number f. Issue number g. Inclusive pages h. DOI (digital object identifier) i. Date accessed only if DOI is unavailable j. URL only if DOI is unavailable k. Example:  i. ii. 11. Website a. Author’s last name and first and middle initial or name of group b. Title of specific item cites (if there is none, reference name of organization responsible for site) c. Name of website d. Date published e. Updated date f. Accessed date g. URL h. Example: i. 12. Database a. Unfortunately, the AMA manual of style does NOT advise on how to cite databases 13. When is it ok NOT to cite? a. When the source and page-location of the relevant passage are obvious b. When dealing with “common knowledge” c. When you use phrases that have become part of everyday speech d. When you draw on ideas or phrases that arose in conversation 14. Citation generators a. Very tempting i. Quick ii. Easy b. Drawbacks i. User error  ii. Computer error (many citations generated are incorrect) c. Double-check every citation if you choose to use 15. Defining a clinical question: a. What are the 5-steps of the EBM process? i. b. Why is it important to define the clinical question? i. Developing a focused and researchable clinical question is one of the many challenging tasks a health care professional will encounter ii. According to the center for evidence-based medicine, “one of the fundamental skills required for practicing EBM is the asking of well- built clinical questions. To benefit patients and clinicians, such questions need to be both directly relevant to patients’ problems and phrased in ways that direct your search to relevant and precise answers.” iii. Identifying/defining/forming will assist you in: 1. Developing an overall strategy to answer the question 2. Guiding you to the best resource(s) to use for retrieving the pertinent literature/information 3. Remembering throughout the process what you are trying to answer so you don’t waste time with distractions iv. Clinical question can provide key search terms to use in your medical literature retrieval process c. Creating a well-built clinical question i. Background questions 1. Asks for general knowledge about a disease or clinical problem 2. These questions ask what, when, how, and where about the disease/treatment/disorder 3. Not normally asked because of a need to make a clinical decision about a specific patient ii. Foreground questions 1. Asks for specific knowledge about managing patients with a disease 2. Patient-oriented questions involving interpretation of therapy or disease 3. Consideration of risk vs. benefit 4. Best answered by primary or pre-assessed studies in the literature d. Which resource do I use to answer a background vs foreground question?  i. Background questions 1. Textbooks 2. Compendia 3. Review articles ii. Foreground questions 1. Secondary resources (PubMed, Embase, Medline) 2. Primary resources (clinical trials) e. PICO i. P = patient/population ii. I = intervention iii. C = comparison iv. O = outcome f. Patient/population/problem i. Most important characteristics of the patient or population of patients ii. Demographic information 1. Age (pediatric, adult, geriatric) 2. Gender 3. Ethnicity 4. Presenting complaint 5. History/comorbidities g. Intervention (or treatment of interest) i. What main intervention are you considering? 1. Treatment (medication/non-medication) a. If medication, what drug? What dose? 2. Procedure 3. Diagnostic test ii. What are you considering for this patient or population? h. Comparison (or control) i. What would you like to compare with the intervention? 1. An alternative treatment 2. Drug 3. Placebo 4. Di_erent diagnostic test ii. Often, a new therapy is compared to an existing one iii. Essential to be as specific as possible i. Outcome i. The e_ect of the intervention 1. May be disease-oriented or patient-oriented ii. What is your end goal? 1. May be looking at benefit – e_icacy of drug 2. May be looking at risk – what’s causing a problem/harm iii. Examples: change in A1c, mortality rate, number of days hospitalized, pain, etc. j. using PICO during literature searches  i. these key words will serve as your search terms when performing literature searches on PubMed, Medline, EMBASE, and Google Scholar ii. DO NOT cherry-pick articles when searching iii. PICO is DIRECTLY tied to therapeutic decision making Clinical Guidelines & Landmark Literature 1. Clinical guidelines a. “systematically developed statements to help clinicians and patients with decisions about appropriate health care for specific clinical circumstances.” b. Components of guidelines: i. Background and etiology ii. Diagnostic criteria and testing iii. Assessing and characterizing disease state iv. Treatment recommendations v. Monitoring c. What are the benefits and uses of guidelines? i. Benefits 1. (relatively) concise summaries 2. Pool up-to-date, high-quality evidence on topic 3. Allow for consistency in practice between providers and sites ii. Uses 1. Individual patient management 2. Support for protocols and formulary decisions 3. Quality metrics and value-based payment models d. Development of guidelines i. Often a partnership between stakeholders 1. Professional associations 2. Government organizations 3. Managed care organizations and third-party payors ii. Should be performed systemically 1. Can be considered multiple systematic reviews in one document e. What are the 3 types of guidelines?  i. ii. 1. Types of guidelines continued! f. Evaluating guidelines 1. Development group 2. Clinical questions defined 3. Most recent evidence 4. Recommendations clear and actionable 5. Alternatives clear 6. Patient-oriented outcomes considered 7. Values informing recommendations clear 8. Grading of recommendations ii. Development group 1. Many guidelines are joint e_orts a. Were the groups included reputable? b. Were all relevant groups included? – is everyone @ the table? c. Are there competing guidelines? 2. Many authors have conflicts of interest a. Financial: conflicts related to fiscal relationship and manufacturers b. Intellectual: involvement in research to be reviewed for guidline iii. Clinical questions defined  1. Guidelines must start with a systematic review of literature a. Systematic review requires defined question (PICO) 2. Authors should disclose the questions they are expecting to answer within their guideline 3. Guidelines may address up to 30 questions in one document 4. Authors may choose to divide guideline by topic or chapter 5. Questions can determine if guideline applies to your patient iv. Most recent evidence 1. Guidelines take time to develop — may not always include most recent evidence a. Older guideline reviews should be accompanied by a literature search v. Recommendations clear and actionable 1. Wording matters in recommendations! 2. Unclear or vague wording can lead to inconsistent application a. Background evidence may help clarify this information in some guidelines vi. Alternatives clear 1. Omitting the alternative may make it di_icult to implement or develop a systematic approach to care a. What is the recommendation to ADD an agent or SUBSTITUTE it? b. Was the recommendation for treatment compared to a lower dose? Higher? c. Was the duration compared to a shorter treatment course? Longer? vii. Patient-oriented outcomes included and values informing recommendations clear 1. Consider if outcomes that the guidelines focus on matter in day-to-day patient life a. Example: lowering LDL vs. lowering risk of ASCVD 2. Authors should be transparent in what they used as guidance in valuing certain outcomes a. Example: screening causes small reduction in cancer mortality but moderate increase in unnecessary biopsies i. Value: decreased mortality – screening more important ii. Value: decreased unnecessary testing and healthcare costs – screening less important b. Overcome by including patients and community members in process viii. Grading of recommendations  1. May be di_erent rating systems between di_erent development groups a. Crucial to understand methods for grading — may use same terminology but mean very di_erent things 2. May be di_erent grades of recommendation on same topic 3. Will indicate if recommendation is evidence- or consensus- based g. Identifying & navigating guidelines i. Finding guidelines 1. Developed by many di_erent groups — no single database of guidelines for all disease states 2. Some disease states will have multiple groups of stakeholders producing guidelines — need reliable way to review all available options 3. Guidelines can be updated frequently — regularly need to research available guidelines a. Some guidelines may be considered living documents ii. Groups for endocrine disorders? 1. American diabetes association (ADA) 2. American association of clinical endocrinology (AACE) 3. American thyroid association (ATA) iii. Groups for anticoagulation and cardiovascular disorders? 1. American heart association (AHA) 2. American collect of cardiology (ACC) 3. American college of chest physicians (CHEST) iv. Groups for urological disorders? 1. American urological association (AUA) v. Groups for GI disorders? 1. American association for the study of liver diseases (AASLD) 2. American gastroenterological association (AGA) vi. Groups for infectious diseases? 1. Infectious diseases society of America (IDSA) 2. Centers for disease control (CDC) vii. Groups for respiratory disorders 1. Global initiative for obstructive lung disease (GOLD) 2. Global initiative for asthma (GINA) 3. National heart, lung, and blood institute (NHLBI) viii. Groups for renal disorders 1. Kidney disease: improving global outcomes (KDIGO) 2. Kidney disease quality outcomes initiative (KDOQI) ix. Groups for psychiatric disorders 1. American psychological association (APA) 2. Veteran’s a_airs/department of defense (VA/DoD) x. Groups for neurologic disorders  1. American academy of neurology (AAN) xi. Groups for women’s health 1. American college of obstetricians and gynecologist (ACOG) 2. National American menopause society (NAMS) xii. Groups for oncologic disorders 1. National comprehensive cancer network (NCCN) xiii. Preventative measures 1. United states preventative services task force (USPSTF) xiv. Critical care 1. Society of critical care medicine (SCCM) h. Finding common guidelines i. Most guideline development organizations have a “guidelines” tab on their website that allow you to browse the guidelines ii. Additional information may be available 1. Next guideline update 2. Corrections to published guidelines 3. Executive summaries or algorithms i. Finding unfamiliar guidelines i. Secondary resources o_er filters for guidelines when conducting a literature search 1. PubMed: article type — guideline 2. EMBASE: study type — practice guideline ii. Tertiary resources may include a section on clinical guidelines with references to review 1. Lexicomp: clinical practice guidelines in most drug monographs iii. Review articles will often provide reference to multiple guidelines considered j. Multiple guidelines i. Some disease states will have multiple guidelines from di_erent organizations ii. Choice of guideline to follow can be based on multiple factors 1. Use evaluation criteria to ensure both are high-quality evidence 2. Consider who the guideline was originally written to address (patient populations & provider practice area) 3. Review PICO questions included in guideline k. Guideline formatting i. Usually have bolded or highlighted recommendations to allow easy navigation 1. Often have summary tables of recommendations for each section 2. May be organized by PICO question answered  ii. Each summary recommendation will have text associated with it to provide justification and additional detail 1. May be directly under each recommendation or associated with the number/letter of the recommendation l. Executive summaries and algorithms i. Many guidelines will publish executive summaries or separate algorithms intended for quick reference 1. Typically much shorter than full guideline 2. Will not have complete reasoning and justification ii. Excellent references after you have established a complete understanding of the recommendation by reviewing the recommendation with the associated text m. Referencing a guideline i. 1. Guidelines should be referenced in all clinical decision-making ii. In formal writing, use AMA citation format 1. Most guidelines are published in journals — cite as a journal article 2. Living guidelines that are only online may be more appropriately cited as a website iii. In a day-to-day clinical practice, citing guidelines in documentation is done by an accepted shorthand 1. n. Summarizing guidelines  i. ii. Guideline recommendation relevant to the problem or question being reviewed 1. Guidelines may have hundred of recommendations a. Goal is to be concise and complete b. Can combine more than one guideline statement 2. Will use this skill in many ways a. Clinical documentation b. Background of journal club, drug info question, or formulary recommendation c. Verbally in clinical settings iii. Patient-specific, primary literature, or drug information tat may influence decision 1. Used to further refine guideline recommendations to fit current problem 2. Four broad categories to consider in reviewing literature a. E_icacy b. Safety c. Cost d. Special populations 3. Consider preferences, organ function, drug interactions, and other relevant info for patient-specific recommendation iv. Final recommendation 1. Pulls together the guidelines and literature to form a final recommendation 2. Usually written with “I” or “we” language to indicate this is your work of combining multiple pieces of information 2. Landmark literature a. Defining landmark literature i. No formal definition, but most practitioners would agree landmark literature has certain qualities in common:  1. b. Integrating landmark literature i. Landmark literature is not used in place of guidelines, but can be used to supplement guideline knowledge ii.