Best Evidence Resources Whats fast, free and efficient Melanie Browne BHSc, MLIS Information...

Best Evidence ResourcesBest Evidence ResourcesWhat’s fast, free and efficientWhat’s fast, free and efficient

Melanie Browne BHSc, MLIS Information Specialist, Mount Sinai Hospital, Toronto, Canada

Sandra Kendall MLSDirector of Library Services, Mount Sinai Hospital, Toronto, Canada

Copyright © 2006. All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.

What we will be discussing today

• The strengths and weaknesses of Google and Google Scholar

• Introduction to medical librarianship and our arena of information overload

• Clinical queries and best evidence resources including consumer health resources

With an emphasis on Fast, Free and Efficient

The Evidence Issue

• Medical libraries support evidence-based decision-making.

• What is evidence?• “Evidence is information that comes closest to

the facts of a matter. The findings of high quality, methodologically appropriate research are the most accurate evidence.”

Canadian Health Services Research Foundation 2005

Google’s Mission

“To organize the world's information and make it universally accessibleaccessible and usefuluseful”

(http://www.google.com/corporate/ )

Google Newsletter for Librarians: http://www.google.com/newsletter/librarian/librarian_2006_01/article1.html

Enter search term / phrase

Click “Advanced

Search”

Use the advanced screen to narrow your

search further

Specify how many results you want

displayed

Limit Results

Limit by LanguageFile Format

Last updatedLocation on page

Statistics Bar

Page Title

URL of Result

Interpreting Your Google Results

Google Search Tips

• Google Guide - www.virtualchase.com/howto/gg_tips.html

• Gary Price Google tips - www.googleguide.com/advanced_operators.html

• Gadgetopia's - www.gadgetopia.com/post/4419

http://www.googleguide.com/experienced_users.html

Google Services

Google Scholar

• Tool in its beta development stage (introduced in November 2004)

• Gets its information directly from publishers and crawling the web

• Seems to focus mainly on science and technology (22% coverage)

• It has an algorithm that tries to provide only “scholarly” results

Google Scholar: Content Types

• Peer-reviewed papers – journal articles• Theses • Books• Pre-prints - collections, personal websites• Abstracts from PubMed etc.• Technical reports• Conference papers

Google Scholar: Relevance Ranking

Takes into account:• Full text of the article• Author• Publication in which the article

appeared• How often it has been cited in Google

Scholar’s scholarly literature

Some are Not that “Scholarly”

Cited By Link

Indicates the number of times this document was cited by otherworks that are indexed in Google Scholar.

Links

The links across the bottom indicate where Google Scholar foundthis document on the internet. Ingenta is a fee based link.

Google Scholar: Concerns

• Indexes a subset of scholarly literature in all fields.

• Search result content varies. – Full text is often available, but sometimes links lead

only to abstracts or citations.

– Some duplicate and fragmentary entries appear, as well as variant editions of works (e.g. search results may include a preprint and post print of a work, as well as the version published in a journal).

It is unclear what Google Scholar is saying

about their content and relevancy

NodularRegenerativehyperplasia

Publication where two different articles are

transposed into this one

Pancreaticcancer

Google Scholar: Search Features

• Boolean – AND is the default; OR

• Phrase

• Date

• Title

• Publication

• Author

Google Scholar: Search Strategies

Prefixes.

Use prefixes to limit your terms to a particular field. author: pawson t

To find articles on a given topic, add relevant keywords to the search.

author:pawson cell

Listing of theauthor is random

Versus

Google Scholar: Search features needed for medical librarians

• Controlled indexing

• Truncation

• Limits (especially publication type such as RCT)

How does Google Scholar fit into the medical librarians’ toolkit?

• Everyone knows Google

On Google Scholar. http://schoogle.blogspot.com/

Google Scholar: Conclusions

• Improvements and better features are expected

• Valuable resources, a great supplement but NOT a substitute for subject specific databases

• At least this offering could be working towards universal access to medical and scientific literature

Strengths and Weaknesses of Google Scholar

Strengths Weaknesses

Easy to use• Simple & familiar interface with ability to do keyword searches • Ability to search over a number of databases at one time • Searches a variety of material types including books, journals, websites

Limited search capabilities• No medical subject headings (MeSH) or Boolean operators • You don’t know which databases you are searching • Can’t specify which material type you would like, for example, journals only • No ability to sort by author, title, date, publication

Provides links to full text of both free articles and those in journals to which McMaster subscribes

No information about how frequently Google Scholar is updated

Adapted from: A resource for health sciences research at McMaster. 2005http://www-hsl.mcmaster.ca/resources/googlescholar.htm

Strengths and Weaknesses of Google Scholar

Strengths Weaknesses

Searches for scholarly materials Not sure how ‘scholarly’ is defined, some materials are questionable

Good for an overview of materials on a subject area

Difficult to perform a specific search with precise results

Displays number of citations for each article and links to list of those citing

Questionable reliability of the number of citations compared with Science Citation Index

Brings the most relevant materials (according to Google Scholar) to the top of the list

Relevance is based partially on times cited, therefore older articles may come up first

Adapted from: A resource for health sciences research at McMaster. 2005http://www-hsl.mcmaster.ca/resources/googlescholar.htm

Beaton, James, and Smith, Cheri. 2005. Google versus PubMed.Ann R Coll Surg Engl 87: 491-492.

Clinical Queries

• Occupational safety and needle injuries among nurses

• Application of competitive polymerase chain reaction (PCR)

• Comparison of midwifery services between Canada and the UK

• Total # of hip/knee replacements in Ontario and costs associated

Clinical Scenarios

• Interactions between Acute colonic pseudoobstruction (Ogilvie’s syndrome) and morphine

• Histomorphometry of the orbital

zygomatic bone arch on the face of a rabbit

Clinical question

In patients with an open tibial fracture, is it appropriate to substitute an external fixator with an intramedullary nail, taking into account the risk of infection and consolidation rate?

One ICU patient generates up to 236 variable categories

Morris, Crit Care Clin 1999, 15:523

Humans capable of managing 5 to 9 variables adequately

Miller, Psychol Rev 1956, 63:81

Data overload - patient informationData overload - patient information

TextbooksJournal articlesReview articlesAssociation guidelinesHospital protocolsPharmaceutical company informationElectronic medical literature

Data overload - reference informationData overload - reference information

Do we use this information ?

Studied 4 month periods before and after Studied 4 month periods before and after publication of the landmark ARDSNet trialpublication of the landmark ARDSNet trial

Rubenfeld GD et al. ATS 2001Rubenfeld GD et al. ATS 2001



Percentage of patients receiving ventilation accordingPercentage of patients receiving ventilation accordingto study protocol:to study protocol:

Day 0Day 0 Day 3Day 3 Day 7Day 7before afterbefore after before afterbefore after before afterbefore after

3%3% 6% 6% 9% 9%




Percentage of patients receiving ventilation accordingPercentage of patients receiving ventilation accordingto study protocol:to study protocol:

Day 0Day 0 Day 3Day 3 Day 7Day 7before afterbefore after before afterbefore after before afterbefore after

3%3% 1% 1% 6% 6% 3% 3% 9% 9% 7% 7%


Evidence Based Resources: TIER 1

Evidence Based Medical Evidence Based Medical ResourcesResources

Systematic Literature Searches

• Cochrane Library

• Clinical Evidence

Systematic Literature Surveillance

• ACP Journal Club

Clinical QuestionsFour fundamental types of clinical questions:

1. Therapy Question - Concerns the effectiveness of a treatment ( drugs, surgical procedures, hospitalization) or preventative measure (immunizations etc.)

- determining the effect of different treatments on improving patient function or avoiding adverse events.

– RCT (randomized controlled trial)

Clinical Question

2. Prognosis Question – Deals with outcome of a patient with a particular condition

i.e. how likely is a child with febrile seizures to actually develop a seizure disorder?– observational study assessing prognosis, cohort

Clinical Question

3. Diagnosis Question – Deals with the ability of a test to predict the likelihood of a disease

i.e. usefulness of a (diagnostic peritoneal lavage) DPL in predicting operable abdominal injuries - compare against the gold-standard- case-control, cross-sectional

Clinical Question

4. Harm Question – Deals with the likelihood of a therapeutic intervention to cause harm. Exposure could be to medicine, drugs, foods, environmental agents, or medical procedures. i.e. – Development of cancer after radiation

exposure – observation study, case-control

PICO Model

Population: Who is the patient or what problem is being addressed?

Intervention: What is the intervention / exposure?

Comparison: What is the comparison group?

Outcome: What is the outcome / endpoint?

Richardson et al. 1995. The well-built clinical question: A key to evidence-based decision. ACP Journal Club. A-12.

Where do we Start?

• Provide information based on the best evidence at the time

• In medicine, our best single source is a “Randomized Controlled Trial”– Patients are randomly sorted into a control

group and a treatment group– Neither the patient, nor treatment provider, nor

researcher knows sorting

What’s Even Better?

• A “Systematic Review”• Summaries of RCT’s evaluating similar

interventions• Care is taken to ensure that only quality

studies are included– Well-designed study– Unbiased allocation of participants– Proper training given to researchers– Reasonable attrition rates

What’s Better than That?• A Meta-analysis – A series of methods for

systematically combining information from more than one investigation to draw a conclusion which could not be drawn solely on the basis of the single investigations.

• A systematic review that goes one step further….

• Combines results of similar studies to form a single conclusion

What is the Best?

• A Cochrane Review

• Rigorous peer review process

• Highly structured

• Graphic display of information

• Consumer abstract

• Takes advantage of online environment

• Commitment to maintain currency

Systematic Reviews

• Comprehensive search

• Use only high quality studies

• Summary of the results

Sources of Systematic Reviews

• Cochrane

• DARE – Database of Abstracts of Reviews of Effects

The Cochrane Collaboration

Cochrane's Mission

• The Cochrane Collaboration is an international network of individuals and institutions committed to preparing, maintaining, and disseminating systematic reviews of the effects of health care.

• Not-for- profit charity registered in the UK

Subject Scope: The effects

of healthcare

Cochrane Library - Limitations

• Only addresses questions that can be in randomized controlled trials

• Doesn’t address all subject matter

• Only available through subscription

Clinical Evidence

• A database of questions (summaries) covering the effects of treatments and interventions.

• Online Update Frequency: Monthly • PDA format: Yes• Publisher: BMJ Publishing Group

You get information on …

Synopses

• Published in secondary journals– Appraise for validity– Use only high quality original studies and

review articles– Provide a “bottom line”– Succinct, accurate, and authoritative

ACP Journal Club Resource Information

• Surveys over 150 peer-reviewed medical journals to produce summaries of original studies and systematic reviews

• For the internist or sub-specialist physician• Online Update Frequency: Bi-monthly• Publisher: American College of Physicians

(ACP)

PubMed Central

• U.S. National Institutes of Health (NIH) • Free digital archive of biomedical and life

sciences journal literature• A platform for enriched linking, analysis, and

use of research reports and data• Indexes over 4600 peer reviewed journals• Contains over 13.5 million citations from

1951-

15388 resultsNeed to narrow this toa manageable number

Standard Boolean Logic

545 citations, displayed20 at a time

Select limit to focus the results

Limits

The yellow bar at the top shows that limits have been applied.

PubMed: Conclusions

• Fast• Free!• Efficient…with some training

Case

Greenwald, Robert. 2005. . . . And a Diagnostic Test Was PerformedN Engl J Med 353: 2089-2090

Scenario

Population: • Infant with diarrhea • an unusual rash ("alligator skin") • multiple immunologic abnormalities • including low T-cell function• tissue eosinophilia (of the gastric mucosa) as

well as peripheral eosinophilia• an apparent X-linked genetic pattern (several

male relatives died in infancy).

What is the diagnosis?

Consumer Health

• Growing demand everywhere• 55% of internet users use the internet to find

health information• Very different needs than the health care

professional– Obstacles

• Got to be free!

What does the Healthcare Consumer Look Like?

• 40-44% function at the lowest level of literacy

• 55% of internet users use it to find health information

• Strongly favours community filtered info

• Strongly rely on search engines– 12% first turn to Google

New Role for U.S. Public Libraries

• NCLIS has called on President Bush to support public libraries as health information distribution centers

• Key role as consumer health information provider

• Building on what they already do well!• No Canadian equivalent

How do Consumers Search?

• Rely on search engines

• 65% use single word searches

• 71% select from first 5 results

• Site “usefulness” is key factor in assessing credibility

What are they Finding?

• “Consumers using the Internet may have difficulty in finding complete and accurate information on a health problem” (Berland et al.)

• Reading level is between 10th and 12 grade

• Disconnect between information seekers and application of information

What are they Searching For?

• 93% searching for info on specific illnesses or conditions

• 65% looking for info on drugs; wellness; and weight control

• 40% for info on mental health conditions

• 50% for info on complementary therapies/alternative medicine

Evaluating Consumer Health Information Resources

• Consider the source• Focus on quality• Be a cyberskeptic• Look for the evidence• Check for currency • Beware of bias• Protect your privacy• Consult with a health professional

From MedlinePlus Guide to Healthy Web Surfing: http://www.nlm.nih.gov/medlineplus/healthywebsurfing.html

Cochrane Consumer

• Available via Informed Health Online (Health Research and Education Foundation Ltd. in Melbourne, Australia)

• Promotes the accessibility of health information from the Cochrane Collaboration

Consumer Health Resources

• NLM Gateway– MEDLINEplus– ClinicalTrials.gov– DIRLINE – Directory of Health Organizations– Genetics Home Reference– HEALTHINFOQUEST

MEDLINEplus

• http://medlineplus.gov/

• Brings together authoritative information from NLM, the National Institutes of Health (NIH), and other government agencies and health-related organizations.

MEDLINEplus

• Includes: – Pre-formulated MEDLINE searches to give

easy access to medical journal articles. – Information about drugs – An illustrated medical encyclopedia– Interactive patient tutorials– latest health news

MEDLINEplus

Also includes:Over 700 Health Topics pages in English (over 650 of these are also available in Spanish)

Information from over 1,250 organizationsOver 17,000 links to authoritative health information

MedlinePlus Drug Information

MedlinePlus Medical Encyclopedia

MEDLINEplus: Strengths

• User driven topics• User driven design• Authoritative information• Topics are reviewed at least every six

months and new links are added every day

• Selective comprehensive resource

ClinicalTrials.gov

• Offers up-to-date information for locating federally and privately supported clinical trials for a wide range of diseases and conditions

• Currently contains approximately 22,000 clinical studies

If you want to see if there areclinical trials in your area

Lab Tests Online

• Designed to help consumers and caregivers better understand the many clinical lab tests that are part of routine care

• Covers diagnosis and treatment of a broad range of conditions and diseases

• Product of a unique collaboration among professional societies representing the clinical laboratory community

HEALTHINFOQUEST

• http://nnlm.gov/healthinfoquest/

• Pathfinders are designed for public librarians and health information specialists.

Canadian Health Network

• Canada’s answer to Medline Plus

• Focus is on Health Prevention, rather than disease– “It is a wealth of information to help you

prevent disease and make healthy choices for yourself and your community “

• Coverage is not as extensive

Canadian Health Network

• Works with partner organizations across Canada and provides direct links

• Alphabetically arranged?• Can be overwhelming for users• Not our 1st choice!

In Conclusion: Not all evidence is created equal

Suggested Reading• National commission seeks expanded health information role

for libraries: NCLIS recommends private-public partnership for conducting study. 2005. Public libraries 44 (4): 216.

• Alpi, KM. 2005. Expert searching in public health. Journal of the Medical Library Association 93 (1): 97-103.

• Baker, GR, Norton, P. 2001. Making patients safer! reducing error in canadian healthcare. HealthcarePapers 2 (1): 10-31.

• Beaton J, Smith C. 2005. Google versus PubMed. Ann R Coll Surg Engl. 87(6): 491-2.

• Butler D. 2005. Google makes data free for all. Nature. 438(7067): 400-1.

• Butler D. 2004. Science searches shift up a gear as Google starts Scholar engine. Nature. 432(7016): 423.


Suggested Reading • Crespo, Javier. 2004. Training the health information seeker: Quality

issues in health information web sites. Library trends 53, no. 2: 360-374.

• Ellis-Danquah, La V. 2004. Addressing health disparities: African american consumer information resources on the web. Medical reference services quarterly 23, no. 4: 61-73.

• Eysenbach, G., Kohler, C. 2002. How do consumers search for and appraise health information on the world. BMJ 324, no. 7337: 573-577.

• Kiley R. 2000. Finding health information on the Internet: health professionals. Hosp Med. 61(10): 736-8.

• Fricke, M., Fallis, D., Jones, M., Luszko, GM. 2005. Consumer health information on the internet about carpal tunnel syndrome: The American journal of medicine 118, no. 2: 168-174.


Suggested Reading • Glanville J, Haines M, Auston I. 1998 Finding information on

clinical effectiveness. BMJ. 317(7152): 200-3. • Gillaspy, Mary L. 2005. Factors affecting the provision of

consumer health information in public libraries: The last five years. Library trends 53 (3): 480-495.

• Giustini, D., Barsky, E. 2005. A look at Google Scholar, PubMed, and Scirus : comparisons and recommendations. Journal of the Canadian Health Libraries Association 26: 85-89.

• Golderman, Gail. 2005. Staying healthy. Library journal 18-20, 22-4, 26.

• Henderson, J. 2005. Google scholar: A source for clinicians? CMAJ 172 (12): 1549-1550.

• On Google Scholar. http://schoogle.blogspot.com/Copyright © 2006. All rights reserved. Not to be used or reproduced without the expressed written consent of the authors.

Suggested Reading • Google Newsletter for Librarians: http://www.google.com/newsletter/librarian/librarian_2006_01/article1.html• Schloman BF. 2005. Google extends its reach. Online J Issues Nurs. 10(2):8. • Su KC, Waldren SE, Patrick TB. Differences in the effects of filters on health information retrieval from the Internet in three languages from three countries: a comparative study. Medinfo. 2004;11(Pt 2):1313-7. • Steinbrook R. Searching for the right search--reaching the

medical literature. N Engl J Med. 2006 Jan 5;354(1):4-7. • Younger P. Using the Internet to conduct a literature search.

Nurs Stand. 2004 Oct 20-26;19(6):45-51; quiz 52.


Best Evidence Resources Whats fast, free and efficient Melanie Browne BHSc, MLIS Information...

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