Evidence-based medicine. How to use biomedical literature to solve clinical problems. Italian Group on Evidence-Based Medicine-GIMBE

Clinical practice is constantly changing, the rate of changing is accelerating and consequently it may even take years before the results of clinical research will be incorporated in day-to-day practice. So, there is a large gap between what the biomedical literature contains and the care that most of patients receive. The gap is widened by the extensive processing that results of clinical research require before they can be used. Evidence-based medicine is a new approach to health care promoting the collection, interpretation, and integration of valid, important and applicable research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgements. There are many information tools that facilitate the practice of evidence-based medicine. These include users' guides to the medical literature, strategies to improve the yield of MEDLINE searches, standardized formats for abstracts of journal articles and guidelines, new journals, systematic reviews and meta-analyses, resources on-line and software tools bringing high quality information to the point of clinical decision making. However, these tools are poorly spread and physicians lack of necessary skills for their effective utilization. In this article the authors describe guidelines for efficient and effective utilization of biomedical information tools to solve clinical problems and improve the quality and the cost/effectiveness of health care.     

A second look at psychotherapy integration.

Psychotherapy integration has been a formal approach since 1983 when the Society for the Exploration of Psychotherapy Integration (SEPI) was first formed. Initial concerns included defining the E in SEPI and understanding the relationship among theory, technique, and experience. More recent concerns have included the categorization of approaches to psychotherapy integration, the role of the client, and the relationship of psychotherapy integration to evidence-based practice. The E represents a continuing commitment to exploration, but the categories of integration have become fuzzy. Evidence-based practice is a central concern, but evidence must be defined broadly and the role of the client and of the relationship must be emphasized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is laparoscopic surgical practice "factual" (evidence based)? Results of a prospective regional survey

OBJECTIVE: Evidence-based medicine is a growing paradigm in health care. We conducted a prospective study to determine whether laparoscopic surgery is truly evidence-based in everyday practice. METHODS: A prospective regional survey was performed in 11 French hospitals (one university and 10 district hospitals) to ascertain how general laparoscopic surgery was conducted during the last 3 months of 1997. We also searched the electronic databases for original articles on laparoscopic procedures. The methodology of randomized trials was analyzed and procedures were classed by level of evidence. We assumed that an evidence-based procedure was which had been validated by well-designed randomized controlled or prospective trials giving homogeneous results. RESULTS: One half of the procedures performed had been evaluated by randomized controlled trials. Among the 428 laparoscopic procedures, 334 (78%) were found to be evidence-based (CI 74.1-81.9%). Twelve of the 18 indications for laparoscopy (67%) were evidence based (CI: 62.5%-71.5). There was no difference between university teaching hospitals and general district hospitals. CONCLUSION: Contrary to initial criticisms, the practice of laparoscopic surgery appears to be truly evidence-based in the majority of cases.     

Levels of scientific evidence and strength of clinical recommendations. From trials to guidelines. The Italian Group on Medicine Based on Evidence--(GIMBE)

Evidence-based medicine is a new paradigm of clinical practice that promotes the collection, interpretation and integration of valid, important and applicable to patients research-derived evidence, and it can improve the efficiency and the effectiveness of health care. Nevertheless research often fails to get in clinical practice, also because the traditional tools used by physicians to solve clinical problems are less reliable as the volume/complexity of medical information and biomedical technology have grown exponentially. New tools are emerging to help physicians: the systematic reviews of randomized controlled trials and the clinical practice guidelines that summarize a great volume of medical knowledge to improve health care. Practice guidelines, with a systematic review or meta-analysis pertaining to a definite health problem, summarize the evidence of clinical trials in clinical recommendation. These combine the strength and heterogeneity of the primary studies with magnitude and precision of the treatment effects as it relates to the minimal clinical benefit. The recommendation may suggest therapeutic intervention when the baseline risk is high or otherwise when the baseline risk is low. The Authors discuss principles of evidence-based medicine, measures of treatment effectiveness, systematic reviews and methods used by experts to graduate the strength of clinical recommendations in producing practice guidelines.     

What Works in Psychotherapy and How Do We Know?: What Evidence-Based Practice Has to Offer.

Evidence-based practice may be insufficiently understood by dynamically oriented therapists and analysts. It includes the integration of the best available research evidence, clinical expertise, and considered attention to a patient's personal attributes, sociocultural characteristics, and unique dynamics. These 3 streams of knowledge inform clinical practice. Advocates of a manual approach to treatment have challenged clinicians to rethink the importance of what they consider salient in their therapeutic endeavors. This article demonstrates the relevance of an evidence-based practice perspective for dynamically oriented clinicians. An American Psychological Association task force has been established to develop and elaborate the view of current clinical practice so that it can be disseminated to clinicians and to the public as a policy statement that governs clinicians' thinking and work. The goal is to provide knowledgeable, reasonable, and responsible high-quality health care to those who need it based on these developed practice principles. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evidence-based medicine

The need to improve the quality of health care and to contain its costs has become mandatory. Simultaneously we are confronted by a growing body of clinical information, most of it irrelevant. This paper describes the origin and methods of Evidence-Based Medicine, a new alternative to the usual ways of medical information. The recent development of computerized data bases is permitting the rapid location of relevant clinical information concerning specific questions on diagnosis, therapy or prognosis. Critical analysis is then used to determine the validity of the evidence obtained, which can be employed in clinical decision making. The future role of Evidence-Based Medicine in education and clinical practice seems highly promissory.     

Introducing the new Health Psychology series "Evidence-based treatment reviews": Progress not perfection.

Introduces the new Health Psychology series "Evidence-Based Treatment Reviews." Psychologists struggle continuously with the tension between the general implications of research conducted in their treatment area and the often unique needs and treatment possibilities for their individual patients. Recent concerns about this struggle in psychology have led to the initiation of an American Psychological Association presidential taskforce to propose an evidence-based policy: Evidence-Based Psychology Practice (EBPP). This struggle is not new. Medicine, similarly, has been dealing with the issue of how to translate research findings into evidence-based assessments and treatments. The process of joining our research with our practice, known as Evidence-Based Medicine, will be the cornerstone of a new series of articles in Health Psychology, entitled "Evidence-Based Treatment Reviews." Evidence-Based Behavioral Medicine is an extension of the Evidence-Based Medicine movement that identified the necessity of critically evaluating research to inform clinical practice (Rosenberg & Donald, 1995). In addition to mentoring researchers in presenting their findings in a more user-friendly style (e.g., Consolidated Standards of Reporting Trials, or CONSORT, guidelines; Altman, Schulz, Moher, Egger, Davidoff, Elbourne, et al., 2001), teaching clinicians how to review the evidence (e.g., Evidence Based Medicine Tool Kit), and compiling and summarizing the existing evidence for public consumption (e.g., the Cochrane Collaboration), it makes sense to integrate these efforts by presenting research reviews with clinician commentary in our professional journals as has already been done by the Journal of the American Medical Association (JAMA, e.g., DeAngelis & Fontanarosa, 2002; Levinson & DeAngelis, 2002). We seek to add to the health psychology evidence base by including two articles for each topic chosen: an Evidence Review and a Clinician's Comment. For this series, we envision that three or four evidence-based reviews will be published per year in Health Psychology and that each review will be accompanied by a three- or four-page commentary by a clinician to aid in the application of the research to a clinical practice. In this format, we hope to capture both the state of the clinical science and the challenging art of translating it into clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

That was the year that was: an evidence-based clinical geriatrics update

BACKGROUND: Physicians are faced with an ever-growing information base in medical practice. Studies regularly show a disparity between science and patient care, with scientifically validated practices often taking 20 years and more to enter mainstream clinical practice. OBJECTIVES: To review the recent medical literature for high quality studies that practicing geriatricians should be aware of, either because they provide evidence that might lead to a change in clinical practice or because they provide insight into common geriatric syndromes. DESIGN: Overview. DATA SOURCES: All articles abstracted or noted in ACP Journal Club, Evidence-Based Medicine, or The New York Times from July 1996 to June 1997. STUDY SELECTION: Studies that met the standards for inclusion in ACP Journal Club. STUDY DESIGN: Sampling plan (including eligibility criteria), sample size, response rate, data analysis plan, proportion available for follow-up, main outcomes and measures, main results. RESULTS: Review of the 98 articles that met criteria resulted in the identification of several themes of importance to geriatricians, including the hazards of hospitalization, the prevention of NSAID-induced peptic ulcers, and the treatment and prevention of Alzheimer's disease. The results of these studies expand the therapeutic armamentarium of practicing geriatricians, provide new insights into geriatric syndromes, and raise cautions about the use of certain therapies in older adults. CONCLUSIONS: Many methodologically rigorous studies relevant to the medical care of older people have recently been published. Evidence-based medicine and the use of journals of secondary publication are useful tools to enhance the efficiency of journal reading for geriatric practitioners whose interests span the journals of several disciplines and subspecialties.     

Terrible when life appears to be meaningless...]

Evidence-based practice (nursing practice that relies on information generated from the results of scientific research) is widely recommended as the method of nursing practice of the future. This is particularly the method of choice in perioperative nursing. In this article the literature on evidence-based practice is reviewed with particular emphasis on the role of the perioperative nurse, research utilization, and barriers to evidence-based practice. Suggestions for change to promote evidence-based practice are also outlined.     

Will evidence-based nursing practice make practice perfect?

Evidence-based practice, or evidence-based decision-making, is rapidly developing as a growth industry in nursing and the health professions more widely. It has its origins in the work of the British epidemiologist Archie Cochrane and has recently been re-energized in Canada by the National Forum on Health and its call for a culture of evidence-based decision-making. Before we adopt evidence-based nursing (EBN) as a mantra for the 21st century, we should examine its origins and its consequences, and we should probe related concepts, 2 of which are the nature and structure of practice-based knowledge and the nature and structure of evidence generally. Findings of a recent survey of nurses in western Canada are used to illustrate that nurses use a broad range of practice knowledge, much of which is experientially based rather than research-based.     

Evidence-based practice and the culture of adolescence.

Evidence-based practice requires attention to the client context, including client culture. We propose that the developmental period of adolescence is characterized by a unique culture that has important implications for evidence-based practice. Specifically, this paper explores three features of adolescent culture (importance of technology, centrality of peers, and the ongoing challenge of identity formation and individuation) that may be especially salient when treating adolescents. We then provide recommendations for how these features can be addressed in adapting existing evidence-based protocols and designing new interventions for adolescents, using examples from the literature to illustrate innovative applications. Overall, we argue that considering adolescent culture and thoughtfully tailoring treatment to that culture is consistent with the evidence-based practice framework and could enhance therapeutic outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Information resources at the National Center for Biotechnology Information

The National Center for Biotechnology Information (NCBI), part of the National Library of Medicine, was established in 1988 to perform basic research in the field of computational molecular biology as well as build and distribute molecular biology databases. The basic research has led to new algorithms and analysis tools for interpreting genomic data and has been instrumental in the discovery of human disease genes for neurofibromatosis and Kallmann syndrome. The principal database responsibility is the National Institutes of Health (NIH) genetic sequence database, GenBank. NCBI, in collaboration with international partners, builds, distributes, and provides online and CD-ROM access to over 112,000 DNA sequences. Another major program is the integration of multiple sequences databases and related bibliographic information and the development of network-based retrieval systems for Internet access.     

Fifty years of the column 'Question and Answer'

The section 'Question and answer' in the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) has existed for over 50 years. Medical questions of readers are published anonymously and answered by an anonymous expert consulted by the editorial staff. At first the column grew rather large but in the last few decades it shrank to only few publications a year. Due to improvements in communication (Internet) and provision of information (electronic databases) it appears that the column, as a medium for questions of readers, is becoming obsolete.     

Advances in the diagnosis and treatment of childhood disorders.

Clinicians today face difficulties in appropriately assisting children with mood disorders, whose parents may challenge diagnostic and treatment decisions based on potentially faulty information obtained from unregulated sources (e.g., the Internet, commercial books, other media). In light of this problem, as well as the U.S. Surgeon General's recent call for increases in evidence-based diagnosis and treatment of childhood disorders, it is important that psychologists educate themselves and their clients about evidence-based practices. Evidence-based assessment and psychosocial and psychopharmacological treatment procedures for childhood unipolar and bipolar mood disorders are reviewed, and specific practice recommendations are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

EBP ≠ EST: Reply to Crits-Christoph et al. (2005) and Weisz et al. (2005).

Replies to Crits-Christoph et al. (see record 2005-04167-007) and Weisz et al (see record 2005-04167-008). Evidence-based practice (EBP) is not a synonym of empirically supported therapies (ESTs). ESTs reflect 1 kind of evidence that should guide EBP. The authors focus in this response on 4 issues: the distinction between 2 functions of randomized clinical trials (RCTs) with very different methodological and clinical implications, problems with the experimental designs used to test ESTs that have unnecessarily limited their clinical and scientific utility, the question of how to integrate findings from RCTs with findings from other empirical methods to guide evidence-based interventions, and what one means by clinicians (i.e., whether clinicians should be paraprofessionals who implement procedures developed by researchers or full-fledged partners in the development and implementation of evidence-based psychological practice). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The evidence missing from evidence-based practice.

Comments on the report by the APA Presidential Task Force on Evidence-Based Practice (see record 2006-05893-001) entitled Evidence-based practice in psychology. Regrettably, the task force report was largely silent on three critical issues. As a consequence, it omitted much of the evidence necessary for a complete picture of evidence-based practice. First, the task force report did not operationalize "evidence." Second, the task force report did not address the crucial problem of iatrogenic treatments. Third, the task force report said little about the necessity for ongoing objective evaluation of clinical cases, which is critical to ethically responsible services. Current debate centers on how research findings should be factored into interventions, not on whether it is necessary to do so. Rather than waiting for the resolution of competing views on the matter, psychologists bear an ethical obligation to offer evidence-informed services. Three critical steps that were largely neglected by the task force report can go far toward helping psychologists honor that commitment: (a) providing a clearer operationalization of scientific evidence, (b) using current research to rule out the use of potentially harmful methods, and (c) using objective criteria to evaluate all of their cases on an ongoing basis. These steps, in turn, clarify the menu of options available to therapists, help protect clients from harm, and offer the advantage of allowing clinicians to contribute to the growing body of knowledge about what does and does not work in psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

ARIANE: integration of information databases within a hospital intranet

Large information systems handle massive volume of data stored in heterogeneous sources. Each server has its own model of representation of concepts with regard to its aims. One of the main problems end-users encounter when accessing different servers is to match their own viewpoint on biomedical concepts with the various representations that are made in the databases servers. The aim of the project ARIANE is to provide end-users with easy-to-use and natural means to access and query heterogeneous information databases. The objectives of this research work consist in building a conceptual interface by means of the Internet technology inside an enterprise Intranet and to propose a method to realize it. This method is based on the knowledge sources provided by the Unified Medical Language System (UMLS) project of the US National Library of Medicine. Experiments concern queries to three different information servers: PubMed, a Medline server of the NLM; Thériaque, a French database on drugs implemented in the Hospital Intranet; and a Web site dedicated to Internet resources in gastroenterology and nutrition, located at the Faculty of Medicine of Nice (France). Accessing to each of these servers is different according to the kind of information delivered and according to the technology used to query it. Dealing with health care professional workstation, the authors introduced in the ARIANE project quality criteria in order to attempt a homogeneous and efficient way to build a query system able to be integrated in existing information systems and to integrate existing and new information sources.     

Meeting information needs in health policy and public health: priorities for the National Library of Medicine and The National Network of Libraries of Medicine

Those seeking information in health policy and public health are not as well served as those seeking clinical information. Problems inhibiting access to health policy and public health information include the heterogeneity of professionals seeking the information, the distribution of relevant information across disciplines and information sources, scarcity of synthesized information useful to practitioners, lack of awareness of available services or training in their use, and lack of access to information technology or to knowledgeable librarians and information specialists. Since 1990, the National Library of Medicine and the National Network of Libraries of Medicine have been working to enhance information services in health policy and public health through expanding the coverage of the NLM collection, building new databases, and engaging in targeted outreach and training initiatives directed toward segments of the health policy and public health communities. Progress has been made, but more remains to be done. Recommendations arising from the meeting, Accessing Useful Information: Challenges in Health Policy and Public Health, will help NLM and the National Network of Libraries of Medicine to establish priorities and action plans for the next several years.     

The correct formulation of clinical questions for the practice of evidence based medicine

Evidence-based medicine is the conscientious, explicit, and judicious use of the best evidence available to make decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. The good practice of EBM begins with a well formulated clinical question, meaning that it should be clear, directly relevant to the problem at hand and answerable by searching in medical literature. This paper begins by presenting the central tasks of clinical work from which clinical questions arise. The components of well formulated clinical questions are then presented. Finally, some of the steps for the correct formulation of questions are discussed.     

Clarification and elaboration on evidence-based practice in psychology.

Responds to comments by D. C. Wendt and B. D. Slife (see record 2007-13085-019), P. H. Hunsberger (see record 2007-13085-020), and R. B. Stuart and S. O. Lilienfeld (see record 2007-13085-021) regarding the report by the APA Presidential Task Force on Evidence-Based Practice (see record 2006-05893-001) entitled Evidence-based practice in psychology. The goal of the task force was to create a scheme that would suggest how evidence should be used to design and offer services that will benefit patients and to assure the public and the health care system that psychologists are providing evidence-based services. There were and will continue to be many scientific and philosophical issues inherent in any such enterprise, and agreement by all psychologists with every aspect of EBPP may not be possible. Nevertheless, the APA's EBPP policy and the report that accompanied it are remarkably inclusive of various perspectives while remaining unambiguous about the need to use evidence in a way that leads to effective services. What is needed at this point are clinically relevant evidence and investigations of how such evidence can be used to best benefit those served by psychological interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)