This document discusses strategies for searching secondary sources of evidence to answer clinical questions. It begins by distinguishing between primary sources like original studies and secondary sources like syntheses, synopses, textbooks, and guidelines. It then provides an overview of popular secondary sources within each category, including systematic reviews, critically appraised abstracts, textbooks like UpToDate, clinical practice guidelines, and decision support systems. It emphasizes the importance of appraising the quality of secondary sources. Finally, it discusses paid evidence services and meta search tools that can help clinicians efficiently find relevant evidence to inform decisions.

1. SearchingSecondary Sources SohailBajammal, MBChB, MSc, FRCS(C), PhD(c) ssbajammal@uqu.edu.sa Assistant Professor of Orthopaedics, Faculty of Medicine Vice Dean, Academic Development, Faculty of Dentistry

2. How many questions do you ask yourself at the end of a busy clinical day? What % you look up? What % you answer?

3. Objectives Differences between primary & secondary sources of evidence Overview of popular secondary sources

4. 5A

5. 5S Hierarchy of EvidenceHaynes RB. Evid Based Med 2006;11:162-164 Computerized decision support system Evidence-Based Guidelines & Textbooks Secondary Critically-Appraised Journal Articles & Abstracts Systematic Reviews RCTs, Cohort, Case control, Case series Primary Expert Opinion: Classical Textbooks

6. Studies(Primary Sources)

7. Primary Sources Original articles Through databases: MEDLINE, EMBASE Using: PubMed, OVID You have to retrieve and appraise the articles Strength (pyramid) of evidence

10. MeSH (Medical Subject Headings)

11. It is a “strategy” Low Back Pain Treatment OR OR Low Back Ache Management Acute OR OR Low Backache Therapy AND AND OR OR "Low Back Pain"[Mesh] Surgery

15. In: Glasziou P, Del Mar C: Evidence-based Practice Workbook: Bridging the gap between health care research and practice. Blackwell Publishing - BMJ Books. 2007. PP 3-13

16. In: Glasziou P, Del Mar C: Evidence-based Practice Workbook: Bridging the gap between health care research and practice. Blackwell Publishing - BMJ Books. 2007. PP 3-13

17. Pyramid of Evidence http://library.downstate.edu/EBM2/2100.htm

19. Tough Job Emergency medicine Family medicine Internal medicine Pediatrics

20. Don’t say there is “no evidence” Instead Weak evidence You might not have looked thorough enough

21. Absence of evidence is not the evidence of absence

22. Satisficing ‘‘where busy clinicians will be satisfied with the information they can readily summon, while sacrificing quality for convenience” Carter BS, Leuthner S. Decision making in the NICU—strategies, statistics and ‘‘satisficing.’’ Bioethics Forum. 2002;18:7–15.

23. Usefulness of information Hurwitz SR, Slawson DA, Shaughnessy A. Orthopaedic information mastery: applying evidence-based information tools to improve patient outcome while saving orthopaedists’ time. J Bone Joint Surg Am. 2000;82:888–895.

26. Secondary Sources

27. Syntheses(Systematic Reviews)

28. Syntheses The authors have done the work for you Hopefully: They asked a good question They searched the literature systematically (keywords & MeSH) They identified the studies and assessed their quality This is called Systematic Review If they did statistical combination of results, this is called Meta-analysis

29. How to search for “Syntheses”? Same databases: MEDLINE, EMBASE Cochrane Library

30. PubMed

37. Are all syntheses good? You still have to appraise the quality of these systematic reviews and meta-analyses It’s time consuming

39. Synopses(Critically Appraised Abstracts)

40. Synopses Physicians with training in research methodology: Read the articles Assess their quality Summarize them for you Many sources: Database of Abstracts of Reviews of Effects (DARE) ACP Journal Club Evidence-based sections in many journals Others: DynaMed, EvidenceMatters, EssentialEvidence

49. DAREDatabase of Abstracts of Reviews of Effects

54. SummariesEBM TextbooksEBM Guidelines

55. EBM Textbooks UpToDate

61. Guidelines Types of guidelines: Consensus Evidence-based Use the limiting features in the website

62. Guidelines NICE: National Institute for Health & Clinical Excellence SIGN: Scottish Intercollegiate Guidelines Network NGC: National Guideline Clearinghouse

72. Are all guidelines good quality?

81. Systems

82. Systems This is the ultimate goal Computerized decision support Too sophisticated for us to think about now

88. Paid Services DynaMed EvidenceMatters EssentialEvidence Plus

89. DynaMed

100. EvidenceMatters

116. EssentialEvidencePlus

126. Meta Search (Many-in-one) NHS Evidence TripDatabase Google Scholar

127. NHS Evidence

132. TRIPDatabase

141. Google Scholar

143. Broad Term  Lots of irrelevant results

145. They will email you when new article cites this article

146. Searching for evidence DiCenso A, Bayley L, Haynes RB. Accessing preappraised evidence: fine-tuning the 5S model into a 6S model. ACP Journal Club, 2009