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Brief communications 3 Fong, Y. The value of interlibrary loan: an analysis of customer satisfaction survey comments. In: WeaverMeyers P., Stolt W. & Fong Y. (eds) Interlibrary Loan/ Document Delivery and Customer Satisfaction: Strategies for Redesigning Services. New York: The Howarth Press, 1996: 43 – 54. 4 Line, M. B. Library Surveys: An Introduction to the Use, Procedure and Presentation of Surveys. 2nd edn. London: Bingley, 1982. Received 20 September 2004; Accepted 18 August 2005 Short communication Brief communication Communication 4December 22 2005

How well are we doing in supporting evidence-based health care? The ‘Information Mastery’ perspective Michele Hilton Boon, Information Scientist, National Prescribing Centre, The Infirmary, Liverpool, UK

Using the evidence: practices and problems Evidence-based practice is widely promoted as a means of improving the quality of health care by ensuring that clinical decisions are based on sound, up-to-date research evidence. Reducing the amount of clinical practice that is based on habit, outdated evidence, unsubstantiated opinion or guesswork has the potential to improve patient care, equity across the health-care system, and efficiency. The NHS Executive guidelines on Library and Information Services state that libraries and their staff play a central role in supporting evidence-based clinical practice.1 This support takes the form of providing access to the evidence base and providing training in at least some of the skills required to access, evaluate and implement the evidence, such as IT skills, database and web searching skills and critical appraisal skills. Although training and resources are available, considerable obstacles remain for clinicians in putting evidence into practice and studies suggest that, in the real world of clinical practice, clinicians seldom follow the rational, evidence-based mode of enquiry. In one study of two general practices in England, the authors reported that

Correspondence: Michele Hilton Boon, Information Scientist, National Prescribing Centre, The Infirmary, 70 Pembroke Place, Liverpool L69 3GF, UK. E-mail: [email protected]

‘not once in the whole time we were observing them did practitioners go through the steps of evidencebased enquiry or access a clinical guideline.’2 In another study of 103 general practitioners (GPs) in Iowa, doctors pursued answers to only 36% of the questions that arose in practice and found an answer to 80% of the questions pursued.3 GPs spent an average of less than 2 min pursuing an answer to a clinical question. Not surprisingly, the time pressures of clinical practice do not generally allow for  searches or the retrieval and appraisal of individual articles. Lack of time is the major barrier to the practice of evidence-based health care.4 In addition to finding answers to clinical questions, clinicians must also ensure that their practice is updated as the evidence base grows. Again, health librarians provide support in the form of current awareness services, including journal table of contents alerts, ‘SDI’ alerts from databases such as , and news digests. However, if clinicians do not have time to search  or read guidelines in order to answer clinical questions, how much time do they have to read current awareness bulletins—and then to access, read and critically appraise the articles that appear to be relevant? According to one estimate, some 1200 new articles appear in the medical literature each week that are potentially relevant to a given clinician. If a clinician spent 15 min accessing and reading each relevant article, and read for 10 h a day, 6 days a week, he or she could only read 240 articles per week, meaning that after 1 week the clinician is 4 weeks behind, and after a year the clinician is almost 5 years behind in his or her reading!5 Staying up to date by personally scanning newly published research, then, is no more feasible than expecting busy clinicians to conduct database searches and critically appraise articles in order to answer clinical questions. At present, providing access to thousands of journals and training clinicians in database searching and critical appraisal constitutes a not insignificant use of resources in health libraries. Yet the evidence demonstrates that, in practice, clinicians do not have time to access these resources or use the skills to meet the majority of their information needs. These resources and skills are vital

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Brief communications

tools for evidence-based practice; I am not suggesting that providing them is a waste of time, money or effort. Confronted by this evidence, however, one must ask: isn’t there a better way? Can we not support evidence-based practice with training and resources that better reflect the real needs and circumstances of clinicians?

Part of the solution: Information Mastery ‘Information Mastery’ is a concept that has grown out of the evidence-based medicine movement in the USA.6 Its proponents recognize that clinicians require information management skills to be able to cope with and navigate through the vast quantities of health research produced daily. Slawson and Shaughnessy describe Information Mastery as ‘the applied science of medical information’, which can be used both for finding answers to clinical questions (‘hunting’) and staying up to date (‘foraging’).7 Because Information Mastery takes into account the obstacles and behaviours described by Gabbay and others,2− 4 its principles should be more widely known and could be incorporated into the training and other services provided by health libraries. In one of the earliest articles on Information Mastery,8 the authors argued that the usefulness of medical information can be expressed as an equation: Usefulness = (relevance × validity)/work The more work (time, money, effort) involved in obtaining information, the less useful the information is in the final analysis. Also, as relevance or validity approaches zero, usefulness approaches zero. The time and effort spent assessing validity (using critical appraisal skills to evaluate the study design and statistical results) can be significantly reduced if a relevance filter is applied first. There is simply no point in going to the trouble of accessing and appraising a research article unless the intervention described meets the following criteria: • if the results were valid, the study would require a CHANGE in clinical practice; • the condition studied is COMMON in the clinician’s practice; • the intervention is FEASIBLE in the local context; and, most importantly;

• the study outcome is a POEM—Patient-Oriented Evidence that Matters.7 Much of the research literature studies diseaseorientated outcomes, such as changes in patients’ biochemistry, rather than outcomes that matter to patients, namely ‘Will I live longer and /or better?’ Teaching health-care professionals to employ relevance filters before assessing validity, and to frame search questions so as to focus on POEMs, could help them to navigate clinical databases and current awareness services more efficiently. However, expecting busy clinicians to access and manage the medical research literature themselves—even when armed with the criteria above— is only part of the answer. Even more time could be saved, and more evidence could be put into practice, if clinicians had access to trusted sources that scanned journals for relevant articles and assessed the validity of research for them. Slawson and Shaughnessy advocate specific types of information resources for hunting and foraging based on how much the sources incorporate validity into their selection and reporting process. For ‘hunting’ or finding answers to clinical questions, reliable sources of evidence-based summaries should be the first port of call, such as Cochrane reviews, evidence-based guidelines, and Clinical Evidence; then reliable evidence scan-and-summary services such as InfoPOEMs (http://www.infopoems.com) or journals such as the Evidence-Based titles and ACP Journal Club; then textbooks and evidencebased decision aids; and, only as a last resort if the answer cannot be found above,  and other clinical databases.9 Yet for how many of us is a  search the first port of call in answering a clinical question or conducting a literature search? What role should a  search play if a clear, succinct, evidence-based answer is already available in a Cochrane review or Clinical Evidence? Do we introduce medical and nursing students to these resources, or only to  and ? ‘Foraging’ tools or current awareness services should also focus on POEM-type evidence and should make their selection criteria available to the clinician, who should then critically appraise the criteria. News services that purvey infotainment or ‘medical gossip’8 may be more of a hindrance than a help in promoting evidence-based practice if they take up clinicians’ time unnecessarily and


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disseminate information uncritically. BMJ Updates (http://bmjupdates.mcmaster.ca/index.asp) is a welcome development in this area, selecting journal articles for validity and relevance to selected areas of practice. This free service provides links to PubMed abstracts, but does not summarize or provide an appraisal of the research. The InfoPOEMs service scans over one hundred journals each month, selects research articles for relevance, and provides a summary and assessment of their validity, but is available on an individual subscription basis only. DynaMed (http://www.dynamicmedical.com), which is updated daily, and UpToDate (http:// www.uptodate.com) also provide scanning and summary services for a fee. The development of an evidence scan-and-summary service for the NHS or the purchase of one or more such services via Core Content might be examined as a means of providing good value for money in information management and addressing the time constraints that hinder evidence-based practice. The NeLH/CRD ‘Hitting the Headlines’ service (http://www.nelh.nhs.uk) currently provides a similar service for newspaper items, but not for journal articles. These conclusions drawn from Information Mastery principles support the conclusions of Ely et al. that GPs need ‘bottom-line’ answers and accessible summaries of evidence,3 and of McColl et al. who wrote that ‘Promoting and improving access to summaries of evidence, rather than teaching all general practitioners literature searching and critical appraisal, would be the more appropriate method of encouraging evidence-based general practice’.4 Information overload and time constraints are serious obstacles to evidence-based practice. By simply providing access to an enormous body of research literature and teaching time-consuming practices to navigate that literature, librarians may be part of the problem. However, by teaching more efficient means of information management, such as the use of relevance and validity filters and POEMs, and promoting and developing resources that provide quick summaries of evidence, such as Cochrane Reviews and Clinical Evidence, we can be part of the solution.

Declaration of interest The author’s employer, the National Prescribing Centre, ran two Information Mastery training conferences in March 2005.

Acknowledgements My thanks to my colleagues at the National Prescribing Centre, Annie Coppel and Jonathan Underhill, for reading and commenting on an earlier draft of this paper. All errors remain my own. Key Messages Implications for Policy • Previous research has established that healthcare staff lack time to search databases and critically appraise articles, a problem that constitutes a major barrier to evidence-based practice. • Realistic information management principles, such as the Information Mastery concept, should inform the provision of resources and services to health-care staff. • The development or purchase of an evidence scan-and-summary service for the NHS might be examined as a means of providing good value for money in information management and addressing the time constraints that hinder evidence-based practice. Implications for Practice • Change training programmes so that users learn to treat Cochrane reviews, evidencebased guidelines, Clinical Evidence, and other evidence summaries as first-line sources, with citation databases as a last resort in answering questions. • Add value to training and current awareness services by teaching and implementing relevance filters, focusing on POEMs (PatientOriented Evidence that Matters). • Teach clinicians to use and evaluate evidence scan-and-summary services.

References 1 NHS Executive. Library and Information Services: Health Service Guidelines, HSG (97)47, 1997 Available from:



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http://www.dh.gov.uk / assetRoot/04/01/23/99/04012399.pdf (accessed 29 July 2005). Gabbay, J. & le May, A. Evidence based guidelines or collectively constructed ‘mindlines?’ Ethnographic study of knowledge management in primary care. British Medical Journal 2004, 329, 1013 –7. Ely, J. W., Osheroff, J. A., Ebell, M. H., Bergus, G. R., Levy, B. T., Chambliss, M. L. & Evans, E. R. Analysis of questions asked by family doctors regarding patient care. British Medical Journal 1999, 319, 358 – 61. McColl, A., Smith, H., White, P. & Field, J. General practitioners’ perceptions of the route to evidence based medicine: a questionnaire survey. British Medical Journal 1998, 316, 361–5. Maskrey, N. Using medical poetry to improve health care delivery: the UK Context. Information Mastery UK 2005: Practising and Teaching Evidence-Based Medicine in the Real World, 17–18 March 2005, Warwick, UK. Center for Information Mastery. 2005. Available from: http://www.healthsystem.virginia.edu /internet /familymed/ docs /info_mastery.cfm (accessed 29 July 2005). Shaughnessy, A. F. & Slawson, D. C. Information mastery: evidence-based medicine in everyday practice. Information Mastery UK 2005: Practising and Teaching Evidence-Based Medicine in the Real World, 17–18 March, Warwick, UK. Slawson, D. C., Shaughnessy, A. F. & Bennett, J. H. Becoming a medical information master: feeling good about not knowing everything. Journal of Family Practice 1994, 38, 505–13. Shaughnessy, A. F. & Slawson, D. C. A pocket full of possibilities: ‘Just-in-Time’ information at the point-of-care. Information Mastery UK 2005: Practising and Teaching Evidence-Based Medicine in the Real World, 17–18 March 2005, Warwick, UK.

Received 16 June 2005; Accepted 18 August 2005 September 3B 22 Brief rief communication Communication 2005

Brief communication

Searching a biomedical bibliographic database from Hungary—the ‘Magyar Orvosi Bibliográfia’ Ildiko Kele**, Dániel Bereczki*, Vivek Furtado†, Judy Wright‡ & Clive E. Adams‡, **Department of Psychiatry, University of Debrecen, *Department of Neurology, University of Debrecen, Debrecen, Hungary, †Mary Morris International Residence, Leeds, ‡Cochrane Schizophrenia Group, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds, UK

Correspondence: Professor Clive E. Adams, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds, UK LS2 9LT, UK. E-mail: [email protected]

Introduction The Republic of Hungary is a landlocked country in Central Europe. It is known locally as the Country of the Magyars or Magyarország and has a population of over 10 million. Hungary continues to demonstrate strong economic growth as one of the newest members of the European Union (since 2004). The private sector accounts for over 80% of Gross Domestic Product (GDP). Foreign ownership of and investment in Hungarian firms is widespread. Inflation and unemployment have declined substantially in recent years. Economic reform measures such as health-care reform, tax reform, and local government financing have not yet been addressed by the present government.1 Literature searching over a broad range of sources can produce a more representative picture of research findings compared with searches of readily available databases.2 Cochrane systematic reviews aim to identify all relevant trials in order to increase, at least, the precision of the final summary results. Studies that are difficult to locate may have results that substantially differ from those that are readily accessible. For example, when Egger et al. searched German medical journals for randomized controlled trials (RCTs) and then searched for other trials published in English from the same authors they found that quality was constant but that the size of the estimates of effect were not.3 German trialists, on average, published their more positive work in English and their studies with equivocal or even negative results were more likely to be published in German. There was a language bias operating. The Cochrane Collaboration is acutely aware of this publication and language bias and makes extensive efforts to identify all trials and to make them accessible through the Cochrane Central Register of Controlled Trials (), published in the Cochrane Library. However, many subject-specific and national databases have not yet been searched for inclusion in , leaving the RCT/ Controlled Clinical Trials (CCT) coverage of some areas under represented. For example, searching the Australasian Medical Index (1966–2000) identified 512 relevant citations (RCTs or Controlled Clinical Trials—CCTs) but only 12% could also be found in .4 Inclusion of the remainder into  improves its international coverage.


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