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Chapter 7: Managing knowledge in evidence-based pharmacy
  1. Phil Wiffen1,
  2. Tommy Eriksson2,
  3. Hao Lu3
  1. 1Pain Research Unit, Churchill Hospital, Oxford, UK
  2. 2Department of Clinical Pharmacology, Laboratory Medicine, Lund University, Lund, Sweden
  3. 3Beijing United Family Hospital, Beijing, China
  1. Correspondence to Professor Phil Wiffen, Pain Research Unit, Churchill Hospital, Old Road, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk

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About this chapter

This chapter deals with the challenge of managing data often in the form of citations found in medical databases. The second section covers the need to have a strategy in order to support evidence-based practice. The third section describes in more detail some reliable databases that pharmacists may find useful for their evidence based practice.

Evidence-based Pharmacy was first published as a textbook by Phil Wiffen in 2001. The first chapter was published in Eur J Hosp Pharm 2013;20:308–12. Subsequent chapters have been published in EJHP at approximately 2-month intervals.

Managing publications

The large volume of data that comes across the desk of many pharmacists creates a challenge in finding ways to store and retrieve valuable information. Most of us have moved away from large filing cabinets of photocopied papers and prefer to store information and knowledge electronically. It is remarkable to see medical libraries that were once filled with long rows of bound journals being stripped out to make space for computer terminals with fast access to the same journals electronically.

One of the most useful tools is the bibliographic database which has been popular in many research settings within and outside medicine but has not been adopted into pharmacy world to any great extent. This chapter sets out to describe the benefits of such systems to facilitate some of the key aims of this book including identifying useful evidence and being able to effectively prepare research articles for publication. These software packages are designed to facilitate two important processes:

  1. To store the results of our searches in a format that can be reordered or searched to find a particular paper.

  2. To facilitate the preparation of research papers by providing an electronic means of identifying those articles which you cite and want to include in your reference list. The reference list can then be formatted in a style that is required for the preferred journal you intend to submit to.

We overview such databases without recommending any particular one. The authors are more familiar with EndNote so that1 is used an example among others. However readers may wish to explore all options which suit their needs and budget. There are some 30 plus options to choose from of which about half are free to use. Many universities have preferential rates or central subscriptions that make the choice more obvious.

The basic layout of the database is designed to create records of published material according to its format, for example, journal articles, books, websites, etc, and the fields are set up to store that information. There are additional fields which include sections for key words and reference numbers or your own notes. The simplest use of the database is to manually type in the details into the fields in a logical sequence. The data is held as records that can then be searched using a variety of options such as author, date of publication, keywords, etc. Databases of many thousands of papers can be built up in this way and single articles identified in seconds. For example, a single reference in an EndNote database of 20 000 records can be found in less than 5 s.

An example of such a record (abstract and some other data is excluded due to size) is presented as figure 1.

Figure 1

Illustration of an EndNote X5 single journal article record (part page).

To build a database of some size by entering single records is far from ideal. This is time-consuming and is likely to be fraught with typing errors. Far more useful is the ability to search in one of the main medical databases and then download the results into the bibliographic database. Within PubMed the search is carried out and useful articles selected. The ‘Send to’ option is then chosen and the radio button for ‘Citation manager’ selected. When the ‘Create File’ is used, records download automatically into your bibliographic software; see figure 2.

Figure 2

Screenshot of PubMed search with ‘Send to’ option opened.

In EndNote it is possible to carry out an online search from within the database. For small searches this is the best option and is undertaken by using the correct icon (figure 3).

Figure 3

Icon to search online within a database.

All bibliographic software packages have the means for either simple or complex searches. In EndNote various options are available to search a database. Figure 4 shows the search box provided and each dropdown menu has a variety of options together with Boolean operator choices (AND, OR, etc.).

Figure 4

Search box within EndNote database (part page).

Selected records can be saved into created groups as shown in figure 5.

Figure 5

‘My groups’ section within EndNote database (part page).

This facility can be frustrating as the main record remains in the database so records are not uniquely assigned to one group. Note it is also possible to search by date or a range of dates.

A real strength of these databases is the ability to link a manuscript to the database in order to generate a reference list. This task which is usually time-consuming and tedious is quickly performed as the word processing package commonly but not necessarily Word interacts to find the references mentioned, marks the text in the appropriate way, for example, superscript number and produces the reference list. When the software is installed, an addition command is added to the word processing package (figure 6).

Figure 6

Note the EndNote X7 command on the top line of a Word document (part page).

When this command is activated a dialogue box appears with a range of options (figure 7).

Figure 7

Dialogue box in Word to insert citations (part page).

Various styles of reference are available so if your manuscript in, for example, Vancouver is rejected by your favourite journal it can be submitted to another journal which might require Harvard formatting, for example, with ease.

Once the ‘Insert Citation’ button is selected, the reference is copied into a reference section and a superscript number is inserted in the text at the point where the identifier for the citation was chosen. This is illustrated in figure 8.

Figure 8

Example of citation linked in Word.

Developing a knowledge management strategy

In reality a strategy is needed to cope with the volume and range of material available. It is easy to think of continuous professional development as the answer but in reality that only partly meets the need mainly because this is often thought of in terms of attending workshops or lectures and while those subjects may be interesting, they may not be what we need.

We have quoted Sackett in earlier chapters. The following points are from one of the early works of Sackett2:

  1. As soon as formal education is complete, we hit the ‘slippery slope of declining clinical competence’.

  2. It is not what we don't know that gets us into trouble; it is what we do know but in reality is wrong.

  3. The rate of advance in medical literature is not an excuse; we only need to know a tiny part of it.

  4. We can wait for others to tell us what we need to know but we will always lag behind.

So what is the answer?

Here are some points for consideration:

  1. Concentrate on the peer reviewed literature that provides the best yield for your interest or specialty. This can be quite difficult, as pharmacy has relatively few peer referred journals. It may mean that some of the medical journals have to be sought out and all have a presence on the internet for at least contents and abstracts.

  2. Read only original articles of clinical trials or systematic reviews that are likely to have an impact on your own practice.

  3. Scan the Methods and results section to ensure that the article is likely to come up with a valid answer.

  4. Develop a reading habit. A journal club may help to focus on keeping up to date.

  5. Collaborate with colleagues and share journals around.

  6. Develop a strategy and stick to it.

This sounds like time for action so here are some practical tips:

  • Determine which journals you should read on a regular basis by conducting a personal survey of what you currently read and what can be derived from this reading. Seriously consider deleting those journals which give low yield.

  • Consider scanning index pages as a means of maintaining awareness of content.

  • Add as many high yield journals to your list as you can manage, consider sharing journals with colleagues, or other departments.

  • Develop a library habit; avoid the trap of believing that keeping up to date is somehow not a part of the job, and don't let others tell you that.

  • Set aside a limited amount of time for internet browsing to stay aware of developments, new guidelines, etc.

Acquiring knowledge management skills is another aspect of this strategy

There are sets of basic skills that need to be mastered by pharmacists in order to maintain a good level of ongoing professional development:

  1. Searching. Pharmacists often use a local drug information unit or medical librarian but these can be slow and unresponsive. There are often situations where information is required quickly and pharmacists should be competent to find evidence for them. The following minimum competencies should be acquired:

    • the ability to identify appropriate sources of evidence to answer a particular query

    • the ability to carry out a search of PubMed without the help of a librarian and to find at least 60% of the reviews or research studies that would have been identified by an expert searcher

    • the ability to construct simple search strategies on PubMed using Boolean operators such as ‘AND’ and ‘OR’ for: (See previous chapter 33).

      • The following healthcare terms:

        • Treatment, Test

      • The following service characteristics

        • Effectiveness

        • Safety

        • Acceptability

        • Appropriateness

        • Quality

        • Cost effectiveness

    • The ability to download the end product into reference management software.

      Unfortunately skills tend to atrophy if not used and regular refresher sessions are required to ensure skills are maintained.

  2. Scanning for evidence

    All pharmacists should seek to regularly read certain journals scanning for evidence around topics relevant to their practice. This activity needs to be planned into the working week as a regular and planned activity.

  3. Appraising evidence

    Pharmacists should be competent to appraise the evidence in the following areas:

    • A review article for:

      • a therapy

      • a test

      • health policy or management change

    • Be able to assess the quality of the following research methodologies:

      • Systematic reviews

      • RCTs

      • Qualitative research

      • Case control studies

      • Surveys or cohort studies

    • Assess performance or outcome of an intervention against the following criteria:

      • acceptability

      • effectiveness

      • safety

      • patient satisfaction

      • appropriateness

      • quality

      • cost effectiveness

  4. Storing and retrieving.

    If the above activities are in place then there is a clear need to ensure efficient storage and retrieval. This may consist of a tried and tested storage method but ideally should include the ability to

    • Enter references and abstracts using self-selected keywords into one of the personal bibliographic management systems

    • Search for references in that system

    • Download sets of references onto paper

Evidence-based databases

In chapter 6 we described sources for selecting and individualising medication treatment. In this section we discuss the Cochrane Library and Micromedex, two databases in common use in hospital pharmacy and medicine information services.

The Cochrane Library

The Cochrane Library is indexed in Medline and PubMed but can be searched as a stand-alone database.4 The library consists of seven sections or sublibraries designed as a resource of reliable evidence-based information from the Cochrane Collaboration. The main database is the Reviews section. This contains the full text of Cochrane reviews and also the full text of protocols for reviews in progress. Full text for complete reviews is only available via institutions or countries that pay a subscription5; otherwise just the abstract is available. Protocols do not contain any useful information for decision making. The next section is an ‘Other reviews’ section which contains one page summaries of systematic reviews with some quality assessment published in the general literature. A trials database lists the citations of most randomised controlled trials that have been identified by Cochrane groups. Three databases then list citations for methodology, health technology and economic evaluations. The final section is ‘About Cochrane’ with details of Cochrane groups and contact details.

Micromedex

Micromedex6 is available as a medication information reference tool in a few different formats, including software on personal computers, online (Web 2.0), app (on iPhone/Android) and on tablet computer. It is compiled from several databases based on specific types of information, such as Drugdex, Alternative Medicine, Neofax, Red Book Online and Martindale.

The Drugdex section consists of drug monographs. Within each drug monograph, there is information such as dosing information, pharmacokinetics, cautions, clinical applications, drug interactions, adverse drug reactions and drug comparison.

There are also useful tools within Micromedex, such as drug interactions tool (where many medications can be entered together to check interactions between them), intravenous compatibilities tool and drug identification tool.

Micromedex is useful to pharmacy practice in a few different ways:

  1. Offer information on an international level, so that drugs used in other countries can be reviewed.

  2. Provides comprehensive information for each drug in a single resource, so that information can be easily accessed and searched.

  3. Provide in-depth information beyond the drug licensing authorities’ approval. Unlabelled indications are listed, with thorough references to related literature.

  4. Available as integration to the electronic medical record system so that data can be transferred for real time clinical decision support.

Footnotes

Phil Wiffen is editor-in-chief of EJHP and also teaches methodology for Evidence Based Medicine and systematic reviews.

Tommy Eriksson is Professor in Clinical Pharmacy employed at Lund University

Hao Lu is a clinical pharmacist based at the Beijing United Family Hospital in China.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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