WEBVTT 1 00:00:01.250 --> 00:00:06.719 Welcome to module three of the evidence analysis center orientation tutorial. In 2 00:00:06.989 --> 00:00:08.270 this module, 3 00:00:08.279 --> 00:00:12.869 you will learn about the evidence analysis center's systematic review process. 4 00:00:15.810 --> 00:00:18.950 The information in the evidence analysis library 5 00:00:19.149 --> 00:00:21.379 has been determined through a systematic 6 00:00:21.389 --> 00:00:24.309 process for reviewing nutrition research. 7 00:00:24.840 --> 00:00:28.649 This module covered the roles of the project team and the academy's rigor 8 00:00:28.870 --> 00:00:31.350 fives step systematic review process. 9 00:00:33.479 --> 00:00:38.930 Evidence based dietetics practice involves a process of asking questions, 10 00:00:39.330 --> 00:00:43.610 systematically finding research evidence and assessing its validity, 11 00:00:43.669 --> 00:00:48.689 applicability and importance to nutrition and dietetics practice decisions 12 00:00:48.970 --> 00:00:53.029 and applying relevant evidence in the context of the practice situation 13 00:00:53.279 --> 00:00:55.430 including professional expertise 14 00:00:55.630 --> 00:01:01.209 and the values and circumstances of patients, clients, customers, individuals, 15 00:01:01.220 --> 00:01:04.309 groups or populations to achieve the positive outcomes. 16 00:01:04.958 --> 00:01:08.189 The main objective of the evidence analysis library 17 00:01:08.308 --> 00:01:11.609 is to provide a resource that academy members can use 18 00:01:11.749 --> 00:01:15.259 to implement evidence-based recommendations in practice. 19 00:01:19.230 --> 00:01:22.129 So why incorporate evidence-based practices 20 00:01:22.410 --> 00:01:25.669 for dieticians to remain competitive in health care? 21 00:01:25.959 --> 00:01:28.790 They must incorporate evidence-based practice into 22 00:01:28.800 --> 00:01:30.919 their day to day practice decisions. 23 00:01:31.690 --> 00:01:34.339 Evidence-based practice enhances credibility 24 00:01:34.349 --> 00:01:36.309 with other healthcare team members 25 00:01:36.489 --> 00:01:40.870 and will help dieticians be more effective and efficient in their practice. 26 00:01:41.720 --> 00:01:44.860 Evidence-based practice can improve the quality of healthcare 27 00:01:45.230 --> 00:01:47.660 decrease wide variations in practice, 28 00:01:47.970 --> 00:01:51.980 reduce the gap between what is known from research and what happens in real life 29 00:01:52.580 --> 00:01:55.360 and takes advantage of biomedical knowledge. 30 00:01:58.750 --> 00:02:03.410 Let's get started with how the eal team prepares for the systematic review. 31 00:02:07.059 --> 00:02:07.769 In module two, 32 00:02:07.779 --> 00:02:10.550 we covered how the scoping review is the 33 00:02:10.559 --> 00:02:13.550 first phase in the evidence analysis process. 34 00:02:14.229 --> 00:02:16.490 The project team answers a question. 35 00:02:16.500 --> 00:02:20.490 Does the available literature justify a need for the systematic review? 36 00:02:21.000 --> 00:02:22.369 If the answer is yes, 37 00:02:22.990 --> 00:02:25.449 the team moves forward with the systematic review 38 00:02:25.619 --> 00:02:27.009 and the process begins, 39 00:02:30.949 --> 00:02:35.169 the scoping review results identified nutrition tactics which had 40 00:02:35.179 --> 00:02:37.960 not been covered by a recent review or guideline. 41 00:02:38.500 --> 00:02:42.440 Therefore, the project team decided to move forward with a systematic review. 42 00:02:43.029 --> 00:02:46.449 They will use the results to focus the systematic review scope 43 00:02:46.720 --> 00:02:49.369 including development of the po questions. 44 00:02:53.100 --> 00:02:58.580 The evidence analysis center systematic review process is a state of the art method 45 00:02:58.789 --> 00:03:01.330 for evaluating food and nutrition questions. 46 00:03:01.550 --> 00:03:01.570 It 47 00:03:01.910 --> 00:03:05.139 is conducted by a team consisting of topic experts 48 00:03:05.399 --> 00:03:08.979 and a project team trained in research analysis protocols, 49 00:03:09.220 --> 00:03:13.460 meticulous methods and web-based templates are used throughout the process 50 00:03:13.600 --> 00:03:19.160 to ensure objectivity, transparency and reproducibility of the process. 51 00:03:22.449 --> 00:03:23.279 The systematic 52 00:03:23.520 --> 00:03:27.149 review project team is comprised of the project manager, 53 00:03:27.360 --> 00:03:28.600 lead analyst, 54 00:03:28.720 --> 00:03:31.169 a panel of 6 to 8 topic experts, 55 00:03:31.350 --> 00:03:33.759 patient advocate methodologies, 56 00:03:34.080 --> 00:03:35.449 evidence analyst 57 00:03:35.580 --> 00:03:39.380 and a medical librarian experienced with systematic review searches. 58 00:03:43.440 --> 00:03:45.759 Expert panel members are appointed by the 59 00:03:45.770 --> 00:03:48.899 Council and research work group selection sub-committee. 60 00:03:49.580 --> 00:03:52.830 The sub-committee aims for a multidisciplinary team 61 00:03:52.839 --> 00:03:55.559 with a balance of clinicians and researchers 62 00:03:56.179 --> 00:03:58.779 requirements to become an expert panel member 63 00:03:58.789 --> 00:04:01.360 include a minimum of five years of practice 64 00:04:01.729 --> 00:04:03.399 or research experience. 65 00:04:03.789 --> 00:04:06.869 Three years of work related to the focus of the project 66 00:04:07.149 --> 00:04:09.399 and neither an advanced degree or at least 67 00:04:09.410 --> 00:04:12.080 eight years of experience in the topic area. 68 00:04:12.750 --> 00:04:15.759 This is the get involved section which can be accessed from the E 69 00:04:15.869 --> 00:04:18.850 A homepage for volunteer opportunities. 70 00:04:19.380 --> 00:04:23.769 Responsibilities of the expert panel include finalizing the evidence analysis, 71 00:04:23.779 --> 00:04:25.390 questions and search plan, 72 00:04:25.619 --> 00:04:27.859 reviewing work completed by the analysts and 73 00:04:27.869 --> 00:04:31.350 lead analysts finalizing and grading content, 74 00:04:31.459 --> 00:04:33.529 developing guideline recommendations 75 00:04:33.730 --> 00:04:36.329 and providing final approval and all material 76 00:04:36.720 --> 00:04:40.609 the group needs via teleconference calls usually twice a month. 77 00:04:44.839 --> 00:04:48.470 Patient advocate roles are designed to advise the expert panel 78 00:04:48.480 --> 00:04:50.480 on how particular therapies will 79 00:04:50.489 --> 00:04:53.739 impact the patient population under consideration 80 00:04:54.010 --> 00:04:57.570 and they should be closely involved in developing recommendations. 81 00:04:58.000 --> 00:05:02.459 The academy includes a patient advocate for guideline projects. When possible. 82 00:05:05.790 --> 00:05:09.369 The project manager and lead analyst facilitate and 83 00:05:09.380 --> 00:05:12.609 manage the expert panel in evidence analysis. 84 00:05:13.260 --> 00:05:17.410 Communication is key at every step of the evidence analysis process. 85 00:05:17.880 --> 00:05:20.260 The medical librarian experience with systematic 86 00:05:20.269 --> 00:05:22.890 reviews conducts an extensive literature, 87 00:05:22.899 --> 00:05:24.899 search and documents, the results. 88 00:05:25.329 --> 00:05:28.200 The methodologies oversees the entire process. 89 00:05:31.279 --> 00:05:34.730 The process that we are about to review is available on the E 90 00:05:34.950 --> 00:05:35.010 A 91 00:05:35.149 --> 00:05:37.529 from the policy and process tab 92 00:05:41.109 --> 00:05:45.130 here at a glance are the five steps in the systematic review process. 93 00:05:45.390 --> 00:05:46.779 Formulate the question 94 00:05:46.980 --> 00:05:49.950 gather the research appraise the articles 95 00:05:50.200 --> 00:05:51.820 synthesize the evidence 96 00:05:52.119 --> 00:05:54.399 and develop the conclusion statement and 97 00:05:54.410 --> 00:05:56.820 grade the strength of the supporting evidence 98 00:05:59.760 --> 00:06:00.679 step. One 99 00:06:01.049 --> 00:06:02.790 formulate the research question. 100 00:06:06.010 --> 00:06:09.109 As the expert panel develops the research questions, 101 00:06:09.529 --> 00:06:11.470 they categorize them by steps of the 102 00:06:11.480 --> 00:06:14.450 nutrition care process which includes nutrition, 103 00:06:14.459 --> 00:06:18.190 assessment, nutrition, diagnosis, nutrition, intervention 104 00:06:18.390 --> 00:06:20.790 and nutrition monitoring and evaluation. 105 00:06:24.760 --> 00:06:27.959 The research questions are developed in the PICO format. 106 00:06:28.649 --> 00:06:30.239 PICO stand for population 107 00:06:30.420 --> 00:06:31.390 intervention 108 00:06:32.070 --> 00:06:33.070 comparison 109 00:06:33.450 --> 00:06:34.130 and outcome. 110 00:06:34.880 --> 00:06:35.660 Utilizing the PUP 111 00:06:35.880 --> 00:06:39.040 format helps the expert panel develop questions that 112 00:06:39.049 --> 00:06:41.589 are neither too broad nor too specific. 113 00:06:44.730 --> 00:06:47.519 When developing questions in the PICO format, 114 00:06:47.570 --> 00:06:50.769 it is helpful to plug them into a PICO table 115 00:06:50.910 --> 00:06:53.850 to ensure each component of PICO is included. 116 00:06:54.489 --> 00:06:56.119 You can see by this example. 117 00:06:56.130 --> 00:06:56.899 The other question, 118 00:06:56.910 --> 00:06:59.359 how does daily caffeine intake affect the 119 00:06:59.369 --> 00:07:02.619 blood pressure of patients with chronic heart failure 120 00:07:02.859 --> 00:07:04.339 follows the PICO format. 121 00:07:04.940 --> 00:07:07.730 Patients with chronic heart failure is the population 122 00:07:07.989 --> 00:07:10.440 daily caffeine intake is the intervention. 123 00:07:10.899 --> 00:07:13.079 The comparison is no caffeine intake 124 00:07:13.329 --> 00:07:15.799 and the outcome is fat and blood pressure. 125 00:07:19.040 --> 00:07:23.589 When thinking of nutrition interventions that lead to specific outcomes, 126 00:07:23.899 --> 00:07:26.299 there are a variety of factors to keep in mind 127 00:07:26.390 --> 00:07:31.380 including the content context and delivery method of the intervention 128 00:07:34.540 --> 00:07:37.570 step two gather and classify the research. 129 00:07:40.790 --> 00:07:43.049 Before beginning the literature search, 130 00:07:43.459 --> 00:07:46.619 the expert panel must develop a detailed search plan. 131 00:07:47.239 --> 00:07:50.329 An information specialist conducts the actual search 132 00:07:50.390 --> 00:07:53.420 using appropriate search terms in multiple databases. 133 00:07:54.130 --> 00:07:56.429 The team then reviews the search plan results. 134 00:07:56.769 --> 00:07:58.950 They review the articles and determine which 135 00:07:58.959 --> 00:08:01.279 articles to include and which to exclude 136 00:08:01.839 --> 00:08:06.679 any full text article that is reviewed and excluded must have a valid reason. 137 00:08:06.690 --> 00:08:09.260 All of which is documented and published on the E 138 00:08:09.440 --> 00:08:09.510 A. 139 00:08:10.440 --> 00:08:13.859 The entire search process is thoroughly documented. 140 00:08:17.140 --> 00:08:21.500 Conducting a thorough search of multiple databases is critical. 141 00:08:21.739 --> 00:08:27.190 This diagram shows that the initial search is wide duplicate articles and articles 142 00:08:27.200 --> 00:08:31.239 that don't match the inclusion criteria are excluded in the title screening. 143 00:08:36.158 --> 00:08:36.568 The prison 144 00:08:36.707 --> 00:08:41.609 checklist is an evidence based set of items for reporting and systematic reviews. 145 00:08:42.299 --> 00:08:45.049 A flow chart is generated that depicts the flow of 146 00:08:45.059 --> 00:08:48.739 information through the different phases of a systematic review. 147 00:08:49.198 --> 00:08:53.239 It maps out the number of records identified included and excluded. 148 00:08:53.518 --> 00:08:57.098 The final Prisma chart is included in the published manuscript. 149 00:08:57.479 --> 00:08:59.648 The prisma totals are published in the E 150 00:08:59.778 --> 00:08:59.908 A 151 00:09:00.008 --> 00:09:00.859 sort list. 152 00:09:04.710 --> 00:09:08.929 As you can see from this image study designed in ascending level of 153 00:09:08.940 --> 00:09:11.750 the pyramid generally exhibit increased quality 154 00:09:11.760 --> 00:09:13.929 of evidence and reduce risk of bias 155 00:09:14.619 --> 00:09:18.559 confidence in causal relations increases at the upper levels. 156 00:09:18.820 --> 00:09:23.239 However, it is important to keep in mind that within each type of study design, 157 00:09:23.390 --> 00:09:24.760 there is a spectrum 158 00:09:28.849 --> 00:09:30.429 as previously indicated. 159 00:09:30.599 --> 00:09:33.539 The search is thoroughly documented and published on the E 160 00:09:33.719 --> 00:09:33.789 A 161 00:09:33.960 --> 00:09:36.969 under the section titled search plan and results 162 00:09:37.359 --> 00:09:41.950 listed as the date of the search as well as inclusion and exclusion criteria. 163 00:09:42.219 --> 00:09:47.450 Information on the study participants setting size sample and dropout rate. 164 00:09:47.710 --> 00:09:49.979 The expert panel may decide to specify 165 00:09:49.989 --> 00:09:53.109 additional criteria by which articles are appraised 166 00:09:53.580 --> 00:09:57.080 also included are the total number of hits databases, 167 00:09:57.090 --> 00:10:01.799 search number of included articles and number of excluded articles. 168 00:10:04.390 --> 00:10:09.539 This is an example of an inclusion criteria from the Oncology project. 169 00:10:09.750 --> 00:10:12.809 The layup for the exclusion criteria is similar. 170 00:10:16.049 --> 00:10:16.330 The 171 00:10:16.530 --> 00:10:20.890 E A list of citations that are included in the review and excluded 172 00:10:21.049 --> 00:10:24.890 full text articles that are excluded will have a reason for exclusion, 173 00:10:24.900 --> 00:10:26.190 clearly documented. 174 00:10:28.799 --> 00:10:29.770 Step three 175 00:10:29.880 --> 00:10:31.900 critically appraise each article 176 00:10:35.309 --> 00:10:39.049 evidence analysts critically appraise each article using the 177 00:10:39.059 --> 00:10:42.859 data extraction template designed to capture specific outcomes. 178 00:10:43.210 --> 00:10:47.409 They also complete a risk of bias assessment for each study 179 00:10:51.119 --> 00:10:56.510 in research bias occurs when systemic error is introduced into sampling or testing 180 00:10:56.760 --> 00:11:00.729 by selecting or encouraging one outcome or answer over others. 181 00:11:01.210 --> 00:11:03.349 The tool guides the analyst to recognize 182 00:11:03.359 --> 00:11:06.270 various threads that may undermine sound research 183 00:11:06.549 --> 00:11:09.250 and that could lead to invalid conclusions. 184 00:11:09.799 --> 00:11:12.750 Each article included in the systematic review 185 00:11:13.030 --> 00:11:16.190 is critically appraised by a double blind assessment. 186 00:11:16.739 --> 00:11:19.070 Two evidence analysts complete the risk of 187 00:11:19.080 --> 00:11:21.900 biased tool blinded to each other's answers. 188 00:11:22.330 --> 00:11:26.419 Disagreements are reviewed by a third party and the consensus is then reached. 189 00:11:30.070 --> 00:11:33.140 This is an example of a completed worksheet. 190 00:11:33.340 --> 00:11:36.179 It includes the study characteristics, 191 00:11:36.409 --> 00:11:37.729 study design, 192 00:11:38.020 --> 00:11:41.330 research purpose, inclusion and exclusion criteria 193 00:11:41.700 --> 00:11:43.169 funding information 194 00:11:43.359 --> 00:11:46.809 plus other relevant information for each included article 195 00:11:50.520 --> 00:11:51.539 step four, 196 00:11:51.669 --> 00:11:53.260 synthesize the evidence, 197 00:11:56.419 --> 00:11:58.099 delete analyst reviews, 198 00:11:58.109 --> 00:12:02.799 the completed worksheets and risk a bias assessment completed by the evidence. 199 00:12:02.809 --> 00:12:03.469 Analysts 200 00:12:04.239 --> 00:12:08.530 evidence summaries are a synthesis of the evidence into a narrative format 201 00:12:08.919 --> 00:12:10.960 and a meta analysis when possible. 202 00:12:11.390 --> 00:12:12.320 Additionally, 203 00:12:12.330 --> 00:12:15.419 a summary table is created to provide information 204 00:12:15.429 --> 00:12:17.820 and the studies and outcomes at a glance 205 00:12:21.469 --> 00:12:21.890 meta 206 00:12:22.039 --> 00:12:26.479 analysis is conducted when multiple studies report data and an outcome 207 00:12:26.619 --> 00:12:28.010 that can be pulled together, 208 00:12:28.479 --> 00:12:30.820 findings are reported in forest plots. 209 00:12:31.200 --> 00:12:34.929 Here is an example from the nutritional genomics systematic review. 210 00:12:39.150 --> 00:12:42.239 The narrative summary should provide an overall summary of 211 00:12:42.250 --> 00:12:45.869 the findings of the included studies and their biases, 212 00:12:45.880 --> 00:12:48.239 Strengths and limitations. 213 00:12:51.890 --> 00:12:54.570 Here is an example of a narrative summary. 214 00:12:54.849 --> 00:12:58.390 The evidence is synthesized summary of finding tables are 215 00:12:58.400 --> 00:13:00.780 provided at the end of the narrative section. 216 00:13:05.059 --> 00:13:08.830 A summary of findings table provides the ability to evaluate the 217 00:13:08.840 --> 00:13:13.250 quality of evidence being analyzed in the clear and transparent format 218 00:13:13.390 --> 00:13:16.979 considering the number of studies included and the study designs 219 00:13:16.989 --> 00:13:21.840 risk of bias across studies precision of findings and other information 220 00:13:22.359 --> 00:13:25.799 links to the summer tables are available within the evidence narrative. 221 00:13:30.760 --> 00:13:35.539 This is an example of a summary of findings table from the preterm infant project. 222 00:13:39.979 --> 00:13:41.849 Expand the worksheet section 223 00:13:41.989 --> 00:13:45.340 to see a bibliography for each research question. 224 00:13:45.679 --> 00:13:48.840 Click on each citation to see detailed information 225 00:13:48.849 --> 00:13:52.280 on each study including the risk of bias assessment 226 00:13:56.309 --> 00:13:57.299 step five 227 00:13:57.679 --> 00:14:02.090 develop conclusion statement and grade the strength of the supporting evidence. 228 00:14:06.599 --> 00:14:10.830 The conclusion statement is the answer to the evidence analysis question. 229 00:14:11.289 --> 00:14:13.359 This is why following the po format 230 00:14:13.369 --> 00:14:16.559 during the question development process is so important 231 00:14:16.799 --> 00:14:20.679 to be able to provide a concise answer for each question. 232 00:14:21.219 --> 00:14:24.059 Conclusion statements are drafted by the leading analyst and 233 00:14:24.070 --> 00:14:27.130 reviewed approved and graded by the expert panel. 234 00:14:30.849 --> 00:14:35.500 The expert panel uses this conclusion grading table. During the grading process, 235 00:14:36.150 --> 00:14:37.690 they consider the quality, 236 00:14:37.700 --> 00:14:41.750 consistency and quantity of studies as well as clinical impact 237 00:14:41.940 --> 00:14:43.239 and generalisability. 238 00:14:43.250 --> 00:14:47.239 When discussing and deciding upon a grade for the conclusion statement, 239 00:14:51.159 --> 00:14:53.130 conclusion statements are created 240 00:14:53.280 --> 00:14:57.609 by the expert panel to help the user interpret the strength of the evidence, 241 00:14:58.299 --> 00:14:59.880 the lower the value of the grade, 242 00:15:00.119 --> 00:15:01.599 the stronger the evidence. 243 00:15:02.020 --> 00:15:04.559 You can download a copy of the grading table from the 244 00:15:04.570 --> 00:15:08.599 home page or the quick view link section of the EAL. 245 00:15:12.440 --> 00:15:15.119 This is an example of a published conclusion 246 00:15:15.130 --> 00:15:18.900 statement from the Pediatric White Management project and the 247 00:15:19.280 --> 00:15:19.349 E A, 248 00:15:20.020 --> 00:15:23.679 the expert panel assigned a grade one good or strong 249 00:15:23.809 --> 00:15:25.659 to the strength of the evidence. 250 00:15:29.590 --> 00:15:31.599 The final step is to publish all of 251 00:15:31.609 --> 00:15:34.700 the content on the evidence analysis library website. 252 00:15:34.929 --> 00:15:35.179 All 253 00:15:35.359 --> 00:15:35.419 E 254 00:15:35.549 --> 00:15:37.789 content is free to academy members. 255 00:15:38.419 --> 00:15:38.619 Non 256 00:15:38.820 --> 00:15:40.890 academy members may subscribe to the 257 00:15:41.429 --> 00:15:41.570 EAL. 258 00:15:45.700 --> 00:15:48.390 Once the systematic review is finalized, 259 00:15:48.450 --> 00:15:52.210 it may be used to develop evidence-based nutrition practice guidelines, 260 00:15:53.169 --> 00:15:54.349 position papers, 261 00:15:55.280 --> 00:15:56.659 consensus reports 262 00:15:57.320 --> 00:15:58.770 presented at meetings 263 00:15:59.130 --> 00:16:00.780 and submitted for publication. 264 00:16:04.330 --> 00:16:06.169 You have completed module three. 265 00:16:06.340 --> 00:16:08.729 Please proceed to module four to learn about 266 00:16:08.739 --> 00:16:12.460 the development of evidence-based nutrition practice guidelines. 267 00:16:12.469 --> 00:16:13.030 Thank you.