Question+Formulation+And+Search+Strategydevelopment 0805081

E\EBP\EBP_1\PICO workbook.doc

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Question formulation for EBP and an introduction to EBP web resources

Kieran LambHead of Library Service, Fade Library

Prepared with

Lisa AndersonBusiness Intelligence Service Project Manager

From the original work developed by

Michelle MadenClinical Information Specialist, Edge Hill University


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Objectives

• Understand the reasons for focused questions

• Learn how to ask focused questions• Use the question to formulate your search

strategy• Introduction to search techniques• Systematic approach to locating the evidence• Introduction to evidence-based practice

(EBP) resources on the world wide web(www)


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Online workbook

Session supported byonline workbook –Question Formulationand developing asearch strategyworkbook


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What is EBP?

• “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research”

Sackett D et al. BMJ 1996;312:71-2.


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EBP steps

• Ask answerable questions• Search for the evidence• Appraise the evidence• Apply the evidence• Evaluate the results


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Asking answerable questions

• What treatment is indicated for my patient?• What is the likely prognosis for this condition?• What diagnostic tests should be arranged?• What is the cause of this disease?• What are the costs of this treatment?• What are the potential benefits and harms of

this treatment?• Write down your question on page 3


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Example

• Want to know about diagnosing epilepsy?

• Medline search ‘epilepsy’ –77336articles

• What would you search for next?


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Background vs Foreground questions

• Background– ask for general knowledge about a disorder, e.g.

what causes pneumonia?, what is nosocomialpneumonia?

– Basic understanding about healthcare practice– Textbooks

• Foreground– ask for knowledge about managing specific

patients with a disorder – Often comprise of 4 elements Patient,

Intervention, Comparison, Outcome– Search for the original evidence– Focused question


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Focused questions

• Well built• Structured• Relevant• Answerable


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Why focus the question?

• Define important outcomes• Define the most valid study design to

answer the question• Structure your search for the evidence


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Question types

• Treatment/therapy• Diagnostic• Prognostic• Aetiology/harm• Cost effectiveness• Qualitative• Etc…


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Structuring the question PICO

What are you looking to achieve?

Outcomes

What are the alternatives?(NB may not always have a comparison)

Comparison

What action are you considering?/what exposure?

Intervention (/Exposure)

What patient characteristics are important?(Disease, presentation, age, gender…)

Patient group


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Example

• A young child presents with a fever. You think that you should prescribe paracetamol (Calpol) to reduce the fever but a colleague suggests ibuprofen (Junifen). You wonder which to prescribe?

BestBETs: http://www.bestbets.org/cgi-bin/bets.pl?record=00032


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Question structure

reducing feverOutcomes

ibuprofenComparison

paracetamolIntervention

young child with feverPatient group


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Question

• In a young child with fever is paracetamol (Calpol) better than ibuprofen (Junifen) at reducing fever?


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Diagnosis – comparing 2 tests

• An adult presents to the review clinic two weeks after falling onto his outstretched hand. A scaphoid fracture was suspected but no fracture was seen on plain scaphoidviews. He continues to have scaphoidtenderness. You wonder whether a magnetic resonance scan would be better than a bone scan in confirming or excluding a scaphoidfracture.



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Question structure

reaching a diagnosisOutcomes

bone scanComparison

magnetic resonance imagingIntervention

Adult with clinically suspected scaphoid fracture

Patient group


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Question

• In an adult with a clinically suspected scaphoid fracture is magnetic resonance imaging better than bone scintigraphy at reaching a diagnosis?


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Diagnosis – accuracy of test

• A 44 year old man presents to the ED with a 4 hour history of severe abdominal pain. You consider a diagnosis of pancreatitis and organise a serum amylase to be taken. You wonder if a single normal serum amylase result is sufficiently sensitive to rule out pancreatitis in this patient.



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Question structure

Exclude the diagnosis of pancreatitis

Outcomes

Comparison

normal serum amylaseIntervention

Adult with abdominal painPatient group


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Question

• In patients with abdominal pain does a normal serum amylase exclude the diagnosis of pancreatitis?


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Prognosis• A 69 year old woman attends outpatients to review

her test results. A month ago she presented with symptoms and signs of congestive heart failure. She has had long-standing essential hypertension, but had been otherwise healthy until now.

• An Senior House Officer (SHO) reviews the test results, the patient’s medication use and the patient’s general well-being. During the appointment, she asked, "Heart failure sounds serious - is it? What do I have to look forward to?" The SHO decides to find out the average survival time for a patient with heart failure.

ADEPT


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Question structure

SurvivalOutcomes

Comparison

Average length of timeIntervention

Elderly adult with congestive heart failure and hypertension

Patient group


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Question

• In an elderly adult with congestive heart failure and hypertension what is the average length of time of survival?

ADEPT


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Aetiology

• A 22-year old girl collapsed at home and had been rushed to the local Accident and Emergency (A&E)

• Unfortunately she had been pronounced dead on arrival. The casualty doctor had mentioned a “clot on the lung”. The girl had been started on oral contraceptives a year before her death. The General Practitioner (GP) wants to get an idea of how strong the scientific evidence is for a link between oral contraceptive use and thromboembolism.


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Question structure

Risk of thromboembolismOutcomes

Comparison

Oral contraceptive pillIntervention

Young womenPatient group


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Question

• In young adult females does taking oral contraceptive pills increase the risk of thromboembolism?

• Now re-write your question using the PICO format on page 6


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EBP steps

• Ask answerable questions• Search for the evidence• Appraise the evidence• Apply the evidence• Evaluate the results


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Developing a search strategy

• Ask a focused question• Select resource• Identify search terms• Identify synonyms/spelling variants• Combine using search operators

(AND/OR)• Review results


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Ask a focused question

• Use the PICO framework where appropriate

In children with fever is paracetamolbetter than ibuprofen at reducing fever?


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Identify search terms

Reducing feverO

ibuprofenC

paracetamolI

Child fever

P


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Identify synonyms/spelling variants/related terms

Reducing feverO

Ibuprofen JunifenC

Paracetamol CalpolI

Children child infant paediatrics pediatricsFever febrile

P


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Combine using search operators

• Often called Boolean logic– Or– And– Not/And Not

• Different search tools handle search operators differently. Use the help screens when applying these


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AND

AND

reducing feverOAND

ibuprofen OR JunifenCAND

paracetamol OR CalpolI

fever OR febrile

Children OR child OR infant OR paediatrics OR pediatrics

P


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Search strategy

(paracetamol OR Calpol) AND (ibuprofen OR Junifen) AND (fever OR febrile) AND (child OR infant OR paediatrics OR pediatrics)

Use PICO search formulation in this way to search the healthcare databases (Medline, Cinahl, The Cochrane Library, etc) and e-journal collections (Proquest)


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Which concept should I search first?

• The concept you search first depends upon the question asked

• Start with concepts relating to interventions and disease or presentation in the patient group

• Searching on outcomes is difficult. Search on other aspects first (including study design), then if you still need to refine your search add in the outcomes

• Search on age groups last • Be flexible


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Where do you start?

• Think about– What study designs would best answer

your question– The subject area you are looking at


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Study designs

• Systematic Reviews/Meta analysis• Randomised Controlled Trials• Cohort Studies• Case-control• Cross-sectional survey• Case Series/Case reports


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Levels of evidence

Double blind RCTs /Single blind RCTs

Cohort studies

Case control studies

Case Series

Case Reports

Expert opinion / animal /experimental

Systematic Review & Meta analysis / Systematic Review


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Best study designs

Systematic Review > Cohort > Case-control

Prognosis

Systematic Review > Prospective cohort with blind comparison to a gold standard

Systematic Review > RCT

DiagnosisTo assess the accuracy of the test

To assess the effect of the test on health outcome

Systematic Review > RCT > Cohort > Case-control

Therapy/Treatment/Eti-ology/prevention/Harm


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Select resource

• Healthcare Databases (bibliographic)– Medline, Cinahl, BNL, Embase, PsycInfo, AMED,

DH-data• The Cochrane Library (full-text or

bibliographic)• Guidelines (full-text)• EBP web resources (full-text)• E-journal collections (full-text)

– Science Direct, InterNurse, BML Journals• LJMU resources (full-text or bibliographic)

– http://www.ljmu.ac.uk/lea/info/health/


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Systematic Reviews

• The Cochrane Library– Cochrane Database of Systematic

Reviews (CDSR)– Database of Abstracts of Effects (DARE)

• Healthcare databases– Medline +other subject specific


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The Cochrane Library

• Accessed via National Library for Health• Provides access to information on the effects

(including the cost-effectiveness) of interventions of health care

• Systematic reviews (therapy, diagnosis, harm, prevention), RCTs, cost-effectiveness

• Comprises of 8 databases– Controlled Central Register of Controlled Trials (CENTRAL)– NHS Economic Evaluation Database (NHS EED)– The Health Technology Assessment Database (HTA)


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Cochrane Library – advanced search• Go to ‘Advanced Search’

• Type all terms for the first concept on the first line and combine terms with OR

• Choose where in the record you want to search

• Add in second key idea on the second line, combining all terms with OR

• Choose where in the record you want to search

• The default combines different key ideas with AND


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Healthcare databases

• Bibliographic records of journal articles published in thousands of journals

• General (Medline)• Subject specific (Cinahl, Embase,

PsycInfo, etc)• Contain all study designs• Covered in next session…


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RCTs

• The Cochrane Library– CENTRAL

• Healthcare Databases– Medline +other subject specific– Can often limit search to RCTs


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All study types

• Healthcare databases– Medline + other subject specific (covered in

next session)


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EB digests - features• Drawing together of a body of evidence• Identification of major relevant evidence• Identification of key messages from the best

available evidence• Summarise all study designs and identify

where there is no (good) evidence• Time saving – useful for identifying resources

to search for original research• Short!!• !Check date of publication, resources

searched, search strategy and when the search was last conducted/updated!


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Searching EBP health websites

• Browse topics/subjects– Select subject area and browse through topics– Good way of ensuring you don’t miss anything

• Search using keywords and synonyms– Identify most important term (treatment, disease,

condition) and search on this first, then add more terms (synonyms, alternative spellings) in if required

– Look for the search box– !Look for the help with searching link!


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EB digests - topic

• Clinical Evidence (treatment, therapy, prevention)– access via NLH

• BestBETs (treatment, therapy, diagnosis, prognosis)– www.bestbets.org – !Not all BETs are completed/published!

• Bandolier (all study designs)– Access via NLH


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Guidelines

• NLH Guidelines Finder– Links to full-text UK Guidelines

• NLH Protocols and Care Pathways– Links to full-text NHS Trust Protocols and Care

Pathways• National Institute for Clinical Evidence (NICE)• Access via National Library for Health

– www.library.nhs.uk


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Searching across EBP websites

• TRIP– Turning Research Into Practice– http://www.tripdatabase.com/NB 3 searches per week allowed on each

PC


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other resources

• E-journal collections (full-text)– Proquest via the NLH– Science Direct, InterNurse, BMJ Journals

• JMU resources (full-text or bibliographic)– http://www.ljmu.ac.uk/lea/info/health/


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Where to find the best published research evidence

Healthcare databasesQualitative

The Cochrane Library (HTA, NHS EED) > Healthcare databases

Cost-effectiveness

Healthcare databasesPrognosis

The Cochrane Library (DARE, CENTRAL) > Healthcare databases

Diagnosis

The Cochrane Library (CDSR, DARE, CENTRAL) > Healthcare databases

Therapy/Treatment/Etiology/Prevention/Harm


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Recording your search strategy

• Look for original research (*Medline, other healthcare databases, Cochrane)

• What did you search?• When did you search?• How did you access it?• What search terms did you use?• What was the outcome?


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Health & Medicine

Question+Formulation+And+Search+Strategydevelopment 0805081