Advanced PubMed


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  • We will focus mostly on the first two steps, but I will give you resources at the end to help you with appraisal
  • Advanced PubMed

    1. 1. Advanced PubMed EBP: Searching Clinical Questions Jessica Cole, MLIS, AHIPPHA 520 November 19, 2013
    2. 2. Evidence-Based Practice “Evidence based medicine is 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 evidence from systematic research.”
    3. 3. EBP Research Steps 1. ASK-Convert information need into a question. 2. ACQUIRE-Find best evidence to answer question. 3. APPRAISE-Critically appraise evidence. 4. INTEGRATE evidence with clinical expertise & patient values to apply in practice. 5. EVALUATE performance. Database Searching Skills
    4. 4. Don’t Expect Research to be a Linear Process!
    5. 5. Define Research Question  Convert the information need into a specific question. This will guide your research process.  Convert question to PICO format to help you break it down and plan a database search strategy.  Determine “best” concepts/terms to represent each PICO element. These are the terms you will string together to build your database search. 1. ASK
    6. 6. PICO Question Include the following PICO elements in your question P Patient characteristics/condition I Intervention (or diagnosis/prognosis) C Comparison intervention (if applicable) O Outcome of interest In the elderly, does Tai Chi reduce accidental falls? 1. ASK
    7. 7. QuestionSearch Strategy Transition from Step 1. Asking the Question to Step 2. Acquiring evidence: Planning the database search strategy 1. ASK
    8. 8. Planning the Search In the elderly, does Tai Chi reduce the number of accidental falls? 2. ACQUIRE
    9. 9. Big Picture Example 1: Fast Forward to Strategy This is what our search strategy will look like in the end. What follows in the next slides are the steps taken to build this search: In the elderly (P), does Tai Chi (I) reduce the number of accidental falls? (O) 2. ACQUIRE
    10. 10. Big Picture Example 2: Fast Forward to Strategy This is another example of a search built for the question below. For the last question, P+I+O were searched. For this question and approach, we search P+I+C. In an adult diagnosed with depression(P), is St. John's Wort (C) as effective as SSRIs (I) at reducing depressive symptoms? 2. ACQUIRE
    11. 11. Planning the Search  List the main terms/concepts from your PICO question.  Which terms are most important for the search?  Always search for the P and I elements with the “best” terms to capture a concept. C is optional, depending on whether your question is comparing two interventions. For certain questions, the outcome O will be an important term to search, and for others it will not.  Example of when NOT to search for outcome: If the P is a condition characterized by having pain and your question is how to reduce that pain, PAIN, is already implied. 2. ACQUIRE
    12. 12. Planning the Search Keywords vs. MeSH (Medical Subject Headings) Strengthen a search by using terminology the database understands! 2. ACQUIRE
    13. 13. Cola, Pop, Soda, Coke, Soda Pop? Bill, Money, Dollar, Cash, Currency? 2. ACQUIRE
    14. 14. Planning: MeSH Database Search your keywords in the MeSH database for other terms more likely to be recognized by the database. Write down the MeSH for later. 2. ACQUIRE
    15. 15. Find “Best” Search Terms2. ACQUIRE A search for “fall” in the MeSH Database displays the appropriate MeSH term, “Accidental Falls.”
    16. 16. Find “Best” Search Terms When to search with “OR”  When a term you believe is common has a different MeSH heading.  (Tai Chi OR Tai Ji) will retrieve results that use EITHER term. Tai Chi is our keyword. Tai Ji is the MeSH term. 2. ACQUIRE
    17. 17.  (P) Elderly  (I) Tai Chi (C) –No comparison-  (O) Reduce Falls  Aged (or use age filters) AND  (Tai Chi OR Tai Ji) AND  Accidental Falls Our Original Keywords from Clinical Question Decision: Terms to Search after finding MeSH Terms (with AND) Find “Best” Search Terms2. ACQUIRE
    18. 18. Remember Filters!  Many times the “P” of PICO question has filters to apply at the end of the search so you don’t need to search for terms like “female” or “adolescent.”  Examples: Age groups, gender 2. ACQUIRE
    19. 19. Conduct the Search 2. ACQUIRE
    20. 20. Conduct the Search 2. ACQUIRE Age filters can be applied after the search, or you can search the term “Aged”
    21. 21. Apply Filters  First see # results and review article titles without applying the filters.  View results with filters applied: Be aware that filters might also remove some “good” results. Always try both ways.  Use filters for levels of evidence here or at a later point of refining/appraising the search.  Filter must show checkmark.  Remember to clear filters! 2. ACQUIRE
    22. 22. Filters: Levels of Evidence  Filters for types of evidence can also be applied now. 2. ACQUIRE
    23. 23. Filters: Article Types  Systematic Reviews/Meta-Analysis are strongest level of evidence for most questions because they synthesize several studies. Also see Clinical Practice Guidelines.  For individual studies, best design/article type is: 2. ACQUIRE
    24. 24. Review ResultsAppraise  Transition from Step 2. Acquiring the evidence to Step 3. Critically appraise the evidence – Overlap.  SAVE “good” results as you go!  Even if you are not yet critically appraising individual articles while scanning results, hold onto those that look promising. 2. ACQUIRE
    25. 25. Save “Good” Articles 2. ACQUIRE
    26. 26. Critical Appraisal Are the results valid?  Did intervention and control groups start with the same prognosis? Were patients randomized?  Was group allocation concealed?  Were patients in the study groups similar with respect to known prognostic variables?  Was prognostic balance maintained as the study progressed? To what extent was the study blinded?  Were the groups prognostically balanced at the study's completion? Was follow-up complete?  Were patients analyzed in the groups to which they were first allocated?  Was the trial stopped early? Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition. 3. APPRAISE
    27. 27. Critical Appraisal What are the results?  How large was the treatment effect?  What was the relative risk reduction?  What was the absolute risk red  How precise was the estimate of the treatment effect? What were the confidence intervals? Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition. 3. APPRAISE
    28. 28. Critical Appraisal How can I apply the results to patient care?  Were the study patients similar to my population of interest?  Does your population match the study inclusion criteria?  If not, are there compelling reasons why the results should not apply to your population?  Were all clinically important outcomes considered?  What were the primary and secondary endpoints studied?  Were surrogate endpoints used?  Are likely treatment benefits worth the potential harm and costs?  What is the number needed to treat (NNT) to prevent 1 adverse outcome or produce 1 positive outcome?  Is the reduction of clinical endpoints worth the increase ofUsers' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition. 3. APPRAISE
    29. 29. Critical Appraisal  Critical appraisal information at JAMA Evidence 3. APPRAISE
    30. 30. Summary 1. ASK 2. ACQUIRE 3. APPRAISE First, know what you are looking for! Write a focused clinical question based on PICO format to help you plan your search strategy – translate your question into the best search terms. Conduct an Advanced PubMed search with the best terms identified from PICO, using Boolean operators and applicable filters to limit results. Save good results as you go and experiment for different sets of results. Always search P & I concepts at minimum.Critically appraise individual articles/studies. Upon closer examination, is it still relevant to your PICO question? Are results valid, and have you carefully looked for the “best” highest levels of evidence available on this topic?
    31. 31. PICO Search Demo Video In a 30-year-old male patient diagnosed with depression, is St. John's Wort as effective as SSRIs at reducing depressive symptoms? P: Depressive disorder [MeSH searched as keyword] AND I: Serotonin uptake inhibitors [MeSH searched as keyword] AND C: (Hypericum [MeSH searched as keyword] OR St. John's Wort) O: Desired outcome is efficacy, but this term is not part of the search strategy because it is already implied in the search. Use PubMed Advanced search builder to string these terms together with AND (Enter the OR terms in the same line - which is the third line in this demo, and leave the Boolean operator on the left of the search builder as AND) Click search. Step 3: Apply filters: English, Humans, Systematic Review [subset] See
    32. 32. Tip: How to Cheat Find 1 relevant article and take a closer look for clues.  Examine MeSH terms for ideas for terms to search.  Also view Related Citations.
    33. 33. PubMed Search Tips NOT ENOUGH RESULTS?  Search synonyms with OR (i.e. aqua therapy OR aquatic exercises)  Find one “good” article and view Related Citations & MeSH  Remove filters. Reduce number of ANDs in search strategy (Search P AND I) TOO MANY RESULTS?  Add more search terms with AND. Use filters/limits to narrow results. DO:  Experiment! (Keywords, Boolean operators, filters)  Save “good” references as you go with the Clipboard/email/  When searching with an “OR,” place the two terms on same line in search builder so search functions properly.
    34. 34. Contact Your Librarian for Help! 827-2376