Advanced PubMed: Finding PT Evidence

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Advanced PubMed: Finding PT Evidence

  1. 1. Advanced PubMed Finding Evidence for Clinical Questions in Physical Therapy Jessica Cole, MLIS, AHIPPT 685 November 12, 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 For a 17-year-old female swimmer with neck pain, is a combination of manual therapy and exercise effective for reducing pain and improving function? 1. ASK
  7. 7. Intervention Question: For a 17-year-old female swimmer with neck pain, is a combination of manual therapy and exercise effective for reducing pain and improving function? Diagnosis Question: For a 17-year-old female swimmer with neck pain, how sensitive and specific is the Spurling’s test for detecting cervical nerve root impingement ? Prognosis Question: For a competitive swimmer with recurrent neck pain, what is the likelihood that the athlete will develop chronic neck pain? Sample Question From Fetters text; see pgs. 16-22 1. ASK
  8. 8. QuestionSearch Strategy Transition from Step 1. Asking the Question to Step 2. Acquiring evidence: Planning the database search strategy 1. ASK
  9. 9. Planning the Search For a 17-year-old female swimmer with neck pain, is a combination of manual therapy and exercise effective for reducing pain and improving function? 2. Acquire
  10. 10. Big Picture: 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: For a 17-year-old female swimmer with neck pain, is a combination of manual therapy AND exercise therapy effective for reducing pain and improving function? 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.  See process of selecting search terms in Table 2.4 on page 22 of Fetters textbook. 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 Terms A search for “manual therapy” in the MeSH Database mapped to the term “Musculoskeletal Manipulations” which is the same concept as manual therapy. 2. Acquire
  16. 16. Find “Best” Search Terms When to search with “OR”  When searching for a term you believe is commonly used in your field that has a different MeSH heading.  (Manual therapy OR Musculoskeletal manipulations) will retrieve results that use EITHER term.  Physical therapy language varies – experiment with OR! 2. Acquire
  17. 17.  Neck pain  Manual therapy  Exercise  Neck pain AND  (Musculoskeletal manipulations OR manual therapy) AND  Exercise therapy Our Original Keywords from Clinical Question Decision: Terms to Search after finding MeSH Terms (with AND) Find “Best” Search Terms 2. 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  “For a 17-year old female swimmer with neck pain, is a combination of manual therapy & exercise therapy effective for reducing pain and improving function?” 2. Acquire
  19. 19. Planning the Search: What’s the MeSH? “For a 17-year old female swimmer with neck pain, is a combination of manual therapy & exercise therapy effective for reducing pain and improving function?” Terms from question, re-ordered from most to least important: Neck pain (most important) Manual therapy Exercise therapy Function 17-year-old Swimmer Female • Tip: Start by searching P+I • Remember: Age & Sex can be applied with filters after building and conducting the search (with keywords/MeSH.) • Focus on most important concepts first & keep it simple. 2. Acquire
  20. 20. Conduct the Search Neck pain AND (Musculoskeletal manipulations OR manual therapy) AND Exercise therapy 2. Acquire
  21. 21. Conduct the Search Filters to try after the search: • Female (sex) • Adolescent (ages) 2. Acquire
  22. 22. 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.  Remember to clear filters! 2. Acquire
  23. 23. View Results Before filters: 152 results After filters (Females & Adolescent): only12 results 2. Acquire
  24. 24. Filters: Levels of Evidence  Filters for types of evidence can also be applied now. 2. Acquire
  25. 25. Filters: Article Types  Systematic Reviews/Meta-Analysis are strongest level of evidence for most types of questions because they synthesize several studies.  For individual studies, best design/article type is: 2. Acquire
  26. 26. 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
  27. 27. Save “Good” Articles 2. Acquire
  28. 28. 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
  29. 29. 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
  30. 30. 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 of cost and risk of harm? Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition. 3. Appraise
  31. 31. Critical Appraisal  Critical appraisal information at JAMA Evidence 3. Appraise
  32. 32. 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?
  33. 33. Tip: How to Cheat If struggling, identify one article that is most relevant to your topic/PICO question and take a closer look.  Examine MeSH terms for ideas for terms to search.  Also view Related Citations.

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