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  • 1. Question formulation for EBP and an introduction to EBP web resources Kieran Lamb Head of Library Service, Fade Library Prepared with Lisa Anderson Business Intelligence Service Project Manager From the original work developed by Michelle Maden Clinical Information Specialist, Edge Hill University EEBPEBP_1PICO 1 workbook.doc
  • 2. 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) EEBPEBP_1PICO 2 workbook.doc
  • 3. Online workbook Session supported by online workbook – Question Formulation and developing a search strategy workbook EEBPEBP_1PICO 3 workbook.doc
  • 4. 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. EEBPEBP_1PICO 4 workbook.doc
  • 5. EBP steps • Ask answerable questions • Search for the evidence • Appraise the evidence • Apply the evidence • Evaluate the results EEBPEBP_1PICO 5 workbook.doc
  • 6. 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 EEBPEBP_1PICO 6 workbook.doc
  • 7. Example • Want to know about diagnosing epilepsy? • Medline search ‘epilepsy’ –77336 articles • What would you search for next? EEBPEBP_1PICO 7 workbook.doc
  • 8. Background vs Foreground questions • Background – ask for general knowledge about a disorder, e.g. what causes pneumonia?, what is nosocomial pneumonia? – 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 EEBPEBP_1PICO 8 – Focused question workbook.doc
  • 9. Focused questions • Well built • Structured • Relevant • Answerable EEBPEBP_1PICO 9 workbook.doc
  • 10. Why focus the question? • Define important outcomes • Define the most valid study design to answer the question • Structure your search for the evidence EEBPEBP_1PICO 10 workbook.doc
  • 11. Question types • Treatment/therapy • Diagnostic • Prognostic • Aetiology/harm • Cost effectiveness • Qualitative • Etc… EEBPEBP_1PICO 11 workbook.doc
  • 12. Structuring the question PICO Patient group What patient characteristics are important? (Disease, presentation, age, gender…) Intervention What action are you (/Exposure) considering?/what Comparison exposure? alternatives? What are the (NB may not always have a comparison) Outcomes What are you looking to achieve? EEBPEBP_1PICO 12 workbook.doc
  • 13. 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 EEBPEBP_1PICO 13 workbook.doc
  • 14. Question structure Patient group young child with fever Intervention paracetamol Comparison ibuprofen Outcomes reducing fever EEBPEBP_1PICO 14 workbook.doc
  • 15. Question • In a young child with fever is paracetamol (Calpol) better than ibuprofen (Junifen) at reducing fever? EEBPEBP_1PICO 15 workbook.doc
  • 16. 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 scaphoid views. He continues to have scaphoid tenderness. You wonder whether a magnetic resonance scan would be better than a bone scan in confirming or excluding a scaphoid fracture. BestBETs: http://www.bestbets.org/cgi-bin/bets.pl?record=00109 EEBPEBP_1PICO 16 workbook.doc
  • 17. Question structure Patient group Adult with clinically suspected scaphoid fracture Intervention magnetic resonance imaging Comparison bone scan Outcomes reaching a diagnosis EEBPEBP_1PICO 17 workbook.doc
  • 18. Question • In an adult with a clinically suspected scaphoid fracture is magnetic resonance imaging better than bone scintigraphy at reaching a diagnosis? EEBPEBP_1PICO 18 workbook.doc
  • 19. 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. BestBETs: http://www.bestbets.org/cgi-bin/bets.pl?record=00210 EEBPEBP_1PICO 19 workbook.doc
  • 20. Question structure Patient group Adult with abdominal pain Intervention normal serum amylase Comparison Outcomes Exclude the diagnosis of pancreatitis EEBPEBP_1PICO 20 workbook.doc
  • 21. Question • In patients with abdominal pain does a normal serum amylase exclude the diagnosis of pancreatitis? EEBPEBP_1PICO 21 workbook.doc
  • 22. 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 EEBPEBP_1PICO 22 workbook.doc
  • 23. Question structure Patient group Elderly adult with congestive heart failure and hypertension Intervention Average length of time Comparison Outcomes Survival EEBPEBP_1PICO 23 workbook.doc
  • 24. Question • In an elderly adult with congestive heart failure and hypertension what is the average length of time of survival? ADEPT EEBPEBP_1PICO 24 workbook.doc
  • 25. 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. EEBPEBP_1PICO 25 workbook.doc
  • 26. Question structure Patient group Young women Intervention Oral contraceptive pill Comparison Outcomes Risk of thromboembolism EEBPEBP_1PICO 26 workbook.doc
  • 27. 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 EEBPEBP_1PICO 27 workbook.doc
  • 28. EBP steps • Ask answerable questions • Search for the evidence • Appraise the evidence • Apply the evidence • Evaluate the results EEBPEBP_1PICO 28 workbook.doc
  • 29. 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 EEBPEBP_1PICO 29 workbook.doc
  • 30. Ask a focused question • Use the PICO framework where appropriate In children with fever is paracetamol better than ibuprofen at reducing fever? EEBPEBP_1PICO 30 workbook.doc
  • 31. Identify search terms P Child fever I paracetamol C ibuprofen O Reducing fever EEBPEBP_1PICO 31 workbook.doc
  • 32. Identify synonyms/spelling variants/related terms P Children child infant paediatrics pediatrics Fever febrile I Paracetamol Calpol C Ibuprofen Junifen O Reducing fever EEBPEBP_1PICO 32 workbook.doc
  • 33. 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 EEBPEBP_1PICO 33 workbook.doc
  • 34. P Children OR child OR infant OR paediatrics OR pediatrics AND fever OR febrile AND I paracetamol OR Calpol AND C ibuprofen OR Junifen AND O reducing fever EEBPEBP_1PICO 34 workbook.doc
  • 35. 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) EEBPEBP_1PICO 35 workbook.doc
  • 36. 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 EEBPEBP_1PICO 36 workbook.doc
  • 37. Where do you start? • Think about – What study designs would best answer your question – The subject area you are looking at EEBPEBP_1PICO 37 workbook.doc
  • 38. Study designs • Systematic Reviews/Meta analysis • Randomised Controlled Trials • Cohort Studies • Case-control • Cross-sectional survey • Case Series/Case reports EEBPEBP_1PICO 38 workbook.doc
  • 39. Levels of evidence Systematic Review & Meta analysis / Systematic Review Double blind RCTs /Single blind RCTs Cohort studies Case control studies Case Series Case Reports Expert opinion / animal /experimental EEBPEBP_1PICO 39 workbook.doc
  • 40. Best study designs Therapy/Treatment/Eti- Systematic Review > RCT > ology/prevention/Harm Cohort > Case-control Diagnosis Systematic Review > To assess the accuracy Prospective cohort with blind of the test comparison to a gold standard To assess the effect of Systematic Review > RCT the test on health outcome Prognosis Systematic Review > Cohort > Case-control EEBPEBP_1PICO 40 workbook.doc
  • 41. 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/ EEBPEBP_1PICO 41 workbook.doc
  • 42. Systematic Reviews • The Cochrane Library – Cochrane Database of Systematic Reviews (CDSR) – Database of Abstracts of Effects (DARE) • Healthcare databases – Medline +other subject specific EEBPEBP_1PICO 42 workbook.doc
  • 43. 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) EEBPEBP_1PICO 43 workbook.doc
  • 44. 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 EEBPEBP_1PICO 44 workbook.doc
  • 45. 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… EEBPEBP_1PICO 45 workbook.doc
  • 46. RCTs • The Cochrane Library – CENTRAL • Healthcare Databases – Medline +other subject specific – Can often limit search to RCTs EEBPEBP_1PICO 46 workbook.doc
  • 47. All study types • Healthcare databases – Medline + other subject specific (covered in next session) EEBPEBP_1PICO 47 workbook.doc
  • 48. 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! EEBPEBP_1PICO 48 workbook.doc
  • 49. 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 EEBPEBP_1PICO 49 – !Look for the help with searching link! workbook.doc
  • 50. 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 EEBPEBP_1PICO 50 workbook.doc
  • 51. 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 EEBPEBP_1PICO 51 workbook.doc
  • 52. Searching across EBP websites • TRIP – Turning Research Into Practice – http://www.tripdatabase.com/ NB 3 searches per week allowed on each PC EEBPEBP_1PICO 52 workbook.doc
  • 53. 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/ EEBPEBP_1PICO 53 workbook.doc
  • 54. Where to find the best published research evidence Therapy/Treatment/ The Cochrane Library Etiology/Prevention/Harm (CDSR, DARE, CENTRAL) > Healthcare databases Diagnosis The Cochrane Library (DARE, CENTRAL) > Healthcare databases Prognosis Healthcare databases Cost-effectiveness The Cochrane Library (HTA, NHS EED) > Healthcare databases Qualitative Healthcare databases EEBPEBP_1PICO 54 workbook.doc
  • 55. 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? EEBPEBP_1PICO 55 workbook.doc
  • 56. EEBPEBP_1PICO 56 workbook.doc