2. Learning Objectives
1. Learn how to develop a searchable question
2. Find and appraise valuable evidence in the
literature to support your decision making
3. Learn where and how to find Systematic
Reviews
3. For your assignments
You may need to:
a) See if a systematic review has been
conducted on your topic
b) Conduct a systematic search of the
literature
c) Manage your results
d) Write it up
9. Purposes of a Literature Review
Acquiring knowledge on a topic
Answering questions that arise from clinical
observations
Evaluating current practices
Developing evidence-based clinical protocols
and interventions
10. Question Formulation
VERY Important
Good questions will
– Focus/clarify your information need(s)
– Give you some idea of where to look for
information
– Give you searching concepts and terms
11. PICO Structure
P Patient/Population/Problem - what sorts of participants,
from where, with what features?
I Intervention/Issue - what sort, dose, administered by whom,
with what level of expertise, where, and with what sorts of monitoring?
C Comparison - what sort, dose, administered by whom, with what
level of expertise, where and with what sorts of monitoring?
O Outcome - both good & bad, of what sort, determined when,
defined how, ascertained & adjudicated by whom?
T Type of Study – systematic reviews, RCT, CT, retrospective
study, cohort study, case control, etc.
“T” is optional and depends on your individual research needs !
12. Question Scenario
You work on a general medical floor. Many
patients with congestive heart failure are
readmitted after they go home from the
hospital. You think that if there was better
coordination of care and patient education
before the patient went home many of these
readmissions could be prevented. You want to
find if there are evidence-based nursing
interventions that can reduce the rate of
hospital readmission for heart failure.
13. PICO Model or Structure
P Congestive Heart Failure OR CHF
I Care Coordination OR Patient Education
C Usual care
O Readmission
T Randomized Controlled Trial OR RCT OR Cohort study
14. Your search question
What is the effect of patient education
and/or care co-ordination on
readmissions for patients with CHF?
15. Study types for question types
Diagnosis Prospective cohort study with good quality
validation against “gold standard”
Therapy Randomized controlled clinical trial (RCT)
Etiology / Harm RCT, cohort or case-control study (probably
retrospective)
Prognosis Prospective cohort study
16. Systematic search of the Literature
1. Choose database(s)
2. Search concepts separately and include synonyms
for your concepts
3. Find subject headings
– Scope note, tree
1. Use keywords / textwords as well
2. Combine using OR / AND as appropriate
3. Apply limits
4. Revise
5. Export to RefWorks
17. Databases of interest
• Medline (OVID)
• CINAHL
• EMBASE
• PsycInfo
• Scopus
• Cochrane Library
• PubMed
and the list goes on…
18. Systematic reviews
Synthesis of all high quality research on a topic, carried out
using very rigorous and repeatable methods
Cochrane Library is the most well known source, other sources
include:
1.The Database of Abstracts of Reviews of Effectiveness
(DARE)
2.PubMed Clinical Queries
3.MEDLINE – Limit to systematic reviews, just to name a few
20. Your questions?
Patricia Ayala
anap.ayala@utoronto.ca
416.978.6778
Editor's Notes
nothing
A) What is the evidence implicating obesity in the pathogenesis of diabetes? B) What is the evidence for the effect of obesity on overall health and mortality? Scenario is set up for etiology, but you could also have therapy or prognosis questions emerging, as well, background questions such as: What does a BMI of 35 indicate? What are the risk factors for diabetes? Some relevant questions about the scenario to which we do not have any information would be: What type of diabetes does his mother have? Type I or II? Was she diabetic while pregnant with him? Is he of African Canadian descent?
ask them to read the scenario to self and come up with questions. Have 2 librarians at flip charts—one to capture background questions and 1 to capture foreground questions. Discussion around various ways that PICO can be done. This is an area for which the students will only have a superficial understanding. They likely only know that “obesity is bad”. A BMI of 35 is in the range leading to definite high risk for diabetes, cardiovascular disease, and increased overall mortality. The key consideration here is to find the actual evidence that evaluates obesity in and of itself as a risk factor for these outcomes. Ideally, one should be able to say how much more likely these outcomes are for an obese patient, compared to a non-obese patient. Click to next screen to take up—PICO front and centre so participants can refer to this schematic. This is an etiology question What is the evidence implicating obesity in the pathogenesis of diabetes? What is the evidence for the effect of obesity on overall health and mortality?
Tell them this is just one example of how you can use PICO for this scenario –let them know that “intervention” does not have to be just a treatment that you add to the situation, but can be anything that has been added to the situation/environment, in this case, the patients obesity. The Searchable question: In a 25 yr old obese male, what is the risk of developing diabetes? Can also approach this is a therapy question if you look at lifestyle modifications, and compare to No intervention, or to weight loss, or another option: P= obesity/genetic predisposition to diabetes I= lifestyle modification/diet/exercise C= n/a or no modifications O= therapeutic effectiveness; prognosis; does this change his risk?
Tell them this is just one example of how you can use PICO for this scenario –let them know that “intervention” does not have to be just a treatment that you add to the situation, but can be anything that has been added to the situation/environment, in this case, the patients obesity. The Searchable question: In a 25 yr old obese male, what is the risk of developing diabetes? Can also approach this is a therapy question if you look at lifestyle modifications, and compare to No intervention, or to weight loss, or another option: P= obesity/genetic predisposition to diabetes I= lifestyle modification/diet/exercise C= n/a or no modifications O= therapeutic effectiveness; prognosis; does this change his risk?
RCTs are not necessarily the best type of study to answer your type of question. Here is a loose matching of question types to the ideal kinds of research for answering them Let them know that * In all cases a systematic review of the best stated study type is better than the individual study type. Let them know that in our class example of the obese young man, we would therefore be looking for RCTs, or cohort or case-control studies to answer our question. As another example, refer back to OCD question and search terms (slide 12). Let them know that to be more effective in one ’ s search, if those basic search terms from P-I-C yielded too many results, this is the point where they might consider focusing their search on the appropriate study type for the type of question they are asking I.e., in that question as well you could look specifically for RCTs. If you are searching evidence-based pre-appraised resources (which we will be talking about next) this step has probably already been done for you. BUT “ filtering ” resources to appropriate study types is a useful technique if you are searching databases like MEDLINE.
We know you are familiar with it and MEDLINE is not really a clinical tool—too big and cumbersome plus material must be synthesized by user before it can be applied. can ask for experiences and how they feel about MEDLINE as a tool. PubMed By searching for BMI / Diabetes type 2/ and Risk Factors, and limiting to males, a searcher will have approx. 1100 hits. One quicker way of searching for clinical questions when you do have to search for actual studies, as in this case, is to use pubmed’s clinical queries feature, as you can search by study type. Method A Quickly go to show where Clinical Queries is located, and choose study type etiology, by searching high BMI and Diabetes Mellitus type-2 [etiology], the searcher will have limited his or her search to 46 relevant articles. By limiting to men, and systematic reviews, he or she will find the following article that discusses issues of body mass and diabetes. Janssen I, Katzmarzyk PT, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines. Arch Intern Med. 2002 Oct 14;162(18):2074-9. Method B Alternately, type in obesity diabetes age factors to show that there are answers here, though still a sizeable amount as this is a popular topic, doing it this way, narrows it down to relevant material such as: Schienkiewitz A, Schulze MB, Hoffmann K, Kroke A, Boeing H. Body mass index history and risk of type 2 diabetes: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Am J Clin Nutr. 2006 Aug;84(2):427-33. PMID: 16895894 [PubMed - indexed for MEDLINE] The reason we have put in “age factors” this time was to factor in for the age of our patient—what is the significance of his age? How might this affect his level of risk? Whereas method A takes into account the patients gender.
We know you are familiar with it and MEDLINE is not really a clinical tool—too big and cumbersome plus material must be synthesized by user before it can be applied. can ask for experiences and how they feel about MEDLINE as a tool. PubMed By searching for BMI / Diabetes type 2/ and Risk Factors, and limiting to males, a searcher will have approx. 1100 hits. One quicker way of searching for clinical questions when you do have to search for actual studies, as in this case, is to use pubmed’s clinical queries feature, as you can search by study type. Method A Quickly go to show where Clinical Queries is located, and choose study type etiology, by searching high BMI and Diabetes Mellitus type-2 [etiology], the searcher will have limited his or her search to 46 relevant articles. By limiting to men, and systematic reviews, he or she will find the following article that discusses issues of body mass and diabetes. Janssen I, Katzmarzyk PT, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines. Arch Intern Med. 2002 Oct 14;162(18):2074-9. Method B Alternately, type in obesity diabetes age factors to show that there are answers here, though still a sizeable amount as this is a popular topic, doing it this way, narrows it down to relevant material such as: Schienkiewitz A, Schulze MB, Hoffmann K, Kroke A, Boeing H. Body mass index history and risk of type 2 diabetes: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Am J Clin Nutr. 2006 Aug;84(2):427-33. PMID: 16895894 [PubMed - indexed for MEDLINE] The reason we have put in “age factors” this time was to factor in for the age of our patient—what is the significance of his age? How might this affect his level of risk? Whereas method A takes into account the patients gender.
