1. Searching for a “needle in a haystack” Sarah Glover and Jenny Kendrick Information Specialists Information Services, NICE

2. Outline of presentation What is NICE? Introduction to the Information Services Team Brief overview of the Interventional Procedures Programme Searching for a “needle in a haystack” - the role of the Information specialist in the development of NICE Interventional Procedure guidance

3. Who are we? The National Institute for Health and Clinical Excellence (NICE) is an independent NHS organisation. Set up 1 April 1999 to ensure everyone has equal access to medical treatments and high quality care from the NHS A world leader in setting standards for high quality healthcare The most prolific producer of clinical guidelines in the world We have offices in London and Manchester

4. What we do NICE is responsible for –providing national guidance on the promotion of good health and the prevention and treatment of ill health –setting quality standards –managing NHS Evidence NICE makes recommendations to the NHS on: –new and existing medicines, treatments and procedures –treatment and care for people with specific diseases and conditions NICE makes recommendations to the NHS, local authorities and other organisations on: –how to improve people’s health and prevent illness and disease.

5. The Information Services team at NICE Associate Director, 22 Information Professionals and an Administrator. We offer tailored support to the different Centres and Directorates. We also offer Institute-wide corporate information services.

6. Interventional Procedures (IP) New interventional procedures are notified directly to NICE – usually by clinicians. The potential output of the topic is defined during the topic selection process at NICE NICE Interventional Procedures guidance advises the NHS on when and how new procedures can be used in clinical practice. NICE makes recommendations about whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use.

7. What is an Interventional Procedure? An interventional procedure is a procedure used for diagnosis or treatment that involves one of the following: Making a cut or a hole to gain access to the inside of a patient's body Gaining access to a body cavity (such as the digestive system, lungs, womb or bladder) without cutting into the body Using electromagnetic radiation (which includes X-rays, lasers, gamma-rays and ultraviolet light)

8. Information Services support We carrying out literature searches to support the development of the Interventional Procedure Guidelines The literature search findings are an essential component to the IP overview document development process. The basis of the overview is then discussed at the Interventional Procedures Advisory Committee (IPAC)

9. The literature search Aims to identify as much evidence on the procedure as possible Is a comprehensive and structured search strategy We use a limited number of resources Within a limited timeframe – 2 weeks are allocated for all searching to be completed It’s an unusual and tricky process!

10. Interventional Procedures search request The IP search request is sent to us via a literature search request form This contains the title, a brief description of the procedure, and sometimes key words Also lists key papers that the Analyst is aware of Core databases/websites to be searched

11. Interventional Procedures search request For example: Endoscopic mastectomy and endoscopic wide local excision for breast cancer (Keyhole surgery to treat breast cancer) Brief description: Treatment for early breast cancer usually involves surgery to remove all or part of the breast. In this keyhole procedure, part or all of the breast tissue is removed using special instruments inserted through small skin incisions. The skin envelope of the breast and nipple are left intact, ready for an implant that can be inserted during the same operation.

12. So what are we looking for? We know that there are other mastectomy procedures available in the NHS But we are searching for information on this new procedure only – (Endoscopic or key hole surgery to remove all or part of the breast) So we are looking for a subset of results focused on this procedure only, within a vast amount of information that is already out there on other mastectomy procedures

13. Searching for a “needle in a haystack” Background information: A number of sources are used to find out as much information on the procedure as possible. These include: Literature search request form Medical dictionaries Cochrane reviews Google search Discussion with the Analysts

14. Use of PICO Traditional PICO Patient Intervention Comparator Outcome Interventional procedure PICO Procedure Indication Comparator Outcome Structure is a key component to consider when searching for IPs: Normal rules of PICO do not apply P and I are mainly used but represent Procedure and Indication Sometimes a three-concept search strategy is used to combine two different concepts in the procedure part of the strategy, this ensures we find information on the exact procedure we are looking for.

15. PICO example for Interventional Procedures For example: Endoscopic mastectomy and endoscopic wide local excision for breast cancer Procedure Endoscopic mastectomy Indication Breast cancer

16. Searching for a “needle in a haystack” Before we being searching, we try to identify all the possible search terms that we can use in PICO Use a combination of MeSH and free text searching Use truncation to find alternative spellings and word endings Use Boolean to combine concepts Adj3 operator is often used to help focus the search

17. Search process The first search strategy is composed in Medline Each IP is assigned an Information Specialist (IS) who provides support to the Assistant Information Specialist (AIS) The Information Specialist quality assures the Medline strategy – checking the search terms, the structure of the search, spellings and correct use of boolean Once a Medline strategy has been agreed between the AIS and IS it is then translated into other medical databases These translations are quality assured by the other AISs in the Information Services team Checking searches in this way helps to maintain standards and reduce errors

18. Concept 1 – Procedure Endoscopy/ Endoscop*.tw Surgical Procedures, Minimally Invasive/ (minimal* adj3 invasive* adj3 (surg* or procedure* or technique* or excisi*)).tw (Key*hole* adj3 (surg* or procedure* or technique* or excisi*)).tw (video* adj3 assist* adj3 (surg* or procedure* or technique*)).tw Transareolar*.tw ((Skin* or Nipple* or Areola*) adj3 Spar*).tw. The search terms for each concept are explored in Medline

19. Concept 1 – Procedure Three concept search strategy: Exp Mastectomy/ Mastect*.tw Endoscopic mastectomy is a new procedure There are no relevant thesaurus heading So we need to combine the MeSH headings and free text terms for Endoscopic AND Mastectomy in the Procedure part of the strategy in order to focus the search on this new procedure

20. Concept 2 – Indication Breast Neoplasms/ (Breast* adj3 (Neoplasm* or Cancer* or Metastas* or Carcinoma* or Adenocarcinom* or Tumour* or Tumor* or Malignan* or Lump* or Masses* or Sarcoma*)).tw

21. Combining As with usual searching OR is used to combine the similar search terms in each concept AND is used to combine the Procedure and Indication terms Some IP’s require AND to be used within one concept usually the Procedure section. In this example AND is also used to combine the different Endoscopy and Mastectomy terms in concept 1 to focus the search.

22. Limiting The only limit used for every IP search is to exclude Animal studies. We don’t tend to use any other limits as it is better to keep the search as inclusive as possible so potential relevant references are not excluded If we get quite a large number of results and after discussions with the Analyst we sometimes limit strategies to: –Randomised Controlled Trails –Systematic Reviews –English Language Date limits are also sometimes used

23. Final search strategy 1 Endoscopy/ 2 Surgical Procedures, Minimally Invasive/ 3 Endoscop*.tw. 4 (Minimall* adj3 Invasive* adj3 (Surg* or Procedure* or Technique* or excisi*)).tw. 5 (Key*hole* adj3 (Surg* or Procedure* or Technique* excisi*)).tw. 6 (Video* adj3 Assist* adj3 (Surg* or Procedure* or Technique*)).tw. 7 Transareolar*.tw. 8 ((Skin* or Nipple* or Areola*) adj3 Spar*).tw 9 or/1-8 10 exp Mastectomy/ 11 Mastect*.tw. 12 or/10-11 13 exp Breast Neoplasms/ 14 (Breast* adj3 (Neoplasm* or Cancer* or Metastas* or Carcinoma* or Adenocarcinom* or Tumour* or Tumor* or Malignan* or Lump* or Masses* or Sarcoma*)).tw 15 or/13-14 16 9 and 12 and 15

24. Sources to search Databases: Medline, Medline in Process, EMBASE, CDSR, CENTRAL, HTA & DARE (via CRD), CINAHL and BLIC Websites: NICE website – for related guidance FDA - (MAUDE database) ASERNIP ANZHSN Clinical Trials: Clinicaltrials.gov metaRegister of Controlled Trials – mRCT UK Clinical Research Network (UKCRN) Portfolio Database

25. What happens next? We pass all search results on to the Analysts in the IP team An overview is prepared, and is then discussed at the Interventional Procedures Advisory Committee (IPAC) NICE issues a consultation document on the safety and efficacy of the procedure IPAC then considers the comments from the consultation, and produces final recommendations for the procedure The final recommendations are then submitted to NICE for approval Once NICE formally approves the final guideline, consultees are notified NICE issues the guidance to the NHS

26. IPG296: Endoscopic mastectomy and endoscopic wide local excision for breast cancer Date notified to NICE: 25 January 2008 IS searches complete: 05 August 2008 Consultation date: Winter 2008/9 Guidance issued: 22 April 2009

27. Thank You Any Questions? Contact details: Sarah.glover@nice.org.uk Jenny.kendrick@nice.org.uk