1. Presented by: Robyn Butcher, Sandra Kendall, Carla Hagstrom and Gail Nichol Advanced Searching Methods Family Medicine

2. dfcm.librarian@utoronto.ca

3. Learning Objectives  Summarize evidence based medicine  Plan a search using PICO  Develop advanced searching strategies in Medline  Describe the importance of critical appraisal  Examine open access journals in Africa

4. What Is Evidence Based Medicine? “Evidence based health care is the integration of individual clinical expertise with the best available external clinical evidence and the values and expectations of the patient” – Dave Sackett

5. EBDM – What Is It? Clinical Expertise Research Evidence Patient Preferences EBDM

6. Why Use EBM?  Advances quality of care provided  Increases satisfaction of patients  Refocuses practice away from habits and tradition to evidence and research  Allows you to keep up to date with current literature

7. A cquire the best evidence A ppraise the evidence A pply evidence to patient care Assess your patient A sk clinical questions 5 Step EBM Cycle

8. Adapted from: Brian Haynes, R Evid Based Med 2006;11:162-164 Systems Computerized decision support Summaries Evidence-based textbooks Synopses Evidence-based journal abstracts Syntheses Systematic Reviews Studies Original journal articles Haynes Tiers

9. Type of Question Suggested Type of Study TherapyRCT>cohort>case control>case study DiagnosisProspective, blind comparison to a gold standard Etiology/HarmRCT>cohort>case control>case series PrognosisCohort study>case control>case series PreventionRCT>cohort study>case control>case series CostEconomic analysis Adapted from Duke library guide Introduction to Evidence Based Practice.

10. Planning a Search  Formulate an answerable question  Pull the main concepts from the question  List the terms that relate to your concepts  Combine your terms  Choose your database  Search!

11. Formulating an Answerable Question PICO Model P= Patient, Problem, Population I= Intervention C= Comparison O= Outcome

12. Example Your hospital wants to implement a policy of placing all HIV+ patients on INH prophylaxis therapy. You have been asked to do a review to see if that is successful in preventing tuberculosis, in particular in other African countries.

13. PICO Example Continued P – HIV positive in African countries I – INH prophylaxis therapy C – n/a O – decreased rates of tuberculosis Answerable Question: In African countries does INH prophylaxis therapy help reduce the rates of tuberculosis among HIV positive patients?

14. Putting Together A Search Strategy Pull the main concepts from your question In African countries does INH prophylaxis therapy help reduce the rates of tuberculosis among HIV positive patients? List the terms that relate to your concepts

15. PICO Clinical Question Search Strategy PICOClinical QuestionSearch Strategy Patient PopulationHIV positive patients in African countries HIV positive, HIV infection, human immunodeficiency virus, Africa, Ethiopia, Eastern Africa Intervention INH prophylaxis therapyINH prophylaxis therapy, INH preventive therapy, Isoniazid, IPT Comparison (if any) n/a OutcomeReduction of cases of tuberculosis Tuberculosis

16. Medline Search

18. MeSH: Medical Subject Headings  Every database has its own indexing system  They often use their own thesaurus or controlled vocabulary  Medline uses MeSH  When searching you want to match your keyword to the subject heading  Example: keyword=cancer, MeSH=neoplasms

19. Example – Medline Search

20. Select the Subject Heading

21. View the Scope Note

22. View the Tree

23. View Results and Enter Next Search Term

24. Select the MeSH Heading

25. View Results and Enter Next Search Term

27. Combine Search Terms With “And”

29. Apply Limiters

30. View Results

31. Get Full Text

32. Full Text Article

33. HIV Or HIV Infections?

34. Can You Use DynaMed Or Clinical Evidence For Advanced Searching? Yes and No No  It should not be your sole or even primary searching tool Yes  Monographs do have links to original studies  Think of it as a supplementary tool

35. DynaMed-example

36. DynaMed-example (cont’d)

37. Another Example Patient was diagnosed with diabetes mellitus within the last year. He is a Muslim and wants to know what he should do during Ramadan.

38. PICO Example Continued P – Diabetic Muslims I – Management of diabetes during Ramadan C – n/a O – Safe fasting guidelines Answerable Question: In Muslims with diabetes mellitus are there guidelines or treatment options for safely observing the Muslim fasting month?

39. Putting Together a Search Strategy Pull the main concepts from your question In Muslims with diabetes mellitus are there guidelines or treatment options for safely observing the Muslim fasting month? List the terms that relate to your concepts

40. PICO Clinical Question Search Strategy PICOClinical QuestionSearch Strategy Patient Population Muslims with diabetesMuslims, Islam, diabetes type 1 or type 2, diabetes mellitus InterventionManagement of diabetes during Ramadan Ramadan, fasting Comparison (if any) n/a Outcome Safe fasting guidelinesGuidelines, treatment

41. Example – Medline Search

42. Select the Subject Heading

43. View the Scope Note

44. View the Tree

45. View Results and Enter Next Search Term

46. Select the MeSH Heading

47. View Results and Enter Next Search Term

49. Combine Search Terms With “And”

51. Too Few Results? Remove a Search Term

52. Apply Limiters (Practice guidelines or reviews)

53. View Results

54. Next Steps

55. A cquire the best evidence A ppraise the evidence A pply evidence to patient care Assess your patient A sk clinical questions 5 Step EBM Cycle

56. Why Do We Need To Critically Appraise?  To ensure research is valid and reliable  To ensure the statistics match the information in the discussion section  To decide whether this article is going to help you with your decision making

57. Basic Critical Appraisal  What journal did it appear in?  Who are the authors?  What is the broad question they are asking? Did they actually address this question?  Was the methodology appropriate? Did it produce reliable data?  What are the reported results?

58. Critical Appraisal Forms SIGN (Scottish Intercollegiate Guidelines Network) http://www.sign.ac.uk/methodology/checklists.html Centre for Evidence-Based Medicine http://ktclearinghouse.ca/cebm/teaching/worksheets

60. Where Can I Find This Presentation? www.TAAAC.com Programs Library Science Training

61. Any Questions?