Finding Current Best Evidence (Penelusuran Bukti Ilmiah)

Nawang Purwanti Medical Librarian Perpustakaan FK-UGM upik-fk@ugm.ac.id

Workshop Evidence-Based Practice for Doctors SEA ORCHID Indonesia/HOGSI Malang, 4 April 2008
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Background
Access * Information overload - over 2 millions health research papers published every year * MEDLINE indexes less than 25% of biomedical journals *50% of health research is unpublished *Best electronic searches identify less than 50% RCTs Busy clinicians problems of keeping up-todate with current best evidence for the care of patients
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Objectives
To provide relevant information and tips in formulating answerable clinical questions To introduce the Cochrane database and PubMed as Evidence-Based Practice resources To show how to use the database to find the best evidence

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Elements of EBP
Your Clinical Expertise

The Best Available Evidence

Each Individual Patient

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The 5 steps of EBP

Ask a clear clinical question Search for the evidence Appraise the evidence Apply the results to clinical practice Evaluate the impact on practice
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Stages in searching best evidence

1. 2. 3. 4. 5. 6. Identify types of clinical questions Formulate an answerable clinical question PICO method Choose search terms Develop a search strategy use of searching tools Where to search Find research evidence

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Clinical questions central issues in clinical work

Therapy or Intervention treatments to patients that - do more good than harm - are worth the efforts and costs of using them

Prognosis patients likely clinical course over a time and complications of the disorder
Etiology causes or risk factors of disease Diagnosis - possible causes of patients clinical problems

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FROM QUESTION TO SEARCH STRATEGY

Describe each PICO element, using synonyms where appropriate Begin with the central element/concept Define the type of question Use the tools of each particular database eg descriptors/subject headings/MeSH, filters Add other elements of the question to limit retrieval Examine relevant records for additional terms

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Ask a clinical question

Is ibuprofen or paracetamol better at reducing pain and fever in children?

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PICO method

P : Children with pain and fever I : Ibuprofen C : Paracetamol O : Reduction in pain and/or fever
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Reformatted clinical question P: In children with pain and fever

I: is ibuprofen C: compared with paracetamol O: more effective at reducing pain or fever?

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From Question to Search Terms

Search Terms Patient Alternatives

Child Pain Fever

Ibuprofen Paracetamol Pain Fever

Children, infant, infants Febrile

Intervention Comparison Outcomes

Acetaminophen Febrile

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Points to remember when choosing search terms

Search terms are specific They belong to a controlled language, as found in MeSH (medical subject heading or thesaurus) MeSH available in both the Cochrane database and PubMed Always consult MeSH or thesaurus to identify appropriate search terms

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Searching tools
Boolean operators AND, OR and NOT Truncation Grouping/Nesting

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Searching tools - Boolean Operators AND narrowing

warna

A AND

B
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Searching tools - Boolean Operators OR broadening

OR

B
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Searching tools - Boolean Operators NOT excluding

NOT

B
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Searching tools - Truncation

Symbol of truncation Examples child* = child, or children childcare childhood *

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Searching tools Grouping/nesting

Symbol of grouping () Examples (fever OR febrile) (paracetamol OR acetaminophen)

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Bringing them together

Children with pain and fever

The answer

Paracetamol

Ibuprofen

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Search Phrase
Search Terms Patient Intervention Comparison

(child* OR infant*) AND (pain OR (fever* OR febrile)) ibuprofen (paracetamol OR acetaminophen)

(child* OR infant*) AND (pain OR (fever* OR febrile)) AND ibuprofen AND (paracetamol OR acetaminophen)
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Why bother?
Pubmed 3/27/08
1884467 166801
457 225 13
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Search Phrase
(child* OR infant*) (child* OR infant*) AND pain OR (fever* OR febrile) (child* OR infant*) AND pain OR (fever* OR febrile) AND ibuprofen (child* OR infant*) AND pain OR (fever* OR febrile) AND ibuprofen AND (paracetamol OR acetaminophen)

PubMed Clinical Queries Systematic Reviews

What to look for?

The paper where someone trustworthy has already answered your question

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Primary & Secondary Research

Primary research research undertaken to address a question Secondary research research undertaken to find the existing primary research that addresses a question
reviews (systematic, narrative) and metaanalyses

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Narrative vs Systematic Reviews

Narrative review

Opinion with illustrations from the literature Cannot appraise Not trustworthy because potential sources of bias cannot be assessed

Systematic review
Rigorous research methodology Objective review of all the evidence Can be appraised like other research Trustworthy because potential sources of bias can be assessed

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What type of research to look for?

If your question is about:
Intervention / Therapy Diagnosis / Screening: - Accuracy Cohort studies - Health outcomes RCT Prognosis Aetiology / Risk factors Longitudinal cohort studies RCT, cohort or case-control studies
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Look for a systematic review or

Randomised Controlled Trial (RCT)

Where to search?
The Cochrane Library (www.thecochranelibrary.com)
collection of databases of high quality information about healthcare interventions, including systematic reviews.

PubMed Clinical Queries (www.pubmed.gov)

specialised MEDLINE search engine with built-in search filters designed to find high quality studies in four study categories: therapy, diagnosis, aetiology and prognosis systematic reviews

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www.thecochranelibrary.com

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www.pubmed.gov

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Other sources
National Guideline Clearinghouse (NGC) - a public resource for evidence-based clinical practice guidelines (www.guideline.gov) Canadian Medical Association - voluntary association of physicians that advocates on behalf of its members and the public for access to high quality health care, and provides leadership and guidance to physicians.) (www.cma.ca) BMJ Clinical Evidence (http://clinicalevidence.bmj.com) ACP Journal Club (www.acpjc.org)
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www.guideline.gov

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www.cma.ca

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cma clinical practice guidelines

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BMJ Clinical Evidence

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ACP Journal Club

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Conclusion
Use PICO method to formulate clinical questions Consult and use terms available in MeSH to get the appropriate search terms Develop search strategy using search tools provided Activate search history (if available) to help revise search Practice makes perfect. Asah ketrampilan dengan banyak berlatih. Selamat mencoba.

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Searching practice
Go to www.thecochranelibrary.com and www.pubmed.gov Use the sample search phrase (child* OR
infant*) AND (pain OR (fever* OR febrile)) AND ibuprofen AND (paracetamol OR acetaminophen) and find out the result

How do they differ?

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