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
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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
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3. Online workbook
Session supported by
online workbook –
Question Formulation
and developing a
search strategy
workbook
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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.
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5. EBP steps
• Ask answerable questions
• Search for the evidence
• Appraise the evidence
• Apply the evidence
• Evaluate the results
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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
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7. Example
• Want to know about diagnosing
epilepsy?
• Medline search ‘epilepsy’ –77336
articles
• What would you search for next?
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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
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– Focused question workbook.doc
9. Focused questions
• Well built
• Structured
• Relevant
• Answerable
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10. Why focus the question?
• Define important outcomes
• Define the most valid study design to
answer the question
• Structure your search for the evidence
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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?
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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
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14. Question structure
Patient group young child with fever
Intervention paracetamol
Comparison ibuprofen
Outcomes reducing fever
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15. Question
• In a young child with fever is
paracetamol (Calpol) better than
ibuprofen (Junifen) at reducing fever?
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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
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17. Question structure
Patient group Adult with clinically
suspected scaphoid fracture
Intervention magnetic resonance imaging
Comparison bone scan
Outcomes reaching a diagnosis
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18. Question
• In an adult with a clinically suspected
scaphoid fracture is magnetic
resonance imaging better than bone
scintigraphy at reaching a diagnosis?
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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
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20. Question structure
Patient group Adult with abdominal pain
Intervention normal serum amylase
Comparison
Outcomes Exclude the diagnosis of
pancreatitis
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21. Question
• In patients with abdominal pain does a
normal serum amylase exclude the
diagnosis of pancreatitis?
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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
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23. Question structure
Patient group Elderly adult with congestive
heart failure and hypertension
Intervention Average length of time
Comparison
Outcomes Survival
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24. Question
• In an elderly adult with congestive
heart failure and hypertension what is
the average length of time of
survival?
ADEPT
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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.
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26. Question structure
Patient group Young women
Intervention Oral contraceptive pill
Comparison
Outcomes Risk of thromboembolism
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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
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28. EBP steps
• Ask answerable questions
• Search for the evidence
• Appraise the evidence
• Apply the evidence
• Evaluate the results
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30. Ask a focused question
• Use the PICO framework where
appropriate
In children with fever is paracetamol
better than ibuprofen at reducing fever?
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31. Identify search terms
P Child
fever
I paracetamol
C ibuprofen
O Reducing fever
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32. Identify synonyms/spelling
variants/related terms
P Children child infant paediatrics pediatrics
Fever febrile
I Paracetamol Calpol
C Ibuprofen Junifen
O Reducing fever
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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
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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
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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)
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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
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37. Where do you start?
• Think about
– What study designs would best answer
your question
– The subject area you are looking at
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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
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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
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42. Systematic Reviews
• The Cochrane Library
– Cochrane Database of Systematic
Reviews (CDSR)
– Database of Abstracts of Effects (DARE)
• Healthcare databases
– Medline +other subject specific
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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)
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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
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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…
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46. RCTs
• The Cochrane Library
– CENTRAL
• Healthcare Databases
– Medline +other subject specific
– Can often limit search to RCTs
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47. All study types
• Healthcare databases
– Medline + other subject specific (covered in
next session)
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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!
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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
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– !Look for the help with searching link!
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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
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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
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52. Searching across EBP
websites
• TRIP
– Turning Research Into Practice
– http://www.tripdatabase.com/
NB 3 searches per week allowed on each
PC
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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/
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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
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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?
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