PLANNING THE

SEARCH PROCESS
EKA DIAN SAFITRI

Clinical Epidemiology and Evidence-Based Medicine (CEEBM) Unit

RSUPN Dr. Cipto Mangunkusumo – Fakultas Kedokteran Universitas Indonesia
Outline

 Why do we need to search?

 Formulating the clinical question (PICO)
 Sources to search
 Pyramid of evidence
1. Why do we
need
to(systematic)
search?
Several methode to find information

 Ask Expert
 Call a friend
 Read the text book
 Read the news paper
 Read the online news
 ........................
 ........................
 ........................
Finding information about..........

 EBM Searching workshop

 EVIDENCE-BASED PRACTICE

Clinical Best Available

Patients value
Expertise Evidence

DECISION MAKING
Finding clinical information?

 EBM PROCESS
Patient with
problems

Apply the Formulate

answerable
evidence clinical questions

Critical Search the

appraisal evidence
 Keeping up-to-date with current best evidence for
the care of our patients
 Resources for finding evidence are rapidly evolving
2. Formulating
the clinical
question
(PICO)
Importance of a well-defined review
question

 Essential first step for your review

 Guides many aspects of your methods
 eligibility criteria  Which Studies are included in the review and which
are excluded
 search strategy
 data collection and analysis  Which outcomes do you want to
measure, are there specific issues that want to explore, What
information do you need tofind in the included study?
 Think some details at the beginning of the process  Plan your
work
 Clear Idea of the scope of your review  avoid bias, reduce the
risk of making decisions
 Background Questions

 These questions are general in  Examples

nature and provide  What is the pathology
foundational information on a of rhinosinusitis
single concept.
 What drugs are used to
 Background questions cover: treat asthma
 Terminology  What education resources
 General Pathology exist for patients
with gestational diabetes?
 Patient Education Resources  How
 General Drug Information is rhinosinusitis diagnosed?
 Examination/Assessment
Procedures
Foreground Questions

 These questions bring together multiple concepts related to a

specific clinical situation or research topic.
 Discover cause and effect relationships by comparing two or
more individuals or groups based on differing outcomes
associated with exposures or interventions.
 Detailed information
 Diagnosis
 Therapy
 Prognosis
 Patient focus
 Age group
 Stage of the disease
 Certain risk factors
 Evidence-based process
 Examples:
 In adults with chronic rhinosinusitis, does ultrasound therapy (as an
adjuvant or single therapy) would reduce the symptoms and
recurrence? (Therapy)

 In adults with chronic rhinosinusitis, does CT scan Sinus Paranasal

compare to nasoendoscopy would increase the accuracy of
diagnosis rhinosinusitis?(Diagnosis)

 In adults with chronic rhinosinusitis , does various clinical factors like

allergy and asma would increase reccurency? (Prognosis)
PICO/T CONCEPT
Formulating Foreground Questions
 Eligibility criteria

 Eligibility criteria are the essential components determine

whether a study is included and discussed in the review, or
whether it is excluded
 Based on:
• some or all of your PICO components
plus

• definition of eligible study designs

 Population

 What are the most important characteristics that describe the

people you are interested in?
 two aspects to consider
• health condition
 diagnosed how, by whom?

• population and setting

 any limits should have a clear rationale
• alternative is to include and explore in subgroup analysis
Intervention

 give as much detail as possible

 formulation
 dose, intensity
 delivery
 timing, frequency, duration
 equipment
 personnel (qualifications, training)
 location, context
 alone or in combination with other intervention(s)
 any limits should have a clear rationale
 alternative is to include and explore in subgroup analysis
 Comparison

 based on the objective of your review

• define specific active comparisons in as much detail as the intervention
• be clear what you mean by ‘no intervention’
 e.g. no intervention, placebo, usual care, etc.

• can remain open to any comparisons found, but be explicit

 Outcome

 Systematic Reviews may even focus on single outcome

 e.g the impact of statins on stroke, vitamin D on nonvertebral fractures
 Guidelines may require consideration of all outcomes that are
important to patients, resources paid, or public health
 Cont...

 rarely part of the eligibility criteria

 excluding studies on the basis of outcomes reported may
introduce bias
• outcomes may be selectively reported by trial authors
• additional information may be available
 may be appropriate if outcomes are important to the definition of
your question
• e.g. prevention vs treatment, interventions used for more than one
condition
 What are the main concepts in your question?

To undestand the relationship laryngopharingeal reflux with rhinosinusitis

in asthma patients

How the topic mightbe

rephrases as an article tittle?
 (Populasi OR sinonim1 OR sinonim2.......)AND
 (Intervensi OR sinonim1 OR sinonim2.......)AND
 (Comparator OR sinonim1 OR sinonim2.......)AND
 (Outcome sinonim1 OR sinonim2.......)
 Example
In adults with chronic rhinosinusitis, does ultrasound therapy (as an
adjuvant or single therapy) would reduce the symptoms and
recurrence?

Eligibility Criteria
 Population:
 We included patients of any age (children and adults) with Chronic
Rhinosinusitis (CRS) as defined in either:
 the European Position Paper on Rhinosinusitis and Nasal Polyps 2012: or
 the Rhinosinusitis Task Force Report (RTFR 1996) and its revision by the Sinus and Allergy
Health Partnership Task Force (including the members of RTFR 1996 from the American
Academy of Otolaryngology - Head and Neck Surgery or
 sinusitis symptoms with/without endoscopic evidence and/or radiological evidence of
sinusitis for 12 weeks or more; or
 no complete resolution of rhinosinusitis symptoms after 12 weeks or more (e.g. no
treatment, failed medical therapy)

 We excluded patients in whom ultrasound is contraindicated, e.g. patients

with a pacemaker, cancer, pregnancy or impaired vascular circulation
Continue...

 Types of interventions
 Intervention
 The intervention is ultrasound given as a treatment for CRS, either
continuous or pulsed, at any intensity or frequency and for any number
of sessions or duration.

 Types of Comparison
 The comparisons were sham ultrasound therapy, no treatment or other
treatment.
Continue...

 Types of outcome measures

 1.Resolution of symptoms or reduction in overall symptom severity. Reduction
in symptom severity may be measured using visual analogue scales or a
validated symptom scale, e.g. Sinonasal Outcome Test/SNOT-20
 2. Reduction in overall symptom duration.
 3. Recurrency of symptoms, defined as new episodes of rhinosinusitis or the
proportion of patients with recurrent rhinosinusitis after four weeks from the
start of therapeutic ultrasound.
 4. Adverse effects of treatment.
 PICO define keywords

Patient / Population / Intervention / Comparison Outcome

Problem Exposure

Rhinosinusitis Ultrasound - -
Sinusitis Ultrasound therapy
Chronic rhinosinusitis Ultrasonic
Ultrasonic therapy
 PICO

Patient / Intervention / Comparison Outcome

Population / Exposure
Problem

Patients with Risk of sudden

osteoporosis deafness

Sudden
sensoryneural
hearing loss

Sensoryneural
hearing loss

Hearing loss
 PICO

Patient / Intervention / Comparison Outcome

Population / Exposure
Problem

Hypertension Cocoa Reduce

Blood pressure Chocolate N/A Reducing
Flavanoid* Reduction
Lower
Lowering
3. Sources to
search
Where to find the evidence

 Through internet:
 Database
 Elektronik book
 Harrison’s (www.harrisonsmed.com)

 Journal
 World Association of Medical Editors (www.wame.org)
 NEJM, Lancet, BMJ, Pediatrics, Pediatrics Infectious Disease

 Website
 Other sources
 Useful resources: Free

1. TRIP http://www.tripdatabase.com
2. NICE Evidence Search http://www.evidence.nhs.uk
3. Epistemenikos http://www.epistemonikos.org/
4. SUMSearch2 http://sumsearch.org/
5. PubMed Clinical Queries http://www.pubmed.gov
6. Google http://www.google.co.uk
7. GoogleScholar http://scholar.google.co.uk
 Useful resources: Subscription-based

1. Cochrane Library http://www.cochranelibrary.com

2. Point of care information tools
 Best Practice, Clinical Evidence, DynaMed, UpToDate…
3. Bibliographic databases
 CINAHL, Embase, Medline, PsycINFO, Scopus…
4. Electronic text-books
4. Pyramid of
evidence
 4. Pyramid of evidence

 Systems
 Integrating information from the lower levels of the hiearchy
with individual patient records

 systems represent the ideal source of evidence for clinical

decision-making.

 Summaries
 Summaries are regularly updated clinical guidelines or
textbooks that integrate evidence-based information about
specific clinical problems.

 Synopses of syntheses
 summarize the information found in systematic reviews. By
drawing conclusions from evidence at lower levels of the
pyramid, these synopses often provide sufficient information to
support clinical action.

 Syntheses
 Commonly referred to as a systematic review, a synthesis is a
comprehensive summary of all the evidence surrounding a
specific research question.

 Synopses of Single Studies

 summarize evidence from high-quality studies

 Single Studies
 Studies represent unique research conducted to answer
specific clincial questions.
http://hsl.mcmaster.libguides.com/ebmc
Systems

 Integrating information from the lower levels of the hierarchy

with individual patient records, systems represent the ideal
source of evidence for clinical decision-making.
 The ideal
 A perfect evidence-based clinical information system would
integrate and concisely summarize all relevant and important
research evidence about s clinical problem and would
automatically link, through an electronic medical record, a specific
patients circumstances to the relevant information.
 Summaries

Summaries of evidence for individual clinical problem.

Its review of evidence adhere high scientific standard and its post newly
published evidence in an update table for each topic

 Clinical Practice Guidelines  Evidence-Based Texts

 DynaMed Plus
 National Guideline Clearinghouse (Free)
 CPG Infobase  UpToDate

Canadian Medical Association  Best Practice

 NICE Clinical Guidelines
 First Consult (Through Clinical Key)
National Institute for Health and Clinical Evidence, UK
 Evidence-Based Guidelines (Programs in Evidence-Based
Care)
Cancer Care Ontario
 Best Practice Guidelines
Registered Nurses Association of Ontario (RNAO)
 Synopses of syntheses

 NHS Centre for Reviews and Dissemination (CRD)

 Cochrane Summaries

 OrthoEvidence

 HealthEvidence.org (Free)

 Evidence-Based Abstract Journals

 Evidence-Based Medicine

 ACP Journal Club

 Evidence-Based Obstetrics and Gynecology

 Evidence-Based Mental Health

 Cancer Treatment Reviews

 Evidence-Based Healthcare and Public Health

 Evidence-Based Nursing
Syntheses

 Commonly referred to as a systematic review, a synthesis is a

comprehensive summary of all the evidence surrounding a
specific research question.
 Cochrane Library
 Cochrane Neonatal.
 National Institute of Child & Human Development

 EPC Evidence Reports

 Evidence-Based Practice Centers

 The Canadian Cochrane Centre / Centre de Cochrane Canadien

 The Cochrane Collaboration
 Synopses of Single Studies

 Synopses of single studies summarize evidence from high-quality studies.

 The following evidence-based abstract journals are the best place to
find this type of information
 Evidence-Based Medicine.
 ACP Journal Club
 OrthoEvidence
 Evidence-Based Obstetrics and Gynecology
 Evidence-Based Mental Health
 Cancer Treatment Reviews
 Formerly Evidence-Based Oncology

 Evidence-Based Nursing
 Evidence-Based Healthcare and Public Health
Single Studies

 Studies represent unique research conducted to answer specific

clinical questions.
 Article Databases
 CINAHL
 OVID Databases
 Medline, EMBASE, PsychINFO, AMED
 PubMed
 ProQuest Nursing and Allied Health
 Health Services Research (HSR)
Thank you

ekadian.safitri@ceebm.org
ed_safitri@yahoo.com