Ppaare question

Chapter 4 Locating Relevant Evidence

Learning Outcomes

As a result of completing this chapter and its associated activities the student will be able to:

Define each of the key terms for the chapter.

Construct a PPAARE question that is applicable to a specific

individual patient care situation;

public health or community health situation;

epidemiological situation;

patient experience or perception.

Develop a set of search terms derived from a PPAARE question.

Learning Outcomes

Extract the PPAARE components from an abstract and an article.

In PubMed, use MeSHs, Boolean operators, and limits to perform a focused, PPAARE search.

Locate high-level evidence by conducting a search using the Cochrane Library (if available), CINAHL (if available) and Clinical Queries in PubMed as relevant to a PPAARE question.

Learning Outcomes

Evaluate a point-of-care produce (if available) in terms of:

currency of evidence;

relevancy to discipline;

usefulness of features;

amount of time to locate relevant evidence;

quality of the review process for synthesizing evidence; and,

access requirements.

Learning Outcomes

Conduct a PPAARE search utilizing each of the following types of search tools and compare the relevancy of the information located:

meta-search engine

search engine

website

evidence-based journal

open-access evidence

Learning Outcomes

Describe strategies for gaining access to a full-text version of a resource that is not available as free full-text online.

Locate an online calculator that provides information relevant to a clinical situation.

Organize and track PPAARE search strategies utilizing Table 4-11.

Agenda

Reading Assessment

Presentation of Content

Skills Checklist

Additional Active Learning Strategies

Reminders

Reading and Reading Assessment

Reading Assignment: Chapter 4, Locating Relevant Evidence.

Reading Assessment: After reading Chapter 4, complete the reading assessment before proceeding to the rest of this presentation.

Writing a PPAARE Question

Question related to patient care

P = Problem

Brainstorm examples relevant to your discipline

P = Patient or Population

Brainstorm examples relevant to your discipline

A = Action

Brainstorm examples relevant to your discipline

A = Alternative Action (not a required component)

Brainstorm examples relevant to your discipline

R = Result

Brainstorm examples relevant to your discipline

Application of Patient Care PPAARE

Patient Care Example: A mother accompanies her 15 year old son to an appointment at the family physician’s office to receive a physical for playing football. The mother asks the health care provider whether or not her son should get the HPV (Human Papilloma Virus) vaccine, the same one that her daughters received when they were teenagers?

Identify:

Problem

Patient

Action

Alternative Action (not a required component)

Result

Patient Care PPAARE Question

What is the highest level of evidence available to determine whether a patient with (P=disease or condition) who is (P=demographics or risk factors) benefits from (A=Action) as compared to (A=Alternative) to produce, improve, or reduce the (R=Result).

Use this example and write a patient care question related to the example of the HPV vaccine.

ANSWER: What is the highest level of evidence available to determine whether a patient without HPV who is a 15 year old male benefits from the HPV vaccine to reduce susceptibility of contracting HPV.

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Search Terms for Patient Care PPAARE

Search Words Corresponding to PPAARE Alternative Words or Synonyms Search Words to be Excluded for Search

P

P

A

A

R

Search words Alternative words

P=without HPV

P=15 year old male male teenager or adolescent

A=HPV vaccine

A=none

R=prevent HPV papilloma virus immunization

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Application of Public or Community Health PPAARE

Public or Community Health Example: The medical staff at the local hospital has noticed an increase in the number of people who suffer from mental and physical exhaustion. These people are caregivers to family members who have dementia or Alzheimer disease. Staff members want to work with the public health department to implement a community intervention program to provide support to the caregivers.

Identify:

Problem

Patient

Action

Alternative Action (not a required component)

Result

Public and Community Health PPAARE Question

What is the highest level of evidence available to determine whether a community or population with (P=disease or condition) who is (P=demographics or risk factors) benefits from (A= implementation of a health program) as compared to (A=Alternative) to produce, improve, or reduce the (R=Result).

Use this example and write a question related to the example of the caregiver situation.

ANSWER: What is the highest level of evidence available to determine whether a population exhibiting exhaustion, who is fulfilling the role as a caregiver to a family member with dementia or Alzheimer disease, benefits from a community health intervention program to improve the mental and physical health of the caregiver.

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Search Terms for Public or Community Health PPAARE

Search Words Corresponding to PPAARE Alternative Words or Synonyms Search Words to be Excluded for Search

P

P

A

A

R

Search words Alternative words

P=exhaustion

P=caregiver to a family member with

dementia or Alzheimer disease

A=community health program public health

A=none

R=improve the mental and physical health pyschology

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Application of Epidemiological PPAARE

Epidemiological Example: You are part of an interprofessional team of health care professionals who has been given the responsibility of determining a protocol for an outbreak of Avian influenza in the state.

Identify:

Problem

Patient

Action

Alternative Action

Result

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Epidemiological PPAARE Question

What is the highest level of evidence available to determine whether a population with (P=disease or injury) who is (P=demographics or risk factors) benefits from (A=control or prevention strategy) as compared to (A=Alternative) to produce, improve, or reduce the (R=Result).

Use this example and write a question related to the example of the breathing difficulty situation.

ANSWER: What is the highest level of evidence available to determine whether a population with Avian influenza who is exposed benefits from an established protocol to control the flu, to reduce the incidence (number of new individuals who contract the disease) of this disease.

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Search Terms for Epidemiological PPAARE

Search Words Corresponding to PPAARE Alternative Words or Synonyms Search Words to be Excluded for Search

P

P

A

A

R

Search words Alternative words

P=Avian flu bird influenza

P=exposure to Avian flu epidemiology, prevention and control

A=establish a protocol guidelines

A=none

R=reduce the incidence of Avian flu

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Application of Understanding Patient Experiences and Perceptions PPAARE

Example: A 48 year old male comes to the office recently diagnosed with rheumatoid arthritis. As a health care provider, you want to understand the male perspective of having this disease to help this patient prepare for the challenges that he faces.

Identify:

Problem

Patient

Action

Alternative Action (not a required component)

Result

Patient Experiences and Perceptions PPAARE Question

What is the highest level of evidence available to determine the experiences or perceptions of (P=disease, condition, access to care problems) in a (P=demographics or risk factors) patient to (A=gain knowledge) to produce, improve, or reduce the (R=Result).

Use this example and write a question related to the example of the rheumatoid arthritis situation.

ANSWER: What is the highest level of evidence available to determine the experiences of rheumatoid arthritis in a 48 year old male patient, to gain knowledge to improve the challenges the patient faces in the future.

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Search Terms for Understanding Patient Experiences and Perceptions PPPAARE

Search Words Corresponding to PPAARE Alternative Words or Synonyms Search Words to be Excluded for Search

P

P

A

A

R

Search words Alternative words

P=rheumatoid arthritis experiences

P=48 year old male adult male

A=gain an understanding qualitative research

A=none

R=improve the challenges the patient faces in the future

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Searching for Evidence in PubMed

Perform a subject search using, “HPV vaccine” AND males. Record the number of results.

Apply the following filters: Abstract available, 5 years, Humans, and English. Record the number of results.

Go to the MeSH database and find the MeSH for “HPV vaccine” and male. Combine the two MeSH using the Boolean operator “AND.” Record the number of results.

Go to Clinical Queries and perform a search using the two MeSHs combined with the word “AND.” Record the results. Determine which search yielded the most manageable results.

Faculty might need to enlist the help of a health sciences librarian to teach students how to effectively and efficiently use the PubMed database. The PubMed database has numerous resources to help faculty and students learn to use the features of this database. These resources can be accessed by clicking on the link “PubMed Tutorials” located on the PubMed homepage (http://www.nlm.nih.gov/bsd/disted/pubmed.html).

This lesson is most beneficial to students when they have access to PubMed and can search the database along with the faculty member.

Tutorial Topics

Understanding the Vocabulary

Building the Search

Managing the Results

Saving the Search

Getting the Articles

Examples of Interactive Tutorials 1-3 minutes in length

PubMed Simple Subject Search

PubMed: The Filters Sidebar

Search PubMed by Author

Searching with the MeSH Database

Combining MeSH Terms Using the MeSH Database

Applying Subheadings and Other Features of the MeSH Database

Save Searches and Set E-mail

Other Useful Handouts

PubMed Basics

Searching PubMed with MeSH

My NCBI

Full Text and PubMed

Loansome Doc

Please note that your results will differ because new evidence is continually added to PubMed

1. 350+ results

235+ results

MeSH for HPV vaccine is Papillomavirus Vaccines. MeSH for male is Male.

27 results; the search conducted in Clinical Queries yielded the most manageable number of results

The faculty member should conduct this search prior to the class session to identify titles of different levels of evidence including a systematic review, evidence-based practice guidelines or recommendations, RCTs, literature review, etc. The titles or abstracts of the evidence can be viewed by the students and they can determine the level of evidence.

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Evidence Relevancy to PPAARE

Click on the titles of evidence in Clinical Queries that seem relevant and the abstract will appear.

From the abstract or full text article (if you have access to it), identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = Highest level of evidence on the evidence pyramid

Use Table 4-11

Record search in PubMed MeSH database in columns 2-5

Select the most relevant evidence from the MeSH search and complete columns 6-9

Record search in PubMed Clinical Queries in columns 2-5

Select the most relevant evidence from the Clinical Queries search and complete columns 6-9

Search for Evidence in Cochrane Library

Go to PubMed and search for MeSH for caregiver, Alzheimer’s disease, and community intervention.

Access the Advanced Search page and enter the MeSH for caregiver and Alzheimer’s disease. Perform the search.

Read the abstracts of at least two relevant systematic review (SR) and determine which one is the most relevant.

Click on the title of the most relevant SR and then click on the link to the Full PDF document. Observe the content of a Cochrane SR to determine why it is considered the “gold standard” of SRs.

PubMed is accessed to locate the MeSH for the components of the PPAARE before accessing the Cochrane Library. MeSH for caregiver is caregivers; MeSH for Alzheimer’s disease is Alzheimer Disease; and MeSH for community intervention is public health practice (although it is not a very good match and therefore, not used in the search).

In order to make an additional search box appear, click on the + in front of the first search box.

Titles have not been provided because the content of this database continually changes.

See the components of a Cochrane SR on the next slide

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Component of a Cochrane SR

Background

Objectives (purpose)

Methods

Criteria used for selection of studies

Search methods to locate studies

Data collection and analysis

Outcome

Discussion

Conclusions

Tables

Declaration of Interest

Funding Sources

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Evidence Relevancy to PPAARE

Click on the titles of evidence in Cochrane Library that seem relevant and the abstract will appear.

From the abstract or full text article (if you have access to it), identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = highest level of evidence on the evidence pyramid

Use Table 4-11

Record the Cochrane Library search in columns 2-5

Select the most relevant evidence from the search and complete columns 6-9

Search for Evidence in a Point-of-Care Product

Place the phrase “Avian flu” in the search box.

Locate the section on guidelines or protocols.

Click on the links to guidelines to get an idea of the type of evidence available in this resource.

If the point-of-care product does not have guidelines for avian flu, search for HPV vaccine and locate information related to males.

Repeat the same search in another point-of-care product.

Compare Two Point-of-Care Products

Criteria #1 #2

Currency of evidence

Relevancy to discipline

Usefulness of features

Amount of time to locate relevant evidence

Quality of review process

Access requirements

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Evidence Relevancy to PPAARE

Click on the titles of evidence in the two point-of-care resources that seem relevant.

Read the information and identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = highest level of evidence on the evidence pyramid

Use Table 4-11

Record the search in the Point-of-Care Product #1 in columns 2-5

Select the most relevant evidence and complete columns 6-9

Record the search in the Point-of-Care Product #2 in columns 2-5

Select the most relevant evidence and complete columns 6-9

Search for Evidence in CINAHL

Access the Advanced Search page in CINAHL.

Add “rheumatoid arthritis” to one search box, male to the second search box, and “qualitative research” to the third search box.

Set the following limits: abstract available, English, dates 2000-2012, peer-reviewed, male sex.

Perform the search and read the titles of the results. Select one piece of evidence that seems the most relevant.

Repeat the same search in PubMed using a subject search and read the titles of the results.

Determine if the same evidence is available in both databases.

Evidence Relevancy to PPAARE

Click on the titles of evidence in CINAHL that seem relevant and the abstract will appear.

From the abstract or full text article (if you have access to it), identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = highest level of evidence on the evidence pyramid

Use Table 4-11

Record the CINAHL search in columns 2-5

Select the most relevant evidence from the search and complete columns 6-9

Search for Evidence in SumSearch 2

Place these words in the search box: caregiver AND “alzheimer disease” AND “mental health” AND “physical health”

Set the search for focus on intervention, Adult, Human, English, 6 iterations, and target 20 studies

Determine the most relevant evidence in the categories of (a) Original Studies, (c) Systematic reviews, and (c) Guidelines

The SumSearch 2 meta-search engine might generate an overwhelming number of results and ones that are not relevant. Compare the results with those located in the Trip databases.

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Search for Evidence in the Trip Database

Type the word caregiver in the search box and suggestions for phrases will appear. Select “dementia caregivers intervention” and perform the search.

Search each of the following sections and determine the most relevant evidence.

Evidence-based synopses

Systematic reviews

USA guidelines

Key primary research

Evidence updates

Extended primary research

Evidence Relevancy to PPAARE

Click on the titles of evidence from the Trip database that seem relevant.

Read the evidence and identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = Highest level of evidence on the evidence pyramid

Use Table 4-11

Record the SumSearch 2 search in columns 2-5

Select the most relevant evidence and complete columns 6-9

Record the Trip database search in columns 2-5

Select the most relevant evidence and complete columns 6-9

Search for Evidence Using the Google Search Engine

Place the following phrase in the search box: “avian flu guidelines”

Click on the Advanced Search feature at the bottom of the results page. Add the word, evidence-based, to the search.

Limit language to English and perform a search

Look at the results on the first two pages and determine the most relevant evidence

Please note: The Advanced search feature in Google Scholar is no longer available.

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Evidence Relevancy to PPAARE

Click on the titles of evidence in Google that seem relevant.

From the most relevant information, identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = Highest level of evidence on the evidence pyramid

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Search for Evidence on the CDC and WHO Websites

On the CDC website, place “avian flu guidelines” in the search box and perform a search.

Find the Resources for Pandemic Flu and scan the content of several resources.

Open another tab in your browser and access the WHO website. Place “avian flu guidelines” in the search box and perform a search.

Scan the resources identified from your search.

Evidence Relevancy to PPAARE

Click on the titles of evidence that seem relevant on the CDC and WHO websites.

From the most relevant evidence, identify the

P = Problem

P = Patient or Population

A = Action

A = Alternative Action

R = Result

E = Highest level of evidence on the evidence pyramid

Use Table 4-11

Record the Google search in columns 2-5

Select the most relevant evidence and complete columns 6-9

Record the CDC search in columns 2-5

Select the most relevant evidence and complete columns 6-9

Record the WHO search in columns 2-5

Select the most relevant evidence and complete columns 6-9

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Strategies for Locating Full-Text Documents

Use your institution’s Interlibrary Loan service

Determine the method for submitting a request

Determine the fee associated with the service

Determine the length of time to receive the article

Determine the method of delivery (e.g. sent to e-mail or retrieval from library)

Use Loansome Doc on the PubMed website

Follow the directions on the resource located at :

http:// nnlm.gov/training/resources/ldtrifold.pdf

In PubMed, locate LinkOut – more resources to get access to the publisher of the journal

Contact the publisher of the journal directly for their pay-per-view service

Self-assess Your Searching Skills

Distribute the checklists in the Instructor’s Manual that students should complete as part of this assessment activity.

Collect the checklists and determine the searching skills needing additional time to learn

Additional Active Learning Strategies or Assignments

Design a scenario that requires students to use one or several online calculators

Create additional scenarios for students to practice writing PPAARE questions and searching for evidence.

Assignment/Reminders

Read chapter 5, Descriptive Statistics