Efficient strategies to find diagnostic test accuracy studies in kidney journals

Aim Nephrologists looking for quick answers to diagnostic clinical questions in MEDLINE can use a range of published search strategies or Clinical Query limits to improve the precision of their searches. We aimed to evaluate existing search strategies for finding diagnostic test accuracy studies in nephrology journals. Methods We assessed the accuracy of 14 search strategies for retrieving diagnostic test accuracy studies from three nephrology journals indexed in MEDLINE. Two investigators hand searched the same journals to create a reference set of diagnostic test accuracy studies to compare search strategy results against. Results We identified 103 diagnostic test accuracy studies, accounting for 2.1% of all studies published. The most specific search strategy was the Narrow Clinical Queries limit (sensitivity: 0.20, 95% CI 0.13–0.29; specificity: 0.99, 95% CI 0.99–0.99). Using the Narrow Clinical Queries limit, a searcher would need to screen three (95% CI 2–6) articles to find one diagnostic study. The most sensitive search strategy was van der Weijden 1999 Extended (sensitivity: 0.95; 95% CI 0.89–0.98; specificity 0.55, 95% CI 0.53–0.56) but required a searcher to screen 24 (95% CI 23–26) articles to find one diagnostic study. Bachmann 2002 was the best balanced search strategy, which was sensitive (0.88, 95% CI 0.81–0.94), but also specific (0.74, 95% CI 0.73–0.75), with a number needed to screen of 15 (95% CI 14–17). Conclusion Diagnostic studies are infrequently published in nephrology journals. The addition of a strategy for diagnostic studies to a subject search strategy in MEDLINE may reduce the records needed to screen while preserving adequate search sensitivity for routine clinical use

Evidence based testing and outcomes in transplantation

The use of diagnostic tests is central to the practice of modern medicine, but knowing which test to use, and when, can be problematic. To make evidence-based diagnoses, clinicians need efficient ways of accessing diagnostic studies, interpreting the results of several studies, and checking the applicability of studies to their own setting. The aim of this thesis was to explore solutions to these problems by addressing a specific clinical question; What is the best screening test for latent tuberculosis in patients undergoing transplantation? In a study of diagnostic filter performance in MEDLINE, we found that current ‘specific’ clinical queries limit for diagnosis (used in PubMed and Ovid SP) missed up to 80% of studies in nephrology journals. Other filters (Deville 2000 Broad, Deville 2000 Balanced, Haynes 2004 Balanced, and Vincent 2003 Narrow) had similar specificity to the ‘specific’ clinical queries limit, but identified a greater proportion of the total evidence. Using systematic review methodology, we found that current available data was inadequate to determine whether interferon gamma release assays performed better, worse or the same as the tuberculin skin test for diagnosing tuberculosis in candidates for solid organ transplant. Current international guidelines recommend using either the tuberculin skin test or an interferon gamma release assay, or both in combination. Our findings support these guidelines. We conducted a cross-sectional descriptive of candidates for kidney transplantation and found that despite a high prevalence of risk factors among the group, less than a quarter of candidates were screened for latent tuberculosis before transplant, and only 36% of the 101 patients with risk factors for tuberculosis were tested. This study demonstrates that candidates for kidney transplant are at increased risk of tuberculosis and highlights the need for a nation-wide tuberculosis screening protocol in work-up for transplant

A Study to Understand and Compare Evidence Based Practice Among Health Professionals Involved in Pain Management

Pain management is a common concern of multiple health professionals. Evidence-based practice (EBP) in pain management is a recognized approach used to improve health outcomes. EBP tools can facilitate its implementation. PAIN+ is a tool that provides access to pre-appraised current best research evidence on pain to support clinical decisions. It is important to understand the knowledge, attitudes and behavior of professionals towards EBP and more specifically how they access research about pain management. The overarching purpose of this thesis is to better understand how clinicians from different professions involved in pain management view EBP and implement specific strategies to find pain related research evidence. We conducted a series of studies incorporating various methods to address these questions. Data was collected supplementary to a large randomized control trial to compare “Push” vs. “Pull” strategies for uptake of pain research. In the first study, we compared the knowledge, attitudes, outcomes expectations and behaviors of physicians, nurses, physiotherapists, occupational therapists and psychologists towards EBP in pain management using a validated knowledge attitude and behavior (KABQ) questionnaire. In the second study, we used a mixed methods approach to understand the competencies of clinicians accessing electronic databases to search for evidence on pain management. In the third study, we performed a structured classification of the abstracts that were viewed by clinicians to understand their access behaviors. In the last part of the thesis, we compared the usefulness of PAIN+ with PubMed using a randomized crossover trial approach. The results of this thesis indicate that the professionals involved in pain management have good knowledge of and attitudes towards EBP, but behavior i.e. implementation of EBP in practice and perception of outcomes of implementing EBP were low. In the second study, we found that professionals had acceptable levels of basic literature searching skills but had low levels of use of more advanced skills, and were not aware of using clinical queries in their search. In the third study, we found that all professionals accessed research evidence when provided alerts about pain research and some variations in the types of studies accessed were observed. Differences in access behaviors might reflect differences in professional approach to pain management. In our fourth study the crossover randomized controlled trial; we found PAIN+ and PubMed were both rated useful in retrieving pain evidence for clinicians. Professionals showed an interest in evidence-based pain management, but their skills for finding evidence were limited, they appeared to need training in locating and appraising pain related research evidence, and may benefit from tools that reduce this burden