National Health Data Network and personal health records

From iHealthBeat: "National Health Data Network To Include Google, Microsoft PHRs"

Federal officials plan to integrate the Nationwide Health Information Network with personal health record databases launched by Google and Microsoft, according to Charles Friedman, COO of the Office of the National Coordinator for Health IT, Government Executive reports. Friedman made the announcement at the Defense Health Care IT Conference at Georgetown University in Washington, D.C., on Wednesday.

Health and older Americans

Report released yesterday by the National Institute on Aging and the National Center for Health Statistics, among others from the Federal Interagency Forum on Aging-Related Statistics -- Older Americans 2008: Key Indicators of Well-Being, including a special section on literacy and health literacy

More:
- the press release
- PowerPoint slides of charts
- US News & World Report article on the report

African American health literacy

Aetna has put out an African American history calendar this year focusing on health literacy. Each day features facts from African American history (on today in 1924, jazz singer Sarah Vaughan was born) and each month features pictures and profiles of individuals involved in promoting health literacy in different venues (including December - in the library, covered more in an item here in the Charleston Post & Courier).

The introduction to the calendar, Marginal literacy: a growing issue in health care, further discusses both literacy and health literacy issues among African Americans

You can download the calendar from the Aetna site or order your own fancy copy from the company for $4.

(Also, to find literacy programs focused on basic reading proficiency in your area, consult America's Literacy Directory)

Search challenge 4

This week's search challenge question:

What is the incidence of vasovagal syncope in blood donors?

Hint: this one might require some older literature and other things beyond PubMed...

Share your thoughts in the comments!

Search challenge 3: strategies

In the comments on last week's search challenge, margaret recommended a simple search strategy that seems to locate a number of the key items for the question about breastfeeding during methadone maintenance:
"Milk, Human"[MAJR] AND "Methadone"[MAJR] AND "Infant, Newborn"[MeSH Terms]

A search like this may also be worth considering:
methadone[mh] AND (breast feeding[mh] OR milk, human[mh] OR lactation[mh])

It retrieves about 40 citations and it's a little bit broader than the search above and brings in some related issues of potential interest to the health care team, such as psychological effects of breastfeeding for the mother and child in this situation and the effect of methadone on the mother's ability to lactate.

Commenter dewey_decimal reminds us to consult LactMed, the drugs and lactation database from NLM, which provides a succinct and well-referenced overview of the use of this drug during lactation and breastfeeding (also see the LactMed factsheet from NLM for a more detailed description of this resource).

Ethical considerations in organ donation

This week's New England Journal of Medicine includes a perspective piece by Dr. Robert Truong, "Consent for Organ Donation — Balancing Conflicting Ethical Obligations," addressing some of the ethical issues we briefly touched on in a previous JMLA case study about medical support of potential organ donors. Truong discusses potential conflicts between the clinical, the organ procurement organization (OPO), and the potential donor's family, and examines the process of informed consent for these patients and problems with how that process plays out in real life.

This NEJM issue also includes a reaction from one OPO, the New England Organ Bank, printed as a letter to the editor.

Search challenge 3

For this week, we'll tackle a pediatric question.

The question: For babies exposed to drugs in utero, particularly opioids, should breastfeeding be encouraged while the mother is on a methadone drug cessation program?

Share your questions and strategies in the comments!

Search challenge 2: strategies

Search challenge 2 looks at identifying articles that discuss prognosis, with traumatic brain injury as one example "disease" for which one might want to find prognosis information.

The Clinical Queries filters in PubMed, developed by Haynes et al, give us two options for finding prognostic studies:

- the sensitive/broad search hedge: (incidence[MeSH:noexp] OR mortality[MeSH Terms] OR follow up studies[MeSH:noexp] OR prognos*[Text Word] OR predict*[Text Word] OR course*[Text Word])

- the specific/narrow hedge: (prognos*[Title/Abstract] OR (first[Title/Abstract] AND episode[Title/Abstract]) OR cohort[Title/Abstract])


For the brain injuries search, I tried a search like this:
brain injuries[majr] AND ("prognosis"[MeSH Terms] OR "Recovery of Function"[mh] OR outcome[tiab] OR outcomes[tiab] OR recovery[tiab] OR reverse[tiab] OR reversible[tiab] OR death[tiab] OR improvement[tiab] OR improve[tiab] OR mortality[sh] OR improved[tiab] OR prognosis[tiab] OR prognostic[tiab])

but it was a little too broad - I think partly because the term "outcomes" is so common in research but doesn't always mean clinically-relevant outcomes, so then I tried to narrow this part by thinking of what outcomes are important in trauma, and refined the search to this:
brain injuries[majr:noexp] AND ("prognosis"[MeSH Terms] OR "Recovery of Function"[mh] OR mortality[tiab] OR prognosis[tiab] OR prognostic[tiab] OR survival[tiab] OR Glasgow outcome scale[tiab] OR functional[tiab]) AND humans[mh] AND eng[la] NOT (case reports[pt] OR letter[pt] OR comment[pt] OR news[pt] OR editorial[pt])

which returned about 1200 hits from the last 5 years, which is still a lot.

When you start browsing through the list, a lot of them do look at outcomes, but there are a myriad of outcomes - For this search, I think a good next step would be to continue with the requester and figure out what exactly they mean by outcomes - more immediate outcomes like in-hospital mortality, or longer term things like mortality at 30 days, functional outcome, lost work, other morbidity (e.g. posttraumatic seizures). Understandign this would be useful in refining the search or at least informing how we look at the retrieval.

Other thoughts for refining this search?

Another online searching practice opportunity

The Pacific Northwest region is currently doing an online seminar called "Awakening the Searcher Within."

This bi-weekly web session includes a different question to work on for each session.

If you're interested in joining in, you can find more information at: http://nnlm.gov/pnr/dragonfly/2008/01/30/awakening-the-searcher-within/

Searching: purpose of question and time frame

Martin posted a great comment on the search strategy for Search Challenge #1, noting:

I think the strategy depends a lot an the situation: if you want to answer a clinical question rapidly, I go for (systematic) reviews first than do a narrow search as an update to the review.
If the task is to do a systematic review, the strategy must be much more detailed and refined.
Maybe you could define the timeframe for the next challenge...

For these first two questions, I have been thinking of them as basic patient care questions, with about a few days to a week turnaround time.

For last week's question, I think Martin's approach is very reasonable and a judicious use of time - selecting the Cochrane systematic review and the trials published since the date that the search in the systematic review was last updated.

As he noted, if this search request was from someone working on a systematic review or other project requiring comprehensive retrieval, the search would need to be much broader and more complex and would also need to include resources beyond PubMed (the Cochrane strategies include great examples of strategy complexity and broader resource selection) .

We'll have one of our future search challenges examine a hypothetical systematic review topic so we can consider what that means for the strategy and for which resources we search.

Search challenge #2

We've had a few suggestions from readers for topics to tackle in the challenge - we appreciate the feedback very much and please continue to share your ideas!

For Search Challenge #2, we've selected one of these reader suggestions - one reader noted that she finds prognosis searches to always be challenging, commenting that the Clinical Queries filters in PubMed provide some help but that she'd like to get a better sense of how colleagues approach these searches.

So this week's question has a broad issue:
- Do you have a "hedge"/strategy that you reuse for identifying studies that include data on prognosis?

And a more-focused part to try this search with an actual topic:
- How does the literature describe prognosis (e.g. mortality, functional outcome, etc.) in adult patients with moderate to severe traumatic brain injury?

Please share your ideas in the comments!

(P.S. to keep things more simple on our end, we'll post the "answers" to the search challenge and the new challenge on Mondays, instead of the Monday-Friday schedule we'd originally noted)

Search challenge 1: strategies

In the comments on Search Challenge #1, readers proposed several great search strategies and included a few example articles too. In addition to reader-developed strategies, one commenter also included the strategy used in a Cochrane review titled "Support surfaces for pressure ulcer prevention," which fairly comprehensively addresses multiple synonyms for each of the concepts in the question (e.g. multiple words for beds and mattresses, including product trade names).

The Cochrane strategy published in the systematic review is focused on searching the Cochrane Controlled Trials Register via Ovid, which allows proximity operators (e.g. "next") to aid keyword searching, an option not available in PubMed, so creating a workable strategy for PubMed is probably a good supplement to using such an approach.

The systematic review also references the broader search strategies in multiple databases used by the Cochrane Wounds Group, which include strategies Ovid-focused strategies for Medline, CINAHL, the British Nursing Index, and EMBASE. This strategy also notes other databases and resources that may be useful in identifying relevant literature for wound care and prevention topics.

In addition to these strategies, I found a fairly simple PubMed search to be useful in identifying quite a few of the clinical trials and other primary studies of bedding- and bed- related strategies for reducing the incidence of pressure ulcers:

(beds[majr] OR bedding and linens[majr]) AND (pressure ulcer[majr] OR pneumonia[mh] OR complications[sh] OR complications[tiab] OR adverse events[tiab]) AND humans[mh] NOT (case reports[pt] OR letter[pt])

I'd originally just included the MeSH term "beds", then added the "bedding and linens" term when I realized that my initial strategy was excluding some of the big RCTs of mattress supplemental products that were included in the Cochrane review (I'm probably not alone in using the references of articles I retrieve as a "quality check" on my search strategy). In reading some of the abstract and articles, it seemed as if pneumonia was the other main complication that bed-focused techniques were used to prevent, so I tried broadening the search strategy to include pneumonia plus other (as yet unknown to me) potential complications, which added about 100 additional citations to the retrieval:

(beds[majr] OR bedding and linens[majr]) AND (pressure ulcer[majr] OR pneumonia[mh] OR complications[sh] OR complications[tiab] OR adverse events[tiab]) AND humans[mh] NOT (case reports[pt] OR letter[pt])

Then limiting to English language articles further reduced the set to about 600 citations, which is still a fairly large retrieval.

Some of the "false drops" and less relevant/useful items I noticed in the retrieval for this strategy:
- netting over the bed to prevent malaria
- elevating the head of a standard hospital bed to prevent pneumonia
- one to two page educational briefs in nursing- and rehabilitation- focused journals
- pillow selection
- equipment used during an intraoperative period or during prehospital transport
- cooling blankets
- simulation studies

A few questions for our hypothetical requestor that might help us refine the search strategy:
- are they interested only in mattresses and beds, or would other devices (e.g. mattress overlays) be of interest too?
- are they interested in the long-term care literature (e.g. nursing homes, chronic care) in addition to the acute-stay inpatient literature?

This search also made me think about an issue that I've heard often in colleague discussions - how many references are you comfortable browsing through to develop a bibliography for a search? I don't have any problem paging through a few hundred results for a topic like this, when so many of the citations retrieved by the search seem relevant, but I know I've heard colleagues say that they would try to develop a much more narrow strategy as an initial approach, then broaden if it seems necessary. Your thoughts on this and the strategies above and in the comments?

We'll be posting Search Challenge #2 later today...

New feature: weekly search challenge

We've had feedback from readers of the case study column that are interested in getting more "in-depth" into the process of designing a search strategy for patron questions - what terms are useful for a topic, what terms aren't, what databases and other resources are necessary to make sure you've identified as much as possible, etc.

To this end, we're going to start posting a "search challenge" question each Monday. We encourage you to post your ideas and questions in the comments or to us by email (using our profile links above). You can also feel free to "reference interview" us by posting questions for clarification or more detail as needed.

Then, each Friday we'll post a search strategy and other thoughts on that question. We hope this will add to the usefulness of the cases by giving another outlet for developing searching skills and discussing strategies with colleagues.


So, this week's question is:

Does the use of a pressure-reducing bed or mattress lead to a reduction in the incidence of pressure sores or other complications in an adult hospital in-patient population?