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| ACQUIRE the evidence |
3. Select the appropriate resource(s) and conduct a search |
In the previous section, we learned how to construct a well-built clinical question. Using that question, we will move on to the literature search.
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For our patient, the clinical question is: In patients with type 2 diabetes and obesity, is bariatric surgery more effective than standard medical therapy at increasing the probability of remission of diabetes? It is a therapy question and the best evidence would be a randomized controlled trial (RCT). If we found numerous RCTs, then we might want to look for a systematic review.
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Constructing a well-built clinical question can lead directly to a well-built search strategy. Note that you may not use all the information in PICO or well-built clinical question in your MEDLINE strategy. In the following example we did not use the term “male.” We also did not include the word therapy. Instead we used the Clinical Query for Therapy or the publication type, randomized controlled trial, to get at the concept of treatment. However, you may consider the issue of gender later when you review the articles for applicability to your patient.
PICO |
Clinical Question |
Search Strategy |
| Patient / Problem | obese, diabetes type 2, male |
diabetes type 2, obesity |
| Intervention | stomach stapling (gastric bypass surgery; bariatric surgery) | bariatric surgery |
| Comparison (if any) | standard medical care | |
| Outcome | remission of diabetes; weight loss; mortality | |
| Type of Question | therapy | (see below) |
| Type of Study | RCT | Clinical Query – Therapy/narrow or Limit to randomized controlled trial as publication type |
Evidence-Based Practice requires that clinicians search the literature to find answers to their clinical questions. There are literally millions of published reports, journal articles, correspondence and studies available to clinicians. Choosing the best resource to search is an important decision. Large databases such as PubMed/MEDLINE will give you access to the primary literature. Secondary resources will provide you with an assessment of the original study. Systematic reviews which help summarize the results from a number of studies. These are often called “pre-appraised” or EBP resources.
A search of diabetes and bariatric surgery identified this citation: Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577-85. This trial found that for severely obese patients with type 2 diabetes, bariatric surgery resulted in reduced levels of HbA1c, glucose and BMI than did medical therapy.
Enter the term for the patient problem and the intervention: obesity AND diabetes type 2 AND bariatric surgery. PubMed attempts to map your terms to appropriate Medical Subject Headings (MeSH). MeSH is the standard terminology used by the indexer and helps find articles on specific topics, regardless of the exact wording used by the authors.
Step 2. Look at Search Details to verify MeSH terms
Look in the Search Details box (lower right column; click on "See more" to expand) to see the terms that PubMed actually used in its search. You want to be sure PubMed found the appropriate MeSH terms. PubMed will automatically also search for your terms as words in the title and abstract. Obesity is a MeSH term, diabetes type 2 is translated to the MeSH term of diabetes mellitus, type 2, and bariatric surgery is a MeSH term. If your search did not find the appropriate MeSH terms, you would need to look up the topic in the MeSH database.
Step 3. Limit to appropriate study design
This is a therapy question. We know from the previous discussion that the best evidence for a therapy question is a randomized controlled clinical trial (RCT). Use the Filters column from the main results page to limit to Randomized Controlled Trial as an article type. You may need to click on "more" to see additional filters if RCT is not listed.
You can also use the Clinical Queries function to limit the results to study methodologies relevant to therapy questions. Copy your last search strategy obesity AND diabetes type 2 AND bariatric surgery. Click on Advanced under the search box; then click on More Resources near the top of the page; then select Clinical Queries. Paste the search strategy in the Clinical Query search box and hit Search. The first column of results is Clinical Study Categories. Select the type of question (Therapy) and the type of search (Narrow). You may get more search results using the Clinical Queries function.
Step 4. Review the results
Both methods limit your results to RCTs. The fourth citation is the Mingrone article that we found in ACP Journal Club.
The next step is to read the study and determine if the methodology is sound so that we can consider the results.
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