13 August 2007

Necessary as shoes

I do a lot of PubMed searches for patrons, at least one or two a day on average. It is my bread and butter, after all, and I have a demanding clientele. I assume that many fellow librarians out there are doing the same. So I must say I am surprised at how little discussion there is about search strategies in the health library blogosphere. Did I miss the killer PubMed webinar that settled all questions once and for all? Am I the only librarian who harbours lingering doubts about the quality of my searches on complex subjects? Why this peculiar silence? Are we concerned about the critical eye of our peers and therefore prefer to shower in our underwear, so to speak? Do we fret that we don't fully understand the probabilistic content similarity algorithm underlying PubMed's related article search; that we haven't read every last word of the help pages and memorized all the search tags; that we can't easily explain the difference between sensitivity and specificity (quick, in 25 words or less); that we're not always sending a RefShare link with our results; or that our search string is not as big as our rival's?

Or more likely perhaps, are we simply unspeakably bored with PubMed? The pervasiveness, the profuseness of it. It has all the glamour and prolixity of a C++ manual. How can you be mindful of its programming marvels when you are yawning your way through your 69th search on catheter insertion points? Are you really that excited about filter preferences in My NCBI? If you are at lunch with a colleague and raise the issue of fuzzy sets on Boolean lattices, does she suddenly drop her pita and say, "Excuse me, my leg has gone to sleep. Do you mind if I join it?"

Granted: PubMed is as necessary as shoes, and usually worn as hard, redolent with the odour of Heideggerian Zuhandenheit. Like the philosopher's Birkenstock, it is ready-to-hand, a taken-for-granted household item. What was a near miracle just a few years ago now suffers a coolness deficit, especially when most of us would rather go on and on and on about Facebook or Web 3.1415926, or any other of today's objects of hypostatized belief. And yet we're expected to include PubMed in our professional reading. Who among us has dutifully waded through Brian Katcher's edifying if not electrifying MEDLINE : a guide to effective searching in PubMed and other interfaces? Whose heart has thrilled to read the latest NLM Technical Bulletin on terms used in toxicology? Worse still are most scholarly studies on PubMed searching veritable Exocets of ennui. Not poppy, nor mandragora, nor all the drowsy syrups of the world can compete with a long and meticulously footnoted paper on improving the efficacy of PubMed clinical queries. If her bedtime reading had been restricted to papers on the optimal retrieval of randomized controlled trials, the hypersensitive princess of Andersen's tale would never have lost a moment's sleep to that notorious little pea.

The Task

At the risk of causing excess NCBI (narcoleptic coma benevolently induced) in my readers, I wanted to devote this post to a discussion of one PubMed search strategy. I was recently given the task of setting up a PubMed automated update on a number of topics related to health care quality and the patient experience of health care (English articles only). Hospital managers in my neck of the woods are finally discovering the power of periodic email updates on topics that interest them. Would that I could convince them to subscribe to RSS feeds. But, frankly, it would be easier to explain the theory of relativity or go back to photocopying tables of contents. All I have to say about RSS is that, as far as my patrons are concerned, I started out with nothing and I still have most of it left. They thrive in an email ecosystem, and one must adapt or risk utter exclusion. Yet I live in hope.

The patron who consulted me had a broad interest in a number of topics:
  • patient satisfaction
  • patient, family, consumer involvement
  • patient safety
  • health care quality
Having worked with PubMed all these years, I realize that no search so broadly cast would be perfect. For one thing, the database itself is imperfect, being a product of human beings and subject to human error. The MeSH headings for quality are a bit slippery; there is no easy way to specify only those articles that would be of interest to this particular kind of manager; some text string searching would be necessary; in short, it would be a bit of a cat's breakfast. Upon consultation, my patron expressed a philosophical acceptance of the likelihood of inexactitude and database noise, and she is a cat lover. So I went to work.

In addition to a PubMed search on the broad topics, it seemed expedient to add a TOC aspect by including a search for the contents of the best journals in the field of health care quality. I thus ended up with three PubMed searches, which would be combined for one weekly update:
  1. Tables of contents of nine major health quality journals.
  2. Results of a comprehensive search on the broad topics of interest: patient satisfaction, consumer and patient involvement in care, patient safety, quality in general.
  3. To make up for some deficiencies in PubMed's indexing of articles in the areas of interest, I included a roundup of quality-related citations from the ten most important medical and health management journals citations that might not be caught by search strategy no. 2.

1. Major journals on quality

Journals of note were suggested to me by a colleague, by lists I found on the web, and a search of the NLM catalogue for currently published titles. After more consultation these were the nine titles preferred by my patron:

  • Am J Med Qual
  • Healthcare Benchmarks Qual Improv
  • Int J Health Care Qual Assur Inc Leadersh Health Serv
  • Int J Qual Health Care
  • Jt Comm J Qual Patient Saf
  • J Healthc Qual
  • J Nurs Care Qual
  • Qual Manag Health Care
  • Qual Saf Health Care

2. MeSH and text string search

Medical Errors[MAJR] OR Consumer Participation[MAJR] OR Patient Satisfaction[MAJR] OR "patient safety"[TW] OR "public involvement"[TW] OR "consumer involvement"[TW] OR "consumer directed"[TW]

3. Other journal title searches + MeSH search

A search of the following ten journals was performed and ANDed with the following MeSH term: Quality of Health Care[MAJR]. Some articles of importance in these journals might not be caught by strategies 1 and 2. The heading Quality of Health Care by itself is too broad to be of use for this patron. But combined with the following journals, it will gather a few useful articles that would otherwise be missed.

"Big Five" Medical Journals
  • BMJ
  • JAMA
  • Lancet
  • NEJM
  • CMAJ (for Canadian articles)


Health Care Management Journals
Five source journals related to health care management were selected for analysis, based on the findings of a recent article in JMLA:

Health services policy research journals:

  • Health Affairs (Millwood)
  • Health Services Research
  • Medical Care Research and Review

Practitioner-related research journals:

  • Health Care Management Review
  • Journal of Healthcare Management

Source: Taylor MK, Gebremichael MD, Wagner CE. Mapping the literature of health care management. J Med Libr Assoc. 2007 April; 95(2): e58-e65.

Final Search Methodology

#1 "Qual Manag Health Care"[Journal:__jrid2514] OR "Qual Saf Health Care"[Journal:__jrid27051] OR "Am J Med Qual"[Journal:__jrid2239] OR "Healthcare Benchmarks Qual Improv"[Journal:__jrid29857] OR "Int J Health Care Qual Assur Inc Leadersh Health Serv"[Journal:__jrid21292] OR "Jt Comm J Qual Patient Saf"[Journal:__jrid32349] OR "Int J Qual Health Care"[Journal:__jrid20209] OR "J Healthc Qual"[Journal:__jrid1993] OR "J Nurs Care Qual"[Journal:__jrid1231]

#2 Medical Errors[MAJR] OR Consumer Participation[MAJR] OR Patient Satisfaction[MAJR] OR "patient safety"[TW] OR "public involvement"[TW] OR "consumer involvement"[TW] OR "consumer directed"[TW]

#3 ("Health Aff (Millwood)"[Journal:__jrid4064] OR "Health Serv Res"[Journal:__jrid3988] OR "Med Care Res Rev"[Journal:__jrid20809] OR "Health Care Manage Rev"[Journal:__jrid3962] OR "J Healthc Manag"[Journal:__jrid21284] OR "BMJ"[Journal:__jrid2274] OR "CMAJ"[Journal:__jrid20656] OR "JAMA"[Journal:__jrid5346] OR "Lancet"[Journal:__jrid5470] OR "N Engl J Med"[Journal:__jrid5985]) AND Quality of Health Care[MAJR])

#4 #1 OR #2 OR #3

#5 #1 OR #2 OR #3 Limits: English

I set up a weekly updated My NCBI email alert for the patron and hovered a bit until I knew she had verified her email address. A week later the results started rolling in and the document delivery requests started too. Another happy customer.

Web Links

The Ontario Health Quality Council has a handy list of web links. I looked around a bit more, tweaked the list a bit, and sent it to my patron. I also informed her about del.icio.us and how it might be useful in her work. There will be more on that score later, but this is a decent beginning.


Canada Health Infoway
Canadian Council on Health Services Accreditation (CCHSA)
Canadian Institute for Health Information
Canadian Patient Safety Institute
Evaluation Society of Canada
Health Council of Canada
Institute for Safe Medication Practices
Quality Healthcare Network
Safer Healthcare Now!
Statistics Canada


Cancer Quality Council of Ontario
Change Foundation
Guideline Advisory Committee
Hospital Report Research Collaborative
Institute for Clinical Evaluative Studies
Ontario Hospital Association Patient Safety Support Service

Other Canadian provinces

Health Quality Council of Alberta
Health Quality Council (Saskatchewan)
Western Health Improvement Network

Manitoba Institute for Patient Safety


The International Society for Quality in Health Care
Agency for Healthcare Policy and Research
Agency for Healthcare Research and Quality
Balanced Scorecard Collaborative
Joint Commission on Accreditation of Healthcare Organizations
Institute for Healthcare Improvement
NHS National Patient Safety Agency
National Quality Forum (US)
National Patient Safety Foundation