Heart failure is a life threatening disease condition that increased sufferings for patients and increase the care burden for caregivers and health care system (McIlvennan & Allen, 2016). The main issue for heart failure patients with advanced heart failure is that such patients live in frequent cycle of transitions between care settings and they suffer from high level of distress because of unmet needs and poor management of the condition. Recurrent hospitalization worsens functional status and quality of life of such patients (Lowey, 2017). In response to this issue, palliative care is found relevant to address the issue as it can improve the quality of life and provide a good death to patients. However, as palliative care utilization among advanced heart failure is limited, there is a need to find robust evidence that proves the effectiveness of palliative care in management of symptoms. Therefore, this article will develop a PICO question regarding the effectiveness of palliative care for patients with heart failure, subsequent database selection, and search strategy.
The main purpose of this paper is to find out the best evidence regarding the efficacy of palliative care for treatment of heart failure, the development of the PICO (population, intervention, control, and outcomes) question will guide the search process. According to Aslam and Emmanuel, (2010), a well-formulated research question guides the implementation of a research project and the PICO format to help in framing the research question. The four elements of the PICO supports researcher in the identification of appropriate information related to the research problem. The PICO framework has been used to create the research question for this paper too. The PICO for the research problem is as follows:
P (Population): Patients in hospital
I (Intervention): Palliative care
C (Comparator): Community-based patients
Outcome (Outcome): Symptom management for heart failure
The PICO question for retrieving relevant research articles is as follows:
Does participation in the palliative care program help in symptom management of heart failure in patients at the hospital compared to those receiving treatment in a community-based setting?
During a search process it is important to identify the most relevant database that can give answers to the research question. As the problem of symptom management in patients with heart failure is a problem related to the health care field, it is vital to select those database that published research from the field of health care. Some of the important and reliable databases publishing research from the field of health care includes CINAHL, Medline, and PyschINFO. Out of these three, CINAHL database has been selected for searching relevant articles as it publishes in a wide range of literature from the field of nursing, biomedicine, alternative medicine and allied health disciplines. Hence, searching CINAHL will increase the likelihood of getting research papers on the research question. Another reason for selecting CINAHL as a database is that it has an easy-to-use interface with both basic and advanced search features. In addition, it also uses Boolean operators to enhance the exclusiveness of the search process (Wright, Golder & Lewis-Light, 2015). Therefore, it can provide flexibility during the search process.
The search for relevant literature in CINAHL database was started with the use of key terms. The key terms used for the search process included ‘patient with heart failure’ and ‘heart failure at end of life’.
The use of the term ‘patient with heart failure’ without the use of any search limits and thesaurus yielded the following papers:
Figure 1: Output in CINAHL database after use of basic key term
After this another search phrase was used which could help to extract papers that covered both patient with heart failure and palliative care details. For this, the search term that was entered included ‘heart failure at end of life’. The following result was obtained:
Figure 2: Results obtained after entering ‘heart failure at end of life’
At this point of the search, it was found that some relevant articles related to palliative care for heart failure could be retrieved. However, the paper titled ‘caregiver’s perception of end of life service utilization….’ and ‘A survey of clinician attitude …’ cannot be used for this paper because they were not evaluations of the impact of palliative care on the symptom management process. In order to retrieve such articles, more specific search terms were needed.
The next strategy that was considered was to slightly modify the search strategy and use of thesauri or subject heading to get more relevant data (De Brun & Pearce-Smith, 2013). During the first stage, no limits or intervals were applied. However, at this stage, limits were applied for publication data and it was set to 2010 to 2018. The search phrase that was used after applying search limits included ‘palliative care’ and ‘symptom management of heart failure patients’. The results obtained after this strategy was as follows:
Figure 3: Articles retrieved after applying search limits and search phrase.
Application of search limits helped to retrieve papers published within the past 8 years, however, there were no relevant papers that particularly examined effectiveness of palliative care on clinical outcomes of palliative care patients. As no suitable articles related to the search process were retrieved, the advanced search button was clicked in order to use the option of Medical Subject Headings (MeSH). The main advantage of using MeSH is that it allows searching for papers at various level of details (Kehoe et al., 2017). After using the search term ‘patient with heart failure’ and selecting the ‘Suggest subject term’ option, the following list of subject headings were seen:
Figure 4: Search process using MeSH headings in CINAHL
The subject heading was selected to get a combination of search terms and find the results obtained from them. Similarly, ‘heart failure at end of life’ was selected to get the following output:
Figure 5: Search results after using MeSH option
The above literature suggests that no results were obtained even after using subject headings, so, the search strategy was modified. Then, Boolean operators were applied with the use of ‘AND’ and ‘OR’ (De Brun & Pearce-Smith, 2013). The search terms ‘patient with advanced heart failure’ and ‘palliative care’ were applied to search for relevant search papers. Through the use of this approach, finally success was achieved. There were at least three papers that were found relevant to the research question. After this, the full text of each paper was reviewed to find out whether they answered the research question or not. The list of these papers is given below in the figure:
Figure 6: List of papers obtained after combining search terms with Boolean operators
Figure 7: Continued list of papers form data base search
While carrying out searches for literature examining the efficacy of palliative care on patients with heart failure, three types of search strategies were applied. The first strategy was to use basic search features to find out whether relevant articles were obtained or not. If large number of paper were obtained at this stage, then the next approach would have taken would be refine the search results using limiters. However, Figure 1 and Figure 2 have demonstrated that articles related to palliative care and heart failure was obtained, but it was related to perception about care. It did not gave an overview about the outcome of the palliative care program on treatment outcomes. Hence, this strategy was discarded and the advanced search options were used to proceed with the search process.
During the second stage, the strategy was to use subject headings to obtain the combination of search terms, it was found that no significant papers were retrieved. Richter and Austin (2012) explains that the unique feature of the MeSH option is that it is a controlled vocabulary thesaurus of indexing terms that promotes efficiency during the search process. Hence, the MeSH term can result in more-efficient and more-informed searches. However, contrary to this evidence, similar outcomes were not achieved. No relevant search papers could be found using the MeSH option (Refer Figure 5). This might have occurred because of lack of understanding regarding the appropriate headings that needed to be selected in accordance with the PICO question. Hence, the final strategy was to use the Boolean operator ‘AND’ to widen the search process. The Boolean operator ‘AND’ was used to get a large number of articles that had information about both palliative care aspects and outcomes in patients with heart failure.
There were three papers which were found relevant to the research question. The first paper was the study by Taylor et al. (2017) which evaluated the impact of palliative care for health failure patient. Another significant research paper was the study by Kane et al. (2018) which investigated how a palliative specific intervention can work to promote patient-centred care in advanced heart failure patient. Lewin et al. (2017) also gave an insight into benefits of palliative care for advanced heart failure patients. Out of this, Taylor et al. (2017) is identified as the best research paper because it shows that patients receiving palliative care in community-based programs are effective in reducing heart failure admission rates and they got an opportunity to have a ‘good death’. Hence, this research paper answers the PICO question by showing the advantage of heart failure patients receiving care in a community setting. However, the only limitation is that it was not a randomized controlled study (RCT). Use of RCT would have enhanced the credibility of the work.
Conclusion:
This paper gave an insight into the strategy used for searching papers in the CINAHL database. The main purpose was to find relevant research papers that could show the efficacy of palliative care for heart failure patients living in hospitals compared to community settings. Several strategies were used to implement the search. However, use of the MeSH option did not retrieved any positive results. Hence, further study and investigation is needed to improve the understanding of the best subject headings which can be applied for specific research problem.
References:
Aslam, S., & Emmanuel, P. (2010). Formulating a researchable question: A critical step for facilitating good clinical research. Indian Journal of Sexually Transmitted Diseases and AIDS, 31(1), 47–50. https://doi.org/10.4103/2589-0557.69003
De Brun, C., & Pearce-Smith, N. (2013). Searching Skills Toolkit: Finding the Evidence (2nd ed.). John Wiley & Sons.
Kane, P. M., Ellis-Smith, C. I., Daveson, B. A., Ryan, K., Mahon, N. G., McAdam, B., … & Raleigh, C. (2018). Understanding how a palliative-specific patient-reported outcome intervention works to facilitate patient-centred care in advanced heart failure: A qualitative study. Palliative medicine, 32(1), 143-155. https://doi.org/10.1177/0269216317738161
Kehoe, A. K., Torvik, V. I., Ross, M. B., & Smalheiser, N. R. (2017, February). Predicting MeSH Beyond MEDLINE. In Proceedings of the 1st Workshop on Scholarly Web Mining(pp. 49-56). ACM. doi: 10.1145/3057148.3057155
Lewin, W. H., Cheung, W., Horvath, A. N., Haberman, S., Patel, A., & Sullivan, D. (2017). Supportive cardiology: moving palliative care upstream for patients living with advanced heart failure. Journal of palliative medicine, 20(10), 1112-1119. https://doi.org/10.1089/jpm.2016.0317
Lowey, S. E. (2017). Palliative Care in the Management of Patients with Advanced Heart Failure. doi: 10.1007/5584_2017_115.
McIlvennan, C. K., & Allen, L. A. (2016). Palliative care in patients with heart failure. bmj, 353, i1010. https://doi.org/10.1136/bmj.i1010
Richter, R. R., & Austin, T. M. (2012). Using MeSH (medical subject headings) to enhance PubMed search strategies for evidence-based practice in physical therapy. Physical therapy, 92(1), 124-132. https://doi.org/10.2522/ptj.20100178
Taylor, G. J., Lee, D. M., Baicu, C. F., & Zile, M. R. (2017). Palliative Care for Advanced Heart Failure in a Department of Veterans Affairs Regional Hospice Program: Patient Selection, a Treatment Protocol, and Clinical Course. Journal of palliative medicine, 20(10), 1068-1073. https://doi.org/10.1089/jpm.2017.0035
Wright, K., Golder, S., & Lewis-Light, K. (2015). What value is the CINAHL database when searching for systematic reviews of qualitative studies?. Systematic reviews, 4(1), 104. https://doi.org/10.1186/s13643-015-0069-4
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