I'm All Shook Up How to Stay Ahead of the Constantly Changing Medical Information Business

Scott M. Strayer, MD, MPHAssociate ProfessorDepartment of Family MedicineUniversity of Virginia Health System

Objectives1. Apply a practical, evidence-based framework for evaluating medical information tools.

2. Understand how clinicians use point of care technology to huntfor evidence-based information that can be applied toclinical decision making on a daily basis. 3. Understand how clinicians use foraging tools to systematically sift through new medical information that is valid and relevant to clinical practice. 4. Evaluate hunting and foraging tools to determine the validity and relevance of their information sources.

Scientific discoveries will require technological solutions that allow physicians to access the latest findings 24 hours a day, 7 days a week, online and on demand, as medical learning becomes a nonstop processNewt Gingrich, AAFP Assembly, Sep 28, 2006

Medical Information is Big Business Now! New EPS Research Forecasts The Scientific, Technical & Medical (STM) Information Market To Reach Nearly $11 Billion Dollars By 2008 Publicly-traded STM publishers grew 8.6% in their reported currencies in 2005; aggregate profit margins held steady at 25% Thomson posted the strongest increase in profits with a year-over-year gain of 20.5%, outperforming its peers and the market average of 17.7% Elsevier achieved the strongest organic growth: 5% and 6% in its Science & Technology and Health Sciences divisions, respectively The five largest players (Reed Elsevier, Thomson, Wolters Kluwer, Springer and Wiley) continued to acquire scale, and now account for over half (52.3%) of total market revenues Revenues from digital content distribution may be nearing a tipping point: 60% of STM

Recent ChangesSkyscapeWiley publishers now owns InfoRetriever and Info Poems, now Essential EvidenceEbsco publishers owns DynamedLarge publishers will continue to acquire evidence based sources

How did you find out about that new smoking cessation drug?

Varenicline, an 4 2 Nicotinic Acetylcholine Receptor Partial Agonist, vs Sustained-Release Bupropion and Placebo for Smoking Cessation A Randomized Controlled Trial David Gonzales, PhD; Stephen I. Rennard, MD; Mitchell Nides, PhD; Cheryl Oncken, MD; Salomon Azoulay, MD; Clare B. Billing, MS; Eric J. Watsky, MD; Jason Gong, MD; Kathryn E. Williams, PhD; Karen R. Reeves, MD; for the Varenicline Phase 3 Study Group JAMA.2006;296:47-55. Context The 4 2 nicotinic acetylcholine receptors (nAChRs) are linked to the reinforcing effects of nicotine and maintaining smoking behavior. Varenicline, a novel 4 2 nAChR partial agonist, may be beneficial for smoking cessation. Objective To assess efficacy and safety of varenicline for smoking cessation compared with sustained-release bupropion (bupropion SR) and placebo. Design, Setting, and Participants Randomized, double-blind, parallel-group, placebo- and active-treatmentcontrolled, phase 3 clinical trial conducted at 19 US centers from June 19, 2003, to April 22, 2005. Participants were 1025 generally healthy smokers ( 10 cigarettes/d) with fewer than 3 months of smoking abstinence in the past year, 18 to 75 years old, recruited via advertising. Intervention Participants were randomly assigned in a 1:1:1 ratio to receive brief counseling and varenicline titrated to 1 mg twice per day (n=352), bupropion SR titrated to 150 mg twice per day (n=329), or placebo (n=344) orally for 12 weeks, with 40 weeks of nondrug follow-up. Main Outcome Measures Primary outcome was the exhaled carbon monoxideconfirmed 4-week rate of continuous abstinence from smoking for weeks 9 through 12. A secondary outcome was the continuous abstinence rate for weeks 9 through 24 and weeks 9 through 52. Results For weeks 9 through 12, the 4-week continuous abstinence rates were 44.0% for varenicline vs 17.7% for placebo (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.70-5.50; P

How Well Do We Distribute New Information?Left to our own devices1987: Of 28 Landmark trials, only 2 had an immediate (1-2 year) effect on clinical practice Fineberg HV. Clinical evaluation: how does it influence medical practice? Bull Cancer 1987;74:333-46.

1992: Thrombolytic therapy for acute MI: 13 years after proof of benefit before review articles suggest it for routine useAntman EM, et al. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA 1992;268:240-8.

How Well Do We Distribute New Information? 1996: Little effect of publication of the ISIS-2 (Aspirin works post-MI) and diltiazem post-infarction trial (diltiazem doesnt work).---ASA and Diltiazem use---no change after trialCol NF, et al. The impact of clinical trials on the use of medications for acute myocardial infarction. Arch Int Med 1996; 156: 54 - 60.

Majumdar 2003:HOPE study in ramipril prescribing by 5% per month without advertising, 12% per month with advertising over the next 2 yearsMajumdar SR, et al. Synergy between publication and promotion: Comparing adoption of new evidence in Canada and the United States. Am J Med 2003;115:467-72.

How Well Do We Distribute New Information?Bottom Line:Change occurs quicklyWhen supported by lots of publicity or pharmaceutical company marketing (like any consumer product)Change is much slowerWhen left up to publications or word of mouth for dissemination of information

Two Tools Needed to Master Information- BMJ 1999A method of being alerted to new information (a foraging tool)A tool for finding the information again when you need it. (a hunting tool)Without both:You dont know that new info. is availableYou cant find it when you doClinical example- Riboflavin for migraines

Shaughnessy AF, Slawson DC. Are we providing doctors with the training and tools for lifelong learning? British Medical Journal 1999 (13 Nov): www.bmj.com. (http://bmj.com/cgi/reprint/319/7220/1280.pdf)

Information Mastery in a NutshellClinically useful information can be defined by:

Usefulness = Relevance x Validity Work

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a Medical Information Master:Feeling Good About Not Knowing Everything. The Journal of Family Practice 1994;38:505-13.

Strayers Corollary: Information Mastery and Computers

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a Medical Information Master:Feeling Good About Not Knowing Everything. The Journal of Family Practice 1994;38:505-13.

Highly Controlled ResearchRandomized Controlled TrialsSystematic ReviewsPhysiologic ResearchPreliminary Clinical ResearchCase reportsObservational studiesUncontrolled Observations&Conjecture

Effect on Patient-Oriented OutcomesSymptomsFunctioningQuality of LifeLifespanEffect on Disease MarkersDiabetesArthritisPeptic UlcerEffect on Risk Factors for DiseaseImprovement in markers (blood pressure, cholesterol)Valid Patient-OrientedEvidence

Validity of EvidenceRelevance of Outcome

Clinicians demand just-in-time resources48 randomly selected generalist physicians in ambulatory careAsked 1062 questions but only answered 585 (55%)Obstacles:Doubt that answer exists (11%)Selected source doesnt have answer (26%)Requested comprehensive sources that answer questions likely to occur in clinical practice with emphasis on treatment and bottom-line adviceHelp locating information quickly with lists, bolded sub-headings, algorithms.avoid lengthy textEly et al J Am Med Inform Assoc. 2005 Mar-Apr;12(2):217-24.

Quality Hunting and Foraging Systems---A New Definition1. How is the information filtered?Patient- vs disease- oriented?Specialty-specific?Comprehensive? Which journals?Does it matter (change my practice?) or is it simply news?

2. Is the information valid?must have levels of evidence labelsBeware Trojan Horse!

Quality Hunting and Foraging Foraging Systems3. How well is information summarized?2000 - 3000 words accurately in 200 words

4. Is the information placed into context?Much more than abstractsTranslational Validity

Hunting ToolsHuntingFirst Consultwww.firstconsult.comEssential EvidenceUp To Date---www.uptodateonline.comDynaMed---www.dynamicmedical.com/Medscape---www.medscape.comDatabase of Abstracts of Reviews of Effectiveness DARE---http://agatha.york.ac.uk/darehp.htmTranslating Research Into Practice (TRIP)--- www.tripdatabase.com

Foraging ToolsSystematically identified tools between May-August 2007Searched Internet for all medical content sites (e.g. Medscape, WebMD, etc.)Searched well-known evidence-based databases (e.g. Cochrane, TRIP, DARE)Monitored List-serves for Health IT and PDA tools (e.g. Palm-Med, Wireless Medical Applications, STFM EBM)Consulted with experts and practicing physiciansSent invitations to list-serves for suggestions

Hunting and Foraging SystemRisksSpyware: May be tracking your usageTrojan Horse: whos paying when its free?Abstracts only: Journal Watch, Journal Rack, Tips from other Journals, Clinical Updates, etc. No relevance/ validity filterYou can have information free and you can have it uncensored, but you cant have it both ways. No Free Lunch!

Not All Information Tools are Created Equal!

Quality of Drug Foraging and Hunting ToolsStrayer, SM, Slawson, DC, Shaugnessy, AM, Disseminating Drug PrescribingInformation: The COX-2 Inhibitor Withdrawals. JAMIA 2006. 13:396-398.

A Few Foraging Tools

Beware of the Trojan Horse

A Few Hunting Tools

Rating Hunting and Foraging Tools

Rating Hunting and Foraging ToolsHunting Tool Evaluation WorksheetForaging Tool Evaluation Worksheet

Hunting and Foraging ToolsForagingInfoPoems---www.infopoems.comPeer View Institute---www.peerview-institute.org/Journal Alerts---www.globalfamilydoctor.com/dailyalerts/main.htmMedscape Best Evidence(http://hiru.mcmaster.ca/MORE/HowRatingsAreUsed.htm)MDLinxBMJ Updates (http://bmjupdates.mcmaster.ca)First Watch (www.jwatch.org)Cochrane PEARLSHuntingFirst Consultwww.firstconsult.comInfoPoemsUp To Date---www.uptodateonline.comDynaMed---www.dynamicmedical.com/Medscape---www.medscape.comDatabase of Abstracts of Reviews of Effectiveness DARE---http://agatha.york.ac.uk/darehp.htmTranslating Research Into Practice (TRIP)--- www.tripdatabase.com

Foraging Tools ResultsOnly seven tools had specific criteria for both relevance and validityAmerican College of Physicians Journal ClubBMJ Clinical EvidenceCochrane for CliniciansDynaMedEssential Evidence (formerly InfoRetriever)FPIN Clinical InquiriesTreatment Guidelines (Medical Letter)

SummarizeEvidence-based clinical decision making requires a coordinated hunting and foraging tool.Use the principles of Information Mastery to evaluate your information tools.Not all information tools are created alike---evaluate using worksheets.

Contact InformationE-mail: sstrayer@virginia.eduInformation Mastery Course: http://www.healthsystem.virginia.edu/internet/familymed/information_mastery/information_mastery_course.cfmCenter for Information Mastery: http://www.healthsystem.virginia.edu/internet/familymed/information_mastery/info_mastery.cfm

Elvis sang about being all shook up about love, however I get all shook up over the constantly changing medical information business. Information Mastery Tools to help you find the needle in the haystackDrug reps, consumers, newsIs it better than Zyban?Point out that this only links to abstractsHow well does the current medical system actually distribute new information? Several studies address this question: In 1987 Feinberg identified 28 studies that evaluated the effect of landmark studies on clinical practice, the type that would likely be mentioned on the evening news. He found that only 2 of the studies were able to demonstrate an immediate effect- one to two years after publication on clinical practice. In 1992, Antman and colleagues performed what was termed a cumulative meta-analysis, a sort of running meta-analysis over time. One of the outcomes they showed was that it took about 13 years from the time we had sufficient evidence of a benefit of thrombolytic therapy in the treatment of patients with acute myocardial infarction before this therapy was routinely recommended in review articles on the topic. In 1996, Col and colleagues looked at the effect of 2 major studies on practice in 16 hospitals in Mass. The ISIS-2 trial showed the benefit of aspirin therapy following an acute myocardial infarction, though the rate of increase of aspirin use did not increase after publication of the trial. The Multicenter Diltiazem Postinfarction trial showed that diltiazem had little effect on outcomes in AMI patients, yet usage did not drop following its publication. In 2003 Majumdar did an interesting comparison of drug use in Canada and the US. The HOPE trial showed that ramipril benefited patients at high risk of cardiovascular events, regardless of whether or not they had hypertension. It was the first ACE inhibitor to be shown to have this effect. In Canada, where the drug was promoted heavily through pharmaceutical advertising, ramipril use increased 12% per month, whereas in the US, where it was not promoted, use only increased 5% per month. See: Fineberg HV. Clinical evaluation: how does it influence medical practice? Bull Cancer 1987;74:333-46.Evans DE, Haynes RB, Gilbert JR, et al. Educational package on hypertension for primary care physicians. Can Med Assoc J 1984;130:719-22Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA 1992;268:240-8.Chalmers TC. The impact of controlled trials on the practice of medicine. Mt Sinai J Med 1974;41:753-9.Col NF, et al. The impact of clinical trials on the use of medications for acute myocardial infarction. Arch Int Med 1996; 156: 54 - 60. Majumdar SR, et al. Synergy between publication and promotion: Comparing adoption of new evidence in Canada and the United States. Am J Med 2003;115:467-72.

The Bottom Line: Change occurs, as with everything else, best through advertising and detailing, not from journals and evidence/information. Add better definitions (e.g. from academic medicine paper). Dont try to practice without clinical judgement. Also, know what is under the hood of the hunting and foraging tools that you are using. This slide shows the inter-relationship between relevance and validity.Were aiming for the green section patient-oriented evidence that is valid. This is an example of tools not being updated frequently enoughwould you trust these sources for other medical information?Need to add an example of tool that didnt summarize information well----e.g. CAMELOTGet examples of all the crappy newsletters I getand some of the good onesGlobal Journal WatchNKTetc.Unfortunately, these werent being sent during the week that VIOXX was withdrawnAfter the deaths of Achilles and another hero, Ajax, the Greeks wanted to give up and go home. But the king of Ithaca, Odysseus, came up with a plan to get the Greek army into Troy. The Greeks built an immense wooden horse and Odysseus, Menelaus, and other warriors hid inside it. After leaving the horse at the gates of Troy, the Greek army sailed away. The Trojans thought the Greeks had given up and had left the horse as a gift.Paris's sister Cassandra, a priestess with psychic powers, knew the horse was trouble. She tried to warn her father, King Priam, but he wouldn't listen. A priest named Laocoon also warned the Trojans to beware of Greeks bearing gifts. He too was ignored. The horse was brought inside the walls of Troy.The Fall of TroyThat night, while the Trojans were sleeping, the Greek ships quietly returned. The soldiers in the horse slipped out and opened the city gates, and the Greek army quietly entered Troy. They started fires all over the city. The Trojans awoke to find their city burning. When they tried to flee, they were massacred by Greek soldiers. King Priam and almost all of the other Trojan chiefs were killed. Only Aeneas - the son of Aphrodite and a Trojan royal named Anchises - escaped. The Aeneid, by the Roman writer Virgil, is about Aeneas's travels after the Trojan war. (Homer's Odyssey is about the Greek hero Odysseus's travels after the war.)Vioxx withdrawn from world markets on September 30, 2004Add DARE and TRIP examplesUpdate screen shotDynaMed (Dynamic Medical Information System) is a quick and easy-to-use medical reference system designed for use at the point of care. DynaMed contains clinically organized summaries of nearly 1,800 topics and is updated daily from review of the research literature. This means that the reference information is always up-to-date and does not require new editions. DynaMed is a useful resource in clinical, educational and research settings. DynaMed has been demonstrated to answer more than 50% of family physician's clinical questions during practice. (J Fam Pract 2001 Nov;50(11):960) DynaMed was created by a physician for physicians and other health care professionals primarily as a clinical reference tool which is easily accessible during patient encounters. It was created to fulfill the physician's needs in organizing information and to replace most routine textbook and article searches. Multiple major journals are now reviewed regularly. Click here to view the DynaMed Bibliography. We will use the UVA Hunting and Foraging worksheets to rate a few of the tools by looking at their websites. Have audience present their results.May want to have a list of 5 hunting and 5 foraging toolsGive Center for Information Mastery website and location of toolsUpdate all these screenshotsOnly 5 also included levels of evidence AND distinguished between POEs and DOEs