information mastery. objectives at the end of this seminar, participants should be able to:...
DESCRIPTION
Disclosures No financial disclosures Much of the material and ideas were developed by David Slawson, MD, and Alan Shaughnessy, PharmD, MMedEdTRANSCRIPT
Information Mastery
ObjectivesAt the end of this seminar, participants should be
able to: Incorporate information mastery principles into daily
learning and patient care activitiesFormulate focused foreground questions in PICO formatDistinguish between disease-oriented and patient-
oriented evidence Identify high quality evidence based on study designUse evidence-based medical databases to research
clinical queries and to stay up to date with medical literature
DisclosuresNo financial disclosuresMuch of the material and ideas were developed
by David Slawson, MD, and Alan Shaughnessy, PharmD, MMedEd
What is EBM?“Evidence-based medicine is the conscientious,
explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”David Sackett, 1996
Why read literature?Answer clinical questionsKeep up to dateFollow your interestsBe the best advocate possible for patients
Limitations of EBMLimited evidencePoor quality evidenceIndividual patient differences
What determines medical decisions?
Decision
Medical Evidence
Prior clinical
experienceIndividual
patient characterist
ics
Classic EBM5 step approach
AskSearchCritically appraise ImplementEvaluate
EBMInformation MasteryTraditional EBM = basic science, primary article
appraisalInformation Mastery = applied science
1994, Slawson and ShaughnessyGather valid, relevant, patient-oriented
information that is critically appraised and apply it to practice.
Use tools that appraise evidence for youAllows you to stay up do date without drowning in
the vast sea of primary journal articles.
UsefulnessUsefulness = (relevance * validity)/workRelevance: Does it matter to my patient?Validity: How well does the study reflect the
truth? Less work is better
Maximize reading high quality information without sifting through poor quality information
Clinical QuestionsType of question determines sources to useBackground (basic science)Foreground (specific clinical question)
PICOPatient population/problemInterventionComparisonOutcome
ACTIVITY 1Write a PICO for each case: Patient population/problem,
Intervention, Comparison, OutcomeCase 1: “A 65 year old man with T2DM checks his blood
sugar daily and does his best to control his blood sugar with exercise and nutrition. He wonders if having well-controlled blood sugars overtime will increase his lifespan.”
Case 2: “A 40 year old woman presents with migraine headaches that are becoming more She is reluctant to use medications other than herbal supplements and tells you that she just read an article about the possible benefits of riboflavin for preventing migraines.
DOE vs POEDisease-oriented evidence/outcomes
Focused around diseases/labs.Patient-oriented outcomes
Focused on outcomes patients care about: Quality of lifeMorbidityMortality
Disease-Oriented Outcome
Patient-Oriented Outcome
Intensive glucose lowering can decrease A1c
Intensive glucose lowering does not decrease mortality
Beta-carotene, Vit E are good antioxidants
Neither prevents cancer or CV disease
Varenicline is effective for helping patients quit smoking
Varenicline increases the risk of adverse CV events
POEMPatient Oriented Evidence that MattersIs information relevant & does it matter? 3
criteria:Do patients care about the outcomes/is it patient-
oriented (quality of life, morbidity, mortality)? Is the intervention feasible? If true, will it require you to change your practice?
Yes to all 3 = POEM
ACTIVITY 2Read 2 evidence summariesDiscuss in small groups to determine if they are
POEMS3 criteria of POEMS
Do patients care about the outcomes/is it patient-oriented (quality of life, morbidity, mortality)?
Is the intervention feasible? If true, will it require you to change your practice?
Evidence Hierarchy
Graded EvidenceSORT
Developed by AAFPTakes POEM into consideration
USPSTF Graded recommendationsGRADE
Developed by international group of physiciansLevel of Evidence
11 categoriesDeveloped at Oxford
SORT (Strength Of Recommendation Taxonomy)
Code DefinitionA Consistent, good-quality patient-oriented evidenceB Inconsistent or limited-quality patient-oriented evidenceC Consensus, disease-oriented evidence, usual practice,
expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening
Highly Controlled Research·Randomized Controlled Trials·Systematic Reviews
Physiologic ResearchPreliminary Clinical Research·Case reports·Observational studies
Uncontrolled Observations&
Conjecture
Effect on Patient-Oriented Outcomes·Symptoms (drivers license)·Functioning (visual loss)·Quality of Life (leg ulcers)·Lifespan
Effect on Disease Markers·Diabetes (Photocoagulation, GFR, NCV)·Arthritis (x-ray, sed rate)·Peptic Ulcer (endoscopic ulcer)
Effect on Risk Factors for Disease·Improvement in markers (blood pressure, HBA1C, cholesterol)
SORTA
Validity of Evidence
Rel
evan
ce o
f Out
com
e
SORTB
SORTC
USPSTF GradesGrade DefinitionA The USPSTF recommends the service. There is high certainty that
the net benefit is substantialB The USPSTF recommends the service. There is high certainty that
the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
GRADE (Grade of Recommendations, Assessment, Development, and Evaluation)
Code
Quality of Evidence
Definition
A High Further research is very unlikely to change our confidence in the estimate of effect. Several high quality studies with consistent results or one large high quality multi-center trial
B Moderate Further research is likely to have an important impact on our confidence in the estimate of the effect and may change the estimate. One high quality study, several studies with some limitations
C Low Further research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. One or more studies with severe limitations
D Very low Any estimate of effect is very uncertain Expert opinion, no direct research evidence, onre or more studies with very severe limitations.
Level of EvidenceDeveloped by Centre for Evidence-Based
Medicine in Oxford, EnglandMore detailed and complex
11 levels1a-c (systematic reviews), 2a-c, 3a-c, 4, 5 (expert
opinion)http://www.cebm.net/oxford-centre-evidence-bas
ed-medicine-levels-evidence-march-2009/ (see for a table)
Information Mastery Toolkit
Journals (2-3)Foraging services (summaries of new
information)Hunting tools (find answers to questions)
“Foraging” ServicesAnalyze articles/evidence for you and send you
summariesDynaMed AlertsEE Plus POEMSBMJ Clinical EvidenceFPIN Clinical InquiriesACP Journal Club
Characteristics of an Ideal Foraging/Alert Tool
How is the information filtered? Specialty specific Patient-oriented (relevance)
Is the information valid? Backed-up by evidence (level of evidence, SORT is always best)
Is the information summarized and easy to access? Comprehensive but summarized (2000-3000 words accurately
in 200 words) Point of care (work) Coordinated with a hunting tool
Is the information placed into context? Translational validity More than abstracts
Characteristics of an Ideal Foraging/Alert Tool
Specialty-specificPatient-oriented (relevance)Backed up by levels of evidence, SORT is best
(validity)Comprehensive but summarized (2000-3000
words accurately in 200 words)Point of care (work)Coordinated with a hunting tool
Foraging/Alert Tool RisksWho’s paying when it is free?
Possibly pharmaceutical companiesAbstracts only contain no relevance/validity filter
Examples are Journal Watch, Clinical Updates
TAKE HOME POINT: If it’s free there may be something wrong with it. Quality often doesn’t come free!
Foraging Tool OverviewTool Less work More workACP Journal Club -Specialty Specific (IM) -Validity assessment but
no LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool
BMP Updates -Specialty Specific (various)
-Validity assessment but no LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool
DynaMed Alerts -Specialty specific (various)-Validity assessment-LOE-Relevance: focuses on patient-oriented evidence-Coordinated hunting tool
Foraging Tool OverviewTool Less work More workJournal Watch -Specialty Specific
(various)-No validity assessment -No LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool
Medscape -Specialty Specific (various)
-No validity assessment-No LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool
Fig 1 Updating curves for relevant evidence (128 systematic reviews) by point of care information summaries (log rank χ2=404, P<0.001).
©2011 by British Medical Journal Publishing Group
Banzi R et al. BMJ 2011;343:bmj.d5856
Summary of Foraging Tools
DynaMed: Fastest to update with new information
BMJ Clinical Evidence: Only sends valid articlesUpToDate: e-mails article authors every 6
months to ask for updates No one has looked at how accurately information
is summarized/said in the tools (are summaries valid?)
EBM “Hunting” ToolsPoint of care evidence-based tools (30-40
seconds)Best tools = useful = (relevance*validity)/work
DynaMedCochrane databaseEssential Evidence PlusBMJ Clinical EvidenceFPIN Clinical InquiriesTrip databasePub Med
Drilling for the Best Information
BMJ Clinical Evidence (therapy)
Dynamed
UpToDate
TRIP Database
TextbooksUs
eful
ness
Medline
Usefulness = Relevance X validityWork
R WV R WV
R WV
R WV
R WV
R WV
R
W
V
Essential EvidencePlus
PIERR WV R WV
Clinical JazzScience (EBM/structure) + Art (improvisation) =
Clinical JazzBoth structure and improvisation are necessary,
but there’s not good evidence for many areas of medicine, so we have a lot of liberty to improvise!
ACTIVITY 3Review use of the following tools:
DynaMedEssential Evidence PlusTRIP DatabaseBMJ Clinical evidence
ACTIVITY: Medical Myths
ACTIVITY: Look-up conference
Some Studies that I Like to Quotehttp://www.youtube.com/watch?v=Ij8bPX8IINg
James McCormack, MD