Kick Your Textbooks to the Curb: Finding Clinically

Relevant Information Quickly

Adrian Banning, MMS, PA-C

Gary M. Childs, MS

Too much info, too little time, chatter and hyperbole (!)

• We are bombarded with information.

• You have to sift the good from the bad.

• You can’t give up and read nothing.

• Where would you prefer to get your daily news?

Your sources count

• Morning news?

• Journal in the office?

• Colleagues?

• Buzz?

• Patients?

• Conferences?

Walter Cronkite

Walter Cronkite was a real news anchor.

http://www.theatlantic.com/international/archive/2012/07/is-it-walter-cronkites-fault-why-olympic-announcers-keep-saying-beizhing/260556/

Ron Burgundy

Not a real news anchor, even though he looks like one.

Source:

http://cdn.sheknows.com/articles/2013/08/ron-burgundy-memoir.jpg

The difference is VALIDITY

In desperation, you may listen to buzz as fact-that’s how rumors get started and we don’t have time or leeway for that.

Something has to be relevant to you, be good info and take little time to find.

No free lunch: You need a level of evidence (LOE)

• Beware things that are mailed to you for free or that can’t account for their levels of evidence (LOE).

• You’ll need to search out what you have at your disposal and the quality of it-or else you’re just doing more of the same

• Look at free mailers with lots of ads skeptically.

• Pharm reps

Making Decisions

• How do we know what to do?

• Knowledge>Fear

• Find good evidence (and experience and opinions), combine with patient risk and values to give us options

• We then weigh the options with the patient and make a decision

• Science and Art

• How do we do this. . . in reality?

Need answers at point-of-care

Internal med residents had 2 questions for every 3 pts seen

Background = epi, pathophys, presentation, requires textbooks

Foreground information is testing, diagnosis, treatment, Need EBM summaries or research

Residents asked mostly about therapy and diagnosis and asked more foreground than background questions as training progressed

Pursued 29% of their questions Used textbooks, original articles, and attendings Pursued an answer if they thought pt wanted it for in fear of

malpractice

Information MasterySlawson and Shaugnessy, et al.

• Finding high quality information to answer YOUR question, quickly.

• You may not be an appraisal expert, but they exist

• You need a level of evidence (LOE)Information sources are not all equal(different databases, journals, experts)

• Go for patient-oriented evidence first•POEM vs DOE

• Hunting vs foraging

Information Mastery

Usefulness of Info=

(Relevance x Validity)Work

Critical appraisal is a total drag, but. . .

Ask, find, assess validity, synthesize

• RECRUITEMENT, Randomized ALLOCATION, ACCOUNTED (ITT), MAINTENANCE/MEASURMENT

• BLINDING, OUTCOME IM lets the experts assess for you.

Are you sure you can assess this expertly? Allocation concealment? You must stay an expert on the interpretations

AND how to interpret AND see patients AND eat AND sleep AND. . .

Evidence Based Medicine Steps

• Have a question (put it into PICO)• Search the literature from the top of the

pyramid (next slide)• Find a study/find evidence • Perform appraisal /find level of evidence

and look for bias • Determine how the results help you-how will

you use them with your patient in their lives using your/others’ experience

• Are the above steps working?

The Evidence HierarchyFrom: http://www.dartmouth.edu/~biomed/services.htmld/EBP_docs/pyramid-loaded.pdf

Levels of Evidence Pyramid Example

http://www.hsl.virginia.edu/collections/ebm/pyramid.cfm

Patient Oriented Evidence that Matters: POEMs

DOE = Disease Oriented Evidence

You will likely have to differentiate POEMs vs DOE yourself

Specialists and researchers may need DOE as well if highly specialized, but DOE doesn’t change your immediate clinical decision with a patient.

POEM Requirement Number 1:

Address a frequently encountered clinical question (in your realm of medicine-family/cardio/oncology). Not too rare and about something you’ll need to a

make a decision on

POEM Requirement Number 2:

• Measures a patient oriented outcome like: mortality morbidity quality of life reduction in symptoms other endpoints that are important to the patient

and you.

• Not a disease-oriented outcome like LV pumping or neuronal death.

• Intermediate or premature evidence is not helpful here-too early in the process.

POEM Requirement Number 3:

Results will require a change in your practice (M) Confirming what you already know and do is a

waste of time. One person’s POEM may be another’s POE

depending on your practice.

DOE

Increase our knowledge of a disease

DOE= prognosis, prevalence, pathophysiology, pharmacology, etiology, etc.

DOEs are crucial to medicine and we can’t dx, tx or prevent a disease before we understand it.

“Comparing DOES and POEMs”Slawson, D.C. & Shaughnessy, A. 2003. Information Mastery: Evidence-Based Medicine in Everyday Practice. PowerPoint file retrieved February 17, 2011 from http://www.bmj.com. Slide 12.

Example

Disease-Oriented Evidence

Patient-Oriented Evidence that

Matters

Comment Antiarrhythmic Therapy

Drug X PVCs on ECG

Drug X increases mortality

POEM study contradicts DOE study

Antihypertensive therapy

Antihypertensive therapy BP

Antihypertensive therapy mortality

POEM agrees with DOE

Prostate Screening

PSA screening detects prostate cancer early

? whether PSA screening mortality

DOE exists, but the important POEM is unknown

Hunting and Foraging

• Forage- have information come to you • POEM of the Week Podcast! Emails!

• Hunting-looking for evidence• Databases

Tips on keeping validity

• Go to trusted sources (use the pyramid).

• Go to relevant items (POEMs).

• Look for LEVELS OF EVIDENCE, resources, someone who is accountable.• A.K.A. “WHO WROTE THIS?”

• Don’t contribute to chatter if you haven’t checked the facts. Read the article.

• Brush-up on how to read a research article. It’s ok. We all forget some things, sometimes.

Immediate Gratification

Many resources can provide an immediate answer at the point-of-care!

Yes!

Part 1: Summary

• Find a realistic way to use evidence

• You DO need the skills to be able to read technical medical information • type of article, type of research, PPV/NPV,

odds and risk ratios

• Does the patient see the difference-can you bring them the evidence and make them part of their own team?

• Application of EBM is not cookbook

Part 2, Hunting Sources:

Finding Clinically Relevant Information Quickly

Cochrane Systematic Reviews

A study done in 1972 showed inexpensive corticosteroids beneficial in preterm delivery.

No systematic review of the literature was done until 1989.

Had it been it would have shown that infant mortality is reduced 30-50% using this evidence that was already on hand.

VERY comprehensive analysis of the research

Links To Video Tutorial Playlist

http://tinyurl.com/m22fosh

-OR-

https://www.youtube.com/playlist?list=PLkr8XTH_bktjgj4V9mxflVvBz7wAkAPIL

Clinical Question

• Suzy, the mother of a 2 y/o girl with asthma is concerned about the upcoming cold and flu season. She’s interested in having her child receive the influenza vaccine, but she’s afraid that the vaccine could trigger her daughter’s asthma. What does the current available evidence suggest?

PICO(T) Format

• P: Patient, population, “problem”

• I: Intervention

• C: Comparison Intervention

• O: Outcome

• (T): Time

Clinical Question in PICO format

• P: 2 y/o girl with asthma

• I: influenza vaccine

• C: no influenza vaccine

• O: possible asthma exacerbation risk

• (T): immediately following vaccination

Cochrane Library: Search Terms

CDSR: Systematic Review Length

CDSR: Plain Language Summary

CDSR: Conclusions

CDSR: References

TRIP: Turning Research Into Practice

TRIP: Article Abstracts

DynaMed

DynaMed: Search - Autocomplete

DynaMed: Search With Records & Level of Evidence (LOE)

DynaMed: LOE Defined

DynaMed: Calculators

National Guideline Clearinghouse (NGC)

NGC: Search Terms

NGC: Results

NGC: Guideline Summaries

NGC: LOE (not standardized!)

NGC: Not All Guidelines Include LOE

MEDLINE (PubMed)

MEDLINE: Clinical Queries Search Terms

MEDLINE: Limits

MEDLINE: Display Settings -- Abstract

Questions?

?

References

Claude Moore Health Sciences Library. Information mastery: navigating the maze. University of Virginia Health System Web site. www.hsl.virginia.edu/collections/ebm/pyramid.cfm. Accessed May 11, 2012.

Dartmouth Biomedical Libraries. Evidence-based medicine (EBM) Resources. Dartmouth College Library Web site. http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_resources.shtml. Accessed May 11, 2012.

Ebell MH, Barry HC, Slawson DC, & Shaughnessy AF. Finding POEMs in the medical literature. J Fam Pract. 1999;48(5):350-355.

Ebell M, Shaughnessy A. Information mastery: integrating continuing medical education with the information needs of clinicians. J Cont Ed Health Prof [serial online]. April 2, 2003;23:S53-62. Available from: CINAHL with Full Text, Ipswich, MA. Accessed May 30, 2013.

Johnson CA. The Information Diet. Sebastopol, CA; O’Reilly Media, Inc.; 2011 

Marks S, McKibbon KA. Posing clinical questions: Framing the question for scientific inquiry. AACN Clin Issues. 2001;12(4):477-481.

Mayer, D. (2009). Essential Evidence-Based Medicine. Oxford, UK. Oxford University Press.

McConaghy JR. Evolving medical knowledge: moving toward efficiently answering questions and keeping current. Prim Care: Clin in Office Prac. 2006 December; 33(4): 831-837

References

Pearce-Smith N, Hunter J. The introduction of librarian tutors into the teaching evidence-based medicine week in Oxford, UK. Health Info Libr J. 2005;22(2):146-149.

Shaughnessy A, Gupta P, Erlich D, Slawson D. Ability of an information mastery curriculum to improve residents' skills and attitudes. Fam Med. 2012 April; 44(4): 259-64.

Shaughnessy AF, Slawson DC, & Bennett JH. Becoming an information master: A guidebook to the medical information jungle. J Fam Pract. 1994;39(5):489-499.

Slawson DC, Shaughnessy AF, & Bennett JH. Becoming a medical information master: Feeling good about not knowing everything. J Fam Pract. 1994;38(5):505-513.

Slawson, D.C. & Shaughnessy, A. Information mastery: evidence-based medicine in everyday practice. 2003. Accessed May 11, 2012 from http://www.bibalex.org/supercourse/bmj/bmj.htm.

Slawson, D.C. & Shaughnessy, A. 2003. Information Mastery: Evidence-Based Medicine in Everyday Practice. PowerPoint file retrieved February 17, 2011 from http://www.bmj.com.

http://www.theatlantic.com/international/archive/2012/07/is-it-walter-cronkites-fault-why-olympic-announcers-keep-saying-beizhing/260556/

http://cdn.sheknows.com/articles/2013/08/ron-burgundy-memoir.jpg

Bonus!

http://www.thennt.com/

The NNT Groups

• Thennt.com

• How many people without heart disease need to be on the Mediterranean diet for 5 years before one person doesn’t have a CVA, MI or die?

http://www.thennt.com

61 and no one gets hurt

More on Information Mastery?

• Tufts Health Care Institute Conference:• http://www.thci.org/educational-activities/conferences/

information-mastery

• UVA School of Medicine:• http://www.medicine.virginia.edu/clinical/departments/

familymed/information_mastery/info_mastery-page

More Foraging-many are both: sign up for emails to forage.

Journal Watch (NEJM) ACCESSSS Federated Search, free, register.

Hunting and foraging: http://plus.mcmaster.ca/accessss/Default.aspx?Page=1

ACP Journal Club (Annals of Internal Medicine) http://www.essentialevidenceplus.com/ National Prescribing Centre (UK):

http://www.npc.nhs.uk/ EssentialEvidencePlus POEM of the week podcasts

(iTunes) Agency for Healthcare Research and Quality subscriptions http://www.ahrq.gov/ National Guidelines Clearinghouse:

http://www.guidelines.gov/