Information Mastery Evidence-Based Medicine in Everyday Practice
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Slide 1 :
Information Mastery: Evidence-Based Medicine in Everyday Practice David C. Slawson, MD Allen Shaughnessy, PharmD
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The Medical Information Business Original Research Clinical experience Production
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Production Refinement The Medical Information Business Systematic reviews (Cochrane) Meta-analysis Practice guidelines POEM Alert System
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Production Refinement Distribution Clinician centered informatics “Just-in-time” info Hand-held computers Internet/Intranet Hunting/Foraging tools The Medical Information Business
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Production Refinement Distribution Sales & Marketing The Medical Information Business Evidence-Based Medicine Information Mastery
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Information Sources for the point of care Everything is based on the usefulness equation: Usefulness = Relevance x Validity Work
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Validity The hard part of Information Mastery Technique: EBM working group Apply to other information sources Responsibility: Self vs. Delegation
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Work Basic law of human behavior: lowest amount of work you can get away with Varies with source and your need Recognizing the balance “Informatics”- “Just -in-time” vs “just-in-case”
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Relevance: Type of Evidence POE: Patient-oriented evidence mortality, morbidity, quality of life DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology
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POEM Patient-Oriented Evidence that Matters matters to you, the clinician, because if valid, will require you to change your practice
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Comparing DOES and POEMs
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Two Tools to Get the Job Done Hunting and Foraging go together like horse and carriage (fish and chips, London and fog, Americans and bad manners . . . ) Without both, you don’t know what you are looking for and can’t find it when you do. Clinical example- Riboflavin for migraines
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Quality Foraging Tools 1. What is the filter? Is it relevant? Patient- vs disease- oriented? Common (specialty-specific?) Comprehensive-which journals? Will it change behavior (POEM)? 2. Is it valid (must have LOE labels)? Beware “Trojan Horse”!
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Quality Foraging Tools 3. How well is information summarized? 2-3000 words accurately in 200 words 4. Bottom Line: Put in context with rest of information and clinical practice Much more than “abstracts”/current content Must be experienced clinician in specialty, well versed in current and past literature “Translational Validity”
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Quality Foraging Tools: Beware “free” software Spyware (e.g. Epocrates, PDR for the Pocket PC) Trojan Horse (e.g. Journals-to-Go, others) Abstracts/ Current Contents/ Journal Watch/ “Journal Rack”/ “Tips”/ etc. None of these have relevance/ validity criteria (LOEs) You can have information “free” and you can have it “uncensored”, but you can’t have it both ways- No Free Lunch!
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Quality Foraging Tools IR/IP = “The Clinical Awareness System” Criteria: specialty-specific, comprehensive, specific and reproducible criteria for relevance and validity available at the point-of-care All backed up by LOEs POEMs for Primary Care, Pediatrics, Internal Medicine Soon to be others! www.InfoPOEMs.com
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Relevance first, validity second Comparison with ACP Journal Club, Best Evidence 13% of POEMs (in Evidence Based Practice) were in ACP JC 70% of abstracts in ACP JC were not POEMs. Many were DOEs without commentary. Gold Standard = Valid POEMs (only 2.6%), 25 – 30/ month
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Quality of Review (Hunting) Information 10 methodological criteria for rigor of 36 published review articles Overall rating: intraclass correlation lowest (0.23) for experts vs non-experts (0.78) trained to do critique More expertise = stronger prior opinion, less time spent on review, lower quality Avg score 1/15; best score 5/15; No LOEs! UTD = 2/15 “evidence-based” Translational validity- worse yet! Experts = original research; Non-experts = refinement/ synthesis due to less bias Oxman AD, Guyatt GH. The science or reviewing research. Ann N Y Acad Sci 1993;703:125-33.
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Translational Validity Can We Trust Review Articles? Reporting of the UKPDS by 40 review articles 85% of reviews: readers not told that good glucose control doesn’t decrease mortality All reported that good control decreased complications None reported that almost all (84%) benefit due to decreased rates of retinal photocoagulation (no change in blindness rate, the POEM) Only 18% (NNR = 6): metformin decreased mortality, independent of BS control
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Translational Validity Can We Trust Review Articles? None reported lack of any benefit (micro- or macrovascular) of insulin/ sulfonylureas in obese diabetics Only 13% (NNR = 8) reported that blood pressure control is more important than BG control
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Drilling for the Best Information
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InfoRetriever 2003 Windows 95/98/NT/ME/2000, PocketPC and Web 650 critical reviews of recent research from the Journal of Family Practice POEMs section Bayesian diagnostic test / H&P calculator Basic drug info by class and cost for 1200 drugs Key evidence-based treatment guidelines Cochrane Database of Systematic Reviews: over 1200 abstracts 102 clinical prediction rules www.MedicalInforetriever.com 1500 short research synopses (400 added per year) 5 Minute Clinical Consult
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Take – Home Points 1. Overall mission of Information mastery: Answer at least 80% of clinicians’ information needs in 50 seconds or less. 2. In order to survive in the information age (the "future" already at hand): every clinician will need a specialty-specific hunting and foraging tool, based on the information mastery equation: Usefulness = Relevance x Validity/ Work
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Take-Home Points 3. Clinicians in the information age will be valued by how they "think" and not by what they "know". 4. (This one is specific for academia) The information age is about information, not research. We need to see ourselves as part of a team: the production of new information is only part of it. Refinement, distribution, and sales/marketing are also necessary components. Only when we have all four do we have sufficiency.
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Information Mastery An Evidence-Based Approach to Medical Education University of Virginia, Charlottesville, VA April 2 - 5, 2003
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