Clinical Decision Making in Three Minutes or Less: Information Mastery at the Point of Care

1. Clinical Decision Making in Three Minutes or Less: Information Mastery at the Point of Care Scott M. Strayer, MD, MPH Assistant Professor Department of Family Medicine University of Virginia Health System

3. Objectives • 1. Apply a practical, evidence-based framework for evaluating new medical information. • 2. Understand how to use point of care technology to "hunt" for evidence-based information that can be applied to clinical decision making on a daily basis. • 3. Understand how to 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.

4. SLU Residency Teach Board

6. How Many People Have Heard of the “ABCD Criteria”?

8. Do We Really Need Help With Clinical Decision Making?Clinical Questions • They’re common • Physician recall: 0.1 information needs per encounter • Direct observation: 0.5 information needs per encounter • They’re important • Only 30% pursued, 75% of those satisfied • Of those not pursued, half were “important” • Journals only used to answer 2 of 1101 questions in busy practice(J Ely, BMJ 99)

9. Clinical Questions • Internal Medicine Residents • 2 for every 3 patients • 29% pursued • textbook (31%); journals (21%); attendings (17%) • Patient expectation, fear of malpractice associated with seeking answer • Lack of time (60%), forgot (29%). Am J Med 2000;109:218-33.

10. How Well Do We Distribute New Information? • Left to our own devices • 1987: 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 use Antman 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.

11. 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 doesn’t work).---ASA and Diltiazem use---no change after trial 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 2003: • HOPE study –  in ramipril prescribing by 5% per month without advertising, 12%  per month with advertising over the next 2 years 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.

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

13. Two Tools Needed to Master Information- BMJ 1999 • A 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 don’t know that new info. is available • You can’t find it when you do • Clinical 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)

14. Foraging InfoPoems---www.infopoems.com Peer View Institute---www.peerview-institute.org/ Journal Alerts---www.globalfamilydoctor.com/dailyalerts/main.htm Medscape Daily Update MDLinx Hunting InfoPoems Up To Date---www.uptodateonline.com DynaMed---www.dynamicmedical.com/ Medscape---www.medscape.com Hunting and Foraging Tools

16. Information Mastery in a Nutshell Clinically 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.

17. Not always assessed by software Usefulness = Relevance x Validity Work Can be reduced by computers 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.

18. Effect on Patient-Oriented Outcomes • Symptoms • Functioning • Quality of Life • Lifespan SORT A SORT B • Effect on Disease Markers • Diabetes (GFR, albumin, HbA1C, photocoagulation) • Arthritis (sed rate, X-ray) • Peptic Ulcer (endoscopic ulcers) SORT C Relevance of Outcome • Effect on Risk Factors for Disease • Improvement in markers (blood pressure, glucose, cholesterol) Uncontrolled Observations & Conjecture • Physiologic Research • Preliminary Clinical Research • Case reports • Observational studies • Highly Controlled Research • Randomized Controlled Trials • Systematic Reviews Validity of Evidence

19. Cochrane Library EB Practice Guideline Clinical Evidence Clinical Inquiries Specialty-specific POEMs Best Evidence Reviews: Textbooks, Up-to-Date, 5-Minute Clinical Consult Usefulness Medline Drilling for the Best Information

20. Web, InfoRetriever CogniQ, BMJ, FPIN InfoRetriever, Journal Watch, AFP Online Best Evidence Unbound, Skyscape Online Textbooks Usefulness CogniQ, Skyscape PubMed, OVID Computers to Drill for the Best Information Cochrane Clinical Evidence Clinical Inquiries POEMs Reviews/Textbooks Medline

21. POEM Patient-Oriented Evidence that Matters matters to the clinician, because if valid, will require a change in practice Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.

22. Relevance: Type of Evidence • POE: Patient-oriented evidence • mortality, morbidity, quality of life • Longer, better or both • DOE: Disease-oriented evidence • pathophysiology, pharmacology, etiology

23. POEMs:The “Change” Factor • Bextra Causes More Heart Attacks and Strokes • ALLHAT study---HCTZ is best first agent in hypertensive patients • 3 questions: • A. Is it an outcome patients care about? • B. Is it common to your practice and the intervention feasible? • C. If valid, would it require you to change your practice?

24. Comparing DOES and POEMs Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60.

25. Validity • The hard part of Information Mastery • Technique: EBM working group • Did the researchers find what they think they found? • Do the results apply to your patients? • Self vs delegation- Take responsibility

26. Determining Validity • Levels of Evidence (LOE): • 1a, b, c; 2a, b, c; etc., 5- expert opinion • A, B, C, D • SORT Criteria • Therapy, diagnosis, prognosis, reviews, etc. • A “moving target”

28. Treatment Validity Worksheets

29. Diagnosis Validity Worksheets

30. Work • Not all information sources are created equal • Two type of information sources • “Just-in-case” sources: high work • “Just-in-time” sources: low work

31. Minimizing Work: Types of Archived Information Sources “Just-in-Case” information • Libraries, Medline, MDConsult, WebMd, MedSites, StatRef, other databases • A “superstore” of information • Focus: a complete “inventory” of information • Benefit: Much information is always “in stock” to meet many needs • Detriments: Even the simplest needs require time to access the information

32. Minimizing Work: Types of Archived Information Sources “Just-in-Time” information • Highly filtered information sources with rapid access: InfoRetriever, Up To Date, Dynamed • A “Seven-Eleven” -- not everything, but quick and what you need most of the time • Focus: the best, most commonly needed information • Benefit: Rapid access (less than one minute); ease of use • Detriments: Reliance on the filtering mechanism---what is the quality of the filtering mechanims?

33. Quality Hunting and Foraging Systems 1. 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 labels • Beware “Trojan Horse”!

34. Quality Hunting and Foraging Foraging Systems 3. How well is information summarized? • 2000 - 3000 words accurately in 200 words 4. Is the information placed into context? • Much more than abstracts • “Translational Validity”

35. Hunting and Foraging SystemRisks • “Spyware”: May be tracking your usage • “Trojan Horse”: who’s paying when it’s free? • Abstracts only: Journal Watch, Journal Rack, Tips from other Journals, ClinicalUpdates, etc. • No relevance/ validity filter • You can have information “free” and you can have it “uncensored”, but you can’t have it both ways. No Free Lunch!

36. Not All Information Tools are Created Equal!

37. Translation of UKPDS into Practice Shaughnessy AF, Slawson DC. What happened to the valid POEMs? A survey of review articles on the treatment of type 2 diabetes. BMJ 2003; 327:266-269.

38. Review Criteria for Study of Information Tools

39. What Happened to the Valid Reviews?

40. Quality of Drug Foraging and Hunting Tools

41. A Few Foraging Tools…

48. Beware of the Trojan Horse