Push, Pull, Prompt …ways to deal with too much information

1. Evidence-Based Information Resources Push, Pull, Prompt …ways to deal with too much information

2. Evolution of EBM Info PreEBM: Passive diffusion (“publish it and they will come”) Early EBM: Pull diffusion (“teach them to read it and they will come”) Current EBM: Push diffusion (“read it for them and send it to them”) Future EBM: Prompt diffusion (“read it for them, connect it to their individual patients, prompt them and their patients”)

3. Information in the Internet Age* Information in the Internet age may be constrained by a variant of Malthus’ law: The amount of information is growing exponentially, but our attention is not. A wealth of information creates a poverty of attention. The low cost of production of poor quality information results in high quality information being drowned out. The cost of finding specific information rises as the amount of information increases. *Coiera E. Information economics and the internet. J Am Med Inform Assoc 2000;7:215-21.

4. The Slippery Slope 100% r = -0.54 p<0.001 . .. . . .... . • Choudhry,Fletcher and Soumerai, • Ann Intern Med 2005;142:260-73 • 94% of 62 studies found decreasing competence for at least some tasks, with increasing physician age. knowledge of current best care ... ... ... 50% ... .. .... .... 0% years since graduation

5. The McMaster PLUS project • only a tiny proportion of all research is “ready for application” • only a tiny fraction of the “ready” research is “relevant” to the practice of a given clinician • only a tiny proportion of the “relevant” research for a given practitioner is “interesting” in the sense of being something new, important, and actionable.

6. Evidence-Based Journals Critical Appraisal Filters ~3,500 articles/yr meet critical appraisal and content criteria (95% noise reduction) 60,000 articles/yr from 120 journals

7. McMaster PLUS Project Clinical Relevancy Filter (MORE) ~25 articles/yr for clinicians (99.95% noise reduction) ~3,500 articles/yr meet critical appraisal and content criteria (95% noise reduction) ~5-50 articles/yr for authors of evidence-based clinical topic reviews

8. McMaster Online Rating of Evidence: >6000 practicing clinicians

10. http://bmjupdates.mcmaster.ca

11. User End • Users sign up according to discipline • Users control relevance and flow • Users can change disciplines at any time, and can sign up for as many as they wish • Users can search according to discipline – or not • Users can access PubMed Clinical Queries • (We can monitor individual use, if agreed)

16. Dear Dr. Haynes,We want to alert you to NEW articles in the PLUS system. These articles that have received very high relevancy and newsworthiness scores: We hope that you will find these articles of value in your clinical practice.Best wishes from the PLUS Team

17. CONCLUSIONS: In this 24-week study, once-daily sitagliptin monotherapy improved glycemic control in the fasting and postprandial states {vs placebo}, improved measures of beta-cell function, and was well tolerated in patients with type 2 diabetes.

18. Medscape Best Evidence Alerts Free at https://profreg.medscape.com/px/newsletter.do

19. The evolution of information resources for evidence-based decisions Examples Computerized decision support Evidence-based textbooks Evidence-based journal abstracts Systematic reviews Original journal articles

20. Premier evidence resources Systems: EMR with decision support Summaries: Clinical Evidence, PIER, UpToDate, Dynamed Synopses: ACP Journal Club, EBM Syntheses: via BMJUpdates+ Studies: via BMJUpdates+, PubMed Clinical Queries

21. 58 year old obese male with …type 2 diabetes mellitus …A1c 9% (elevated) on glyburide and rosiglitazone, with metformin intolerance…continuing to gain weight…very reluctant to take insulin Can the new ‘incretin therapies’ (eg, exenatide, pramlintide or sitagliptin) help?

22. For type 2 diabetes, what are the effects- good and bad -of incretin therapy? Systems:no Computerized Decision Support Summaries:in UTD, PIER, Dynamed, not CE Synopses:sitagliptin in ACP JC Syntheses: one for pramlintide in BMJUpdates+ Studies: exenatide, pramlintide, sitagliptin in UTD, PIER, CE, BMJUpdates+; more on exenatide, pramlintide and sitagliptin in Clinical Queries

23. Section updated June 2007 Comments on exenatide, pramlintide, sitagliptin, with drug monographs for each “Many questions remain unanswered regarding clinical use and long-term outcomes with these drugs.” Januvia is approved for use by people with type 2 diabetes that can't be controlled adequately with diet and exercise. US$5 per pill

24. Includes exenatide, pramlintide, and sitagliptin, with drug monographs for each “Consider metformin as a first-line agent because it causes less hypoglycemia and weight gain, along with possible improvements in cardiovascular risk.” “Consider other oral agents, such as sulfonylureas, thiazolidinediones, and DPP-IV inhibitors {sitagliptin}, as reasonable first-line agents, although some are costly and the long-term benefits of these drugs have not been well studied.”

25. CONCLUSIONS: Incretin therapy offers an alternative option to currently available hypoglycemic agents for nonpregnant adults with type 2 diabetes, with modest efficacy and a favorable weight-change profile. Careful postmarketing surveillance for adverse effects, especially among the DPP4 inhibitors, and continued evaluation in longer-term studies and in clinical practice are required to determine the role of this new class among current pharmacotherapies for type 2 diabetes.

26. Survey of traditional textbooks of medicine Harrison’s Textbook – nothing Books@Ovid – nothing Kelley’s Textbook - nothing

27. My conclusions about exenatide, pramlintide, sitagliptin Interesting new options for diabetes Not well studied (eg, no comparisons with current best medications) Exenatide and pramlintide would likely be out for this patient (injections) Sitagliptin is a possibility, but not until better known options tried (acarbose, Avandamet, repaglinide)

28. Finding evidence when you’re not sure where to look TRIP SUMSEARCH CLINICAL QUERIES

31. To keep up with evidence Pull Push Prompt…some labs and EMRs with a credible evidence-based pedigree (Zynx)