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Information Mastery: Evidence-Based Medicine in Everyday Practice

Information Mastery: Evidence-Based Medicine in Everyday Practice. David C. Slawson, MD Allen Shaughnessy, PharmD. The Medical Information Business. Production. Original Research Clinical experience. The Medical Information Business. Production. Systematic reviews (Cochrane)

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Information Mastery: Evidence-Based Medicine in Everyday Practice

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  1. Information Mastery: Evidence-Based Medicine in Everyday Practice David C. Slawson, MD Allen Shaughnessy, PharmD

  2. The Medical Information Business Production • Original Research • Clinical experience

  3. The Medical Information Business Production • Systematic reviews (Cochrane) • Meta-analysis • Practice guidelines • POEM Alert System Refinement

  4. The Medical Information Business Production • Clinician centered informatics • “Just-in-time” info • Hand-held computers • Internet/Intranet • Hunting/Foraging tools Refinement Distribution

  5. The Medical Information Business Production • Evidence-Based Medicine • Information Mastery Sales & Marketing Refinement Distribution

  6. Information Sources for the point of care Everything is based on the usefulness equation: Usefulness = Relevance x Validity Work

  7. Validity • The hard part of Information Mastery • Technique: EBM working group • Apply to other information sources • Responsibility: Self vs. Delegation

  8. 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”

  9. Relevance: Type of Evidence • POE: Patient-oriented evidence • mortality, morbidity, quality of life • DOE: Disease-oriented evidence • pathophysiology, pharmacology, etiology

  10. POEM • Patient-Oriented • Evidence • that Matters • matters to you, the clinician, because if valid, will require you to change your practice

  11. Comparing DOES and POEMs

  12. 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

  13. 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”!

  14. 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”

  15. 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!

  16. 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

  17. InfoPOEMs - The Clinical Awareness System Alendronate prevents multiple fractures in osteoporotic women over 55 Clinical questionDoes alendronate prevent multiple fractures from occurring in women with osteoporosis?Setting: Outpatient (any)Study design: Randomized controlled trial (double-blinded)SynopsisThe investigators enrolled women between the age of 55 and 81 who had a vertebral fracture or whose bone mineral density (BMD) met the WHO criteria for osteoporosis. They were randomly assigned (allocation method concealed) to receive alendronate (Fosamax, 5 mg/d for 2 years followed by 10 mg/d; n=1841) or placebo (n=1817). All patients with insufficient dietary calcium also received daily supplements of 500 mg of elemental calcium plus 250 IU cholecalciferol (a low dose of vitamin D, by the way). The authors followed the patients for an average of 4 years and analyzed the data based upon the initial group assignment. During this follow-up period, they found a total of 789 symptomatic fractures. 471 of the fractures occurred in 341 patients receiving placebo compared to 308 fractures in 248 of the women receiving alendronate. Two or more fractures occurred in 86 (4.7%) women on placebo compared to 51 (2.8%; NNT= 51 for 4.3 years) on alendronate. Some poor souls had three or more fractures (27 and 7, respectively; NNT=91 for 4.3 years). Since they followed the patients over time, they were able to see how soon any benefit might occur, finding that after 6 months, benefits were already apparent. Bottom lineWomen with established osteoporosis taking alendronate (Fosamax) will have fewer symptomatic fractures than women taking placebos. This study should not be extrapolated to women without established osteoporosis. In a randomized trial (N Engl J Med 1997; 337: 670-6) of primary prevention using 500 mg calcium and 700 IU vitamin D, the NNT to prevent one fracture was 15 for 3 years. Wouldn't it be nice to see a REAL study comparing these expensive drugs to a reasonable dose of calcium and vitamin D?LOE2b-ReferenceLevis S, Quandt SA, Thompson D, et al. Alendronate reduces the risk of multiple symptomatic fractures: results from the Fracture Intervention Trial. J Am Geriatr Soc 2002;50:409-415. Visit us Online • InfoRetriever • InfoPOEMS© • Tour • Purchase • Support • Downloads • Contact Us • LOE Please do not reply to this e-mail. If you wish to receive this email plain text format, please click here.Copyright © 1995-2002 InfoPOEM, Inc. All rights reserved.

  18. 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

  19. 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.

  20. Translational ValidityCan 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

  21. Translational ValidityCan 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

  22. Cochrane Library Clinical Evidence Specialty-specific POEMs Best Evidence Textbooks, Up-to-Date, 5-Minute Clinical Consult Usefulness Journals/ Medline Drilling for the Best Information

  23. InfoRetriever 2003 Windows 95/98/NT/ME/2000, PocketPC and Web Cochrane Database of Systematic Reviews: over 1200 abstracts 1500 short research synopses (400 added per year) 5 Minute Clinical Consult Bayesian diagnostic test / H&P calculator 102 clinical prediction rules 650 critical reviews of recent research from the Journal of Family Practice POEMs section Basic drug info by class and cost for 1200 drugs Key evidence- based treatment guidelines

  24. 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

  25. 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.

  26. Information Mastery An Evidence-Based Approach to Medical Education University of Virginia, Charlottesville, VA April 2 - 5, 2003

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