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Information Mastery for the 21st Century

Information Mastery for the 21st Century. or. how I learned to stop worrying and love evidence based medicine. Peter C. Smith, MD Assistant Professor of Family Medicine, UCDHSC Director, BIGHORN Research Network Assistant Editor, Journal of Family Practice

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Information Mastery for the 21st Century

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  1. Information Mastery for the 21st Century or how I learned to stop worrying and love evidence based medicine Peter C. Smith, MD Assistant Professor of Family Medicine, UCDHSC Director, BIGHORN Research Network Assistant Editor, Journal of Family Practice Assistant Editor, Family Physicians Inquiries Network Faculty, Rose Family Medicine Residency

  2. WARNING!!!! • THIS TALK CONTAINS…. • IDEAS! • CONTROVERSIAL (MANY) • DEBATABLE (ALL) • NEW (SOME) • QUOTATIONS • RECYCLED (MOST) • FROM OLD DEAD WHITE GUYS (MOST) • MOVING TEXT • DISTRACTING • ANNOYING

  3. Road Map • Evidence Based Medicine (EBM) • What It Is • What It Is Not • A Historical Perspective • Why EBM? • Now What?

  4. This is going to be GREAT! “There's nothing more exciting than science. You get all the fun of sitting still, being quiet, writing down numbers, paying attention. Science has it all.” - Principle Seymour Skinner, The Simpsons

  5. What Evidence Based Medicine IS • A way of practicing medicine. • “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” --Sackett et al. JAMA 1993

  6. What Evidence Based Medicine IS 1. Regularly asking specific clinical questions about patients’ problems 2. Efficiently searching existing sources of information for the answers 3. Appraising the quality & validity of the answers 4. Implementing useful findings into everyday practice

  7. What Evidence Based Medicine IS NOT • Cookbook medicine • Tyranny of Randomized Controlled Trials • Telling doctors how to practice • A substitute for sound reasoning, judgement, and knowledge of the patient • A conspiracy to cut costs while depriving people of effective medical care • Impossible

  8. A Quick Timeline • 17th Century EBM • 18th Century EBM • 19th Century EBM • 20th Century EBM • 21st Century EBM

  9. 17th Century EBM • Sir William Petty 1623-1687 • (a) Father of Modern Economics and Political Statistics • The results of care are what matter • People with access to doctors fared no better than people without doctors. • Not very popular!

  10. 18th Century EBM • Pierre Alexander-Charles-Louise 1787-1872 • Applied numerical tools to clinical medicine to prove efficacy of treatment • Observation & comparison • First to declare “therapeutic phlebotomy” as useless and likely harmful • “Radical Empiricism” and “Therapeutic Skepticism”

  11. 19th Century EBM (part I) • Ignatz Semmelweis (1818-1865) • Midwive’s maternity ward mortality: 1% • Doctors’ maternity ward mortality: 34% • Careful observation and early application of statistical techniques indicated the cause: • Dirty hands (pre-germ theory) • Disgraced for his ridiculous ideas • 140 years later…

  12. 19th Century EBM (part II) • Sir James MacKenzie 1853-1925 • State of the Art 1880: • Standard of Care for Heart Murmurs and PVCs = Bed rest • Noticed that many murmurs and “extra systoles” were benign in general practice. • millions saved from life in bed • (and DVTs, bed sores, poverty?)

  13. The Great Quantitative Debate • Competing European Paradigms Imported to the United States • The French/English Empiricists • Observation and Comparison • Focus on Patient Outcomes (POEMs) • The German Etiologists (Koch) • Laboratory Experimentation • Focus on Disease and Etiology (DOE)

  14. The Etiologists “Flex” their Muscles • Abraham Flexner • Charged with up-grading US higher education, then medical education • 1910, The Flexner Report • Brother Simon Flexner was: • A physician • A “Kochian” etiologist

  15. 20th Century EBM • Medical Science as we commonly know it • Explosion in medical knowledge • Largely driven by intermediate endpoints • Blood sugar, BP, fetal heart rate, excision • Influenced by Kochian perspective • Not working: • “Never has a nation spent so much to accomplish so little for so few.” --Larry Green • Late 20th Century resurgence of empirical approach • Called, “Evidence-Based Medicine”

  16. Road Map • What EBM is • What EBM is not • A historical timeline - 21st Century EBM? • Why EBM?

  17. Why Practice EBM? • “An evidence-based approach... liberates you from a reliance on dogma and tradition, and it allows you to critically evaluate both traditional and alternative or complementary therapies in an even-handed manner.” -Mark Ebell, 1999 • “…it is permissible to make a judgment after you have examined the evidence. In some circles it is even encouraged” - Carl Sagan

  18. Why EBM? Practice Variation Prostactectomy rates (per 100,000): Rhode Island 20 Alaska 429 Ratio = 21 to 1! Are Rhode Islanders being negleted? Are Alaskans getting butchered? What the Hell is going on?!?!?!?!?

  19. Why EBM? Practice Variation Wennberg J, Center for the Evaluative Clinical Sciences, Dartmouth Medical School. "Geography and the Debate Over Medicare Reform," Web Exclusive for Health Affairs, 2/02

  20. Why EBM? Practice Variation • Therapeutic decisions are based on…* • Strong evidence from clinical trials • 4% • Minimal evidence from studies but strong clinical consensus • 45% • Neither evidence nor consensus but on personal opinion: • 51% *Field MJ, Lohr KN. Guidelines for clinical practice. Institute of Medicine. Washington, DC: National Academy Press; 1992. p. 34-9.

  21. Why EBM ?: Different Frames of Reference • Selection Bias • Efficacy vs. Effectiveness

  22. Why EBM? Different Frames of Reference

  23. Why EBM? Different Frames of Reference • “The university medical center…sees biased samples of one tenth of one percent of the “sick” adults, from which students of the health professions must get an unrealistic concept of medicine’s task…” - Kerr White

  24. Why EBM? Different Frames of Reference • A personal anecdote • How do you treat chronic fluid behind the ear drum in a patient with allergies? • Ask your friendly neighborhood Otologist: • “You must get a CT scan to rule out naso-pharyngeal carcinoma!” • (I did - negative for diagnosis of naso-pharyngeal carcinoma, but positive diagnosis of anxiety!)

  25. Why EBM? Different Frames of Reference • Efficacy vs. Effectiveness • Efficacy • The ability to produce effect in controlled environment (e.g., RCT) • Physics: “Frictionless Universe”; Economics: “All other things being equal” • Effectiveness • Whether that efficacy persists when introduced into the real world. • Too often ignored in medical research • Patients are sicker; we don’t take our pills; differences in gender, race, and age; it’s too hard; too expensive; side effects; etc. • “Can it work” vs. “Should I use it?”

  26. Why EBM? The Information Tsunami • So much research, so little time • Even the newest textbooks are 5-10 years out of date • 6,935 articles a year in primary care alone = 19 articles a day, 365 days a year….. • FOR THE REST OF YOUR LIFE!

  27. Why EBM? The Information Tsunami 5,000? per day 1,500 per day 55 per day From “Evidence Based Practice, Paul Glasziou University of Queensland & Oxford

  28. Why EBM? The Information Tsunami Your First EBM Equation

  29. The Equation: Validity • Internal Validity: • Does study measure what it says it does? • External Validity: • Can the results be generalized to a larger population? • (efficacy vs. effectiveness)

  30. The Equation: Validity • Worksheets and Tools • http://www.med.ualberta.ca/ebm/ • Study designs and statistics are ways to avoid BIAS. Less bias = closer to the truth • Don’t get scared by statistics • "In science as in love, too much concentration on technique can often lead to impotence.” -P. L. Berger

  31. Why EBM? The Information Tsunami • So much crappy research, so little time • “Education...has produced a vast population able to read but unable to distinguish what is worth reading.” --George Macaulay Trevelyan

  32. Study Designs :Acute MI treatment 60 N=43 % Studies with Significant Case-Fatality Rate Differences 50 40 30 N=45 20 10 N=57 0 Unblinded Randomization Blinded Randomization Non-Random Chalmers,et al. N Engl J Med 1983; 309:1358-61

  33. The Equation: Relevance • Does the study... • Address the issue in which you’re interested? • Provide... • DOE (disease oriented evidence) like FEV1, BP, LAD patency, etc? • or PROSE (Prescriptive Recommendations based on Substandard Evidence), i.e. an uncritical, non-systematic review? • or POEM (patient-oriented evidence that matters, like m&m, symptom reduction,quality of life)?

  34. DOE vs. POEMs

  35. Effect on Patient-Oriented Outcomes • Symptoms • Functioning • Quality of Life • Lifespan Valid Patient-Oriented Evidence • Effect on Disease Markers • A1c in diabetes • MICs in infection • BMD in osteoporosis Disease-Oriented Evidence Relevance of Outcome • Effect on Risk Factors for Disease • Improvement in markers (blood pressure, cholesterol) Uncontrolled Observations & Conjecture • Physiologic Research • Preliminary Clinical Research • Case reports • Observational studies • Highly Controlled Research • Randomized Controlled Trials • Systematic Reviews Validity of Evidence Graphic from Allen Shaughnessy, PharmD “EBM – Is it enough?”

  36. Levels of Evidence • Centre for Evidence Based Medicine, Oxford • Levels of evidence: 1a,b,c;2a,b,c;3a,b;4;5 • Complicated, confusing • Strength of Recommendation Taxonomy • S.O.R.T: Useful, elegant • Levels 1, 2, and 3

  37. Strength of Recommendation Taxonomy (SORT) • Effect on Patient-Oriented Outcomes • Symptoms • Functioning • Quality of Life • Lifespan SORT A SORT B • Effect on Disease Markers • A1c in diabetes • MICs in infection • BMD in osteoporosis SORT C Relevanceof Outcome • Effect on Risk Factors for Disease • Improvement in markers (blood pressure, cholesterol) Uncontrolled Observations & Conjecture • Physiologic Research • Preliminary Clinical Research • Case reports • Observational studies • Highly Controlled Research • Randomized Controlled Trials • Systematic Reviews Validity of Evidence Graphic from Allen Shaughnessy, PharmD “EBM – Is it enough?”

  38. A Tale of 2 Pyramids

  39. Why EBM? The Information Tsunami • So much crappy research, so little time • POEM = Patient Oriented Evidence that Matters • Topics that measure outcomes that are meaningful to patients (e.g. morbidity, mortality, quality of life) that could change practice if true • Ebell M. et al. Finding POEMs in the Medical Literature. J Fam Pract 1999 • Reviewed 8,085 articles in 85 medical journals over 6 months • Only 2.6% qualified as POEMs • Still 211 articles = 1.17 articles per day…. • FOR THE REST OF YOUR LIFE!

  40. Why EBM? The Information Tsunami Your First EBM Equation

  41. Why EBM? The Information Tsunami • Hunters and gatherers • Information Gatherers • Passively “graze” whatever comes along • Journal subscriptions • Email Alerts • CME programs • Pharmaceutical detailing • Information Hunters • Go out and get answers to questions

  42. “Just in Time” learning:Intern’s information needs • Setting: 64 residentsat 2 New Haven hospitals • Method: Interviewed after 401 consultations • Questions • Asked 280 questions (2 per 3 patients) • Pursued an answer for 80 questions (29%) • Not pursued because • Lack of time • Forgot the question • Sources of answers • Textbooks (31%), articles (21%), consultants (17%) Green, Am J Med 2000

  43. Fertile Fields & Happy Hunting Grounds Information Masters do Hunting AND gathering “The next best thing to knowing something is knowing where to find it.” -Samuel Johnson • Primary research (Medline, PubMed,Journals) • Secondary sources of evidence • EBM Books (Best Evidence) • Journals (J. of Family Practice, ACP Journal Club) • Electronic (FPIN/PEPID, Cochrane, DARE, InfoRetreiver, Bandolier, Medline EBM filters, etc.)

  44. (Relevance x Validity) / Work = YODA? “I not only use all the brains that I have, but all that I can borrow.” -- Woodrow Wilson YourOwnDataAnalyzer

  45. Anti-YODAs • PROSE (Proscriptive Recommendations based On Substandard Evidence) • American Family Physician (AFP) • Clinics of North America • Post Graduate Medicine • Old English J. of Esoterica (NEJM) • “throw away” journals • Up to Date

  46. YODAs • Cochrane Database • Systematic reviews and meta-analysis • Journal of Family Practice (JFP) • J. of the American Board of FP (JABFP) • British Medical Journal (BMJ) • Best Evidence • Evidence Based Practice Newsletter • Bandolier • InfoRetriever / InfoPointer • Family Practice Information Network (FPIN)

  47. The risk of PROSE • Expertise is inversely related to the truth!* • Shaughnessy & Slawson, BMJ 2002 • Looked at rates at which non-systematic review articles on diabetes mentioned the best evidence from the United Kingdom prospective diabetes study (UKPDS) • *Joyce J. et alJAMA. 1998

  48. PROSE vs POEMs

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