Information Mastery:

Slide 1:Information Mastery:A Practical Approach to Practicing and Teaching Evidence-Based Medicine

Course Directors: Allen Shaughnessy, PharmD David Slawson, MD Tufts Health Care Institute Tufts University School of Medicine November 18-20, 2010 Boston, Massachusetts This is the introductory overview to the concepts of information mastery. It is crucial to understand these concepts if one is to become a master of information. The first half of the presentation is highly conceptual, but once we get these concepts under our belt we can spend the rest of the workshop on applying them. See: 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. This is the introductory overview to the concepts of information mastery. It is crucial to understand these concepts if one is to become a master of information. The first half of the presentation is highly conceptual, but once we get these concepts under our belt we can spend the rest of the workshop on applying them. See: 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.

Slide 3:Practice Guidelines

The Good, The Not-So-Good The Ugly

Slide 4:Where do practice guidelines come from?

Trust us, we�re the experts: Opinion-based/ consensus guidelines Whose opinion? Do they have a conflict of interest? What is their perspective? Trust us, we have the evidence: �Evidence-based� How was the evidence used? Patient-oriented? Values? Evidence-linked: Here is how we found the evidence, used the evidence Strength of recommendation noted

Slide 5:Guidelines: Ultimately a social exercise

Evidence: It is what it is The human touch: Social judgment layered on top of the evidence

Slide 6:Breast Cancer Screening and the USPSTF

The Evidence

Slide 7:How They Arrived at these Conclusions

Meta-analysis of 8 randomized controlled trials (RCTs) Invited a total of 348,219 women at age 40 yrs for yearly screening 0-3 studies, individually, showed a decrease in breast cancer mortality Meta-analysis: Combining results from all trials and analyzing the results Results:

Slide 8:Figure. Nelson HD. Screening for breast cancer: An update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151:727-737.

Slide 9:Benefits10,000 women ages 40-49 yrs screened yearly

USPSTF Recommendation Statement. Ann Intern Med 2009;151(10):716-726

Slide 12:Breast cancer mortality vs all causes of mortality, all ages

Black WC, et al. All-Cause Mortality in Randomized Trials of Cancer Screening. Journal of the National Cancer Institute, Vol. 94, No. 3, 167-173, February 6, 2002

Slide 13:Causes of death in women, by age Bunker JP, Houghton J, Baum M. Putting the risk of breast cancer in perspective. BMJ 1998;317:1307-9.

Slide 14:But What About �1-in-8�?

Ave lifespan = 79 years Bunker JP, et al. Putting the risk of breast cancer in perspective. BMJ 1998;317:1307-9.

Slide 15:Risks10,000 women ages 40-49 yrs screened yearly

USPSTF Recommendation Statement. Ann Intern Med 2009;151(10):716-726

Slide 16:Pseudodisease (overdiagnosis)

A condition that looks just like the disease, but never would have bothered the patient Disease that would never cause symptoms Asymptomatic disease in people who will die from another cause before disease presents An estimated 10%-30% of breast cancers found and treated would have never affected the patients The question: which ones? Cochrane Database Syst. Rev. 2009;CD001877 doi:10.1002/14651858.CD001877.pub3

Slide 17:Overdiagnosis bias

Gigerenzer G, et al. Helping doctors and patients make sense of health statistics. Psychological Science in the Public Interest 2008;8(2):53-96.

Slide 18:Evaluating Screening Tests

Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94

Slide 19:Can We Trust Guidelines from Specialty Societies?

Or Never ask a barber if you need a haircut

Slide 20:�. . . The guild of health care professionals � including their specialty societies � has a primary responsibility to promote its members� interests. . . Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med 2010; 363:1076-1079

Slide 21:. . . It is a fool�s dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone � to compete on true value when the opportunity to inflate perceived value is readily available.� Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med 2010; 363:1076-1079

Slide 22:�Evidence-based� and the evolution of evidence: subclinical hypothyroidism

Step 1 Search of 10 databases Studies summarized 12 experts rated the evidence Recommendations: �Recommend against routine screening for subclinical hypothyroidism� �Recommend against routine treatment of 4.5 � 10.0 mIU/L� Surks MI, et al. Subclinical thyroid disease. Scientific Review and Guidelines for diagnosis and management. JAMA 2004;291:228-238.

Slide 23:�Evidence-based� and the evolution of evidence: subclinical hypothyroidism

Step 2: Consensus meeting among members of the American Association of Clinical Endocrinologists, The American Thyroid Association, and The Endocrine Society. New recommendation statement Recommendations sent to leadership of the organizations

Slide 24:The evolution of evidence: subclinical hypothyroidism

The result: New recommendations from the three societies: Most patients with TSH levels 4.5 � 10 mIU/L should be treated Should perform routine screening for subclinical hypothyroidism Why? �Although good evidence is unavailable [to support our recommendation], there is a sizable amount of fair evidence and an abundance of opinion by experts . . . The [scientific panel recommendations] are contrary to the practice of many. . . experts� Gharib H, et al. Consensus statement: Subclinical thyroid dysfunction: A joint statement on management from the American Association of Clinical Endocrinologists, The American Thyroid Association, and The Endocrine Society. J Clin Endocrinol Metab 2005;90:581-5.

Slide 25:Bilirubin in term infants (Sept 2009)

USPSTF: Summary of Recommendation �The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy� American Academy of Pediatrics Restatement and Clarification �. . .We recommend universal predischarge bilirubin screening,which helps to assess the risk of subsequent severe hyperbilirubinemia. We also recommend a more structured approach to management and follow-up according to the predischarge TSB/TcB, gestational age, and other risk factors for hyperbilirubinemia. These recommendations represent a consensus of expert opinion based on the available evidence, and they are supported by several independent reviewers. Nevertheless, their efficacy in preventing kernicterus and their cost-effectiveness are unknown. �

Slide 26:Evidence Linked Guidelines

Brief Summary Statement for each recommendation Detailed Discussion of the evidence Long Reference section pointing to original research Methods section showing how evidence was obtained and evaluated It�s easy to spot these types of guidelines: they almost always have summary statements for each specific recommendation, followed by a detailed discussion of the evidence including how it was found, where it was found, and how relevant and valid it was. It�s easy to spot these types of guidelines: they almost always have summary statements for each specific recommendation, followed by a detailed discussion of the evidence including how it was found, where it was found, and how relevant and valid it was.