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Information Mastery: Evidence-Based Medicine in Everyday Practice

Information Mastery: Evidence-Based Medicine in Everyday Practice. David Slawson, MD Allen Shaughnessy, PharmD Mark Ebell, MD, MS Henry Barry, MD, MS. The Present/ The “Near” Future. All of us have been or will be patients Is it true that the information we need is there, when we need it?

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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 Slawson, MD Allen Shaughnessy, PharmD Mark Ebell, MD, MS Henry Barry, MD, MS

  2. The Present/ The “Near” Future • All of us have been or will be patients • Is it true that the information we need is there, when we need it? • Certainly our “PCP” is informed!? • Information Mastery: Answer 80% of information needs in 50 seconds or less.

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

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

  5. The Medical Information Business Production • Clinician centered informatics • “Just-in-time” info • Hand-held computers • Internet/Intranet • Push/Pull technology Refinement Distribution

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

  7. Why Become an Information Master? Clinicians as “informed consumers” of research/Catching your own fish

  8. How Well Do We Distribute New Information? Recognizing Failures In Communication And Learning • Fineberg 1987: Of 28 “Landmark” trials, only 2 had an immediate (1-2 year) effect on clinical practice • 13 years for thrombolytic therapy for acute MI • Evans 1984: The strongest predictor of knowledge of hypertension was the clinician’s year of graduation • Airline industry (3 jets every 2 days!)

  9. How do we learn? • Adults learn by solving problems • Our “problems” = clinical questions • CME can highlight advances and make us aware of our deficits • Answering clinical questions in the context of a real case at the point of care is how we learn

  10. 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) • Guessing at 7- 8/ 10 information needs!

  11. 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.

  12. The Clinician of the Future • “I know a lot, therefore I am” (replaceable by a computer) • “I think, therefore I am” (never replaceable by computer) • How can we “help” make this transition?

  13. Information Sources for the point of care Keep in mind the usefulness equation: Usefulness = Relevance x Validity Work

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

  15. 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”

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

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

  18. Comparing DOES and POEMs

  19. Population Effect (necessary vs sufficient) • Must consider overall effect on population! • PSA: may be good for men destined to die from prostate cancer • Overall may harm more than help (both in terms of quantity and/or quality of life) • We won’t know until 2008 at least (if we believe/accept the results!)

  20. New Technology: Computer-Assisted PAP Smear Rescreening • Rescreened 5,478 smears identified as “normal” • Identified 6 cases of ASCUS or AGUS • Estimated cost for finding one case of LGSIL - $17,475 to $101,343. • Will increase in cost actually lead to increased deaths from cervical cancer? DOEs vs POEMs; sensitivity vs specificity • Who are our patients? (JAMA 1998;279:235-7)

  21. Determining Validity • Levels of Evidence: • 1a, b, c; 2a, b, c; etc., 5- expert opinion • A, B, C, D, I • Therapy, diagnosis, prognosis, reviews, etc.

  22. Was allocation assignment “concealed”? • Did investigators know to which group the potential subject would be assigned before enrolling them? • Concealed allocation  blinding • Blinding can occur without concealed allocation (UVA example) • Allocation can be concealed in an unblinded study (mammograms)

  23. Concealed Allocation Conducting a Study Potential Subjects Trial starts Actual Subjects Randomization Blinding, etc A B

  24. Importance of concealed allocation Trials with unconcealed allocation consistently overestimate benefit by ~40% Schulz KF, Chalmers I, Hayes RJ, et al. JAMA 1995;273:408-12

  25. Importance of concealed assignment • Meta-analysis of trials evaluating screening mammography • In studies in which allocation wasn’t concealed • Higher SE status, education level in screened group • Uneven dropout rate due to pre-mammogram physicals (breast lumps) • Age disparity (average 6 mo older in the unscreened group) • Trials with concealed allocation = screening harmful! • No effect or increased mortality • 20% more mastectomies Lancet Jan 8, 2000; Oct 20, 2001

  26. Minimizing Work: Types of Archived Information Sources “Just-in-Case” information • Libraries, Medline, MDConsult, WebMd, MedScape, 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

  27. Minimizing Work: Types of Archived Information Sources “Just-in-Time” information • Highly filtered information sources with rapid access • 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

  28. Two Tools to Get the Job Done • Hunting (IR) and Foraging (POEM First Alert System- EBP/InfoPOEMs) go together like horse and carriage • Without both, you don’t know what you are looking for and can’t find it when you do. • Clinical example- Riboflavin for migraines • Family Medicine has the best now- only about 2000 are using it – Why?! • www.medicalinforetriever.com

  29. Focus on the Best: Valid POEMs! • Let someone else do the heavy lifting • Only 2.6% of articles, predigested (20-25 per month- only 8/mo in the JFP!)

  30. Medical InfoPOEMs Daily POEMs for Primary Care (Patient-Oriented Evidence that Matters) Increased thrombosis risk with new contraceptives Clinical question Do the new oral contraceptives increase the risk of thrombosis as compared with older products? Study design: Meta-analysis (non-RCT) Setting: Population-based  Synopsis Just like cepahalosporin antibiotics, we have "generations" of oral contraceptives. The newest oral contraceptives containing desogestrel or gestodene (e.g., Mircette, Ortho-Cept) are considered third generation, whereas the rest of the low-dose products are considered second generation. This analysis combined the results of case-control and cohort studies assessing the risk of venous thromboembolism (VTE). Overall, the odds of developing a VTE with the third generation contraceptives was 70% higher than with the second generation products (odds ratio 1.7, 95% CI 1.4-2.0). The risk seems to be higher among first-time users (odds ratio 3.1; 95% CI 2.0 - 4.6). We're still talking about a very small risk; the excess risk of VTE with the new products is 1.5 per 10,000 women per year. The additional risk of death is exceedingly small; 1 additional death in 25,000 women taking these products for 10 years. Bottom-line New oral contraceptives containing the progestins desogestrel or gestodene (e.g., Mircette, Ortho Cept) carry with them an increased risk of causing venous thromboembolism. The risk is still small; however, with the availability of many other equally-useful choices, often less expensive, it makes little sense to take this risk. (AS)  Reference Kemmeren JM et al. Third generation oral contraceptives and risk of venous thrombosis: A meta-analysis. BMJ 2001;323:131-4.

  31. Hunting: Quality of Reviews • 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 (Guess who does most CME talks?) • 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.

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

  33. InfoRetriever 4.1 Windows 95/98/NT/ME/2000, PocketPC and Web 1500 short research synopses (400 added per year) Cochrane Database of Systematic Reviews: over 1200 abstracts 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 www.MedicalInforetriever.com

  34. The Clinician of the Future • “I know a lot, therefore I am” (replaceable by a computer) • “I think, therefore I am” (never replaceable by computer) • Hand held computer = “stethoscope of the future”

  35. 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

  36. 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.

  37. Information Mastery An Evidence-Based Approach to Medical Education University of Virginia, Charlottesville, VA April 3 - 6, 2002

  38. “No one cares how much you know until they know how much you care” “Compassion without competence is dangerous” B. Lewis Barnett, Jr.

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