Transcript Information at the Point of Care

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)
• Meta-analysis
• Practice guidelines
• POEM Alert System
Refinement
The Medical Information Business
Production
• Clinician centered
informatics
• “Just-in-time” info Refinement
• Hand-held computers
• Internet/Intranet
• Hunting/Foraging tools
Distribution
The Medical Information Business
Production
• Evidence-Based
Sales &
Refinement
Medicine
Marketing
• Information
Mastery
Distribution
Information Sources for the
point of care
Everything is based on the usefulness
equation:
Usefulness = Relevance x Validity
Work
Validity
• The hard part of Information Mastery
• Technique: EBM working group
• Apply to other information sources
• Responsibility: Self vs. Delegation
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”
Relevance: Type of Evidence
• POE: Patient-oriented evidence
– mortality, morbidity, quality of life
• DOE: Disease-oriented evidence
– pathophysiology, pharmacology,
etiology
POEM
• Patient-Oriented
• Evidence
• that Matters
• matters to you, the clinician,
because if valid, will require you
to change your practice
Comparing DOES and POEMs
Example
Antiarrhythmic
Therapy
DiseaseOriented
Evidence
Patient-Oriented
Evidence that
Matters
Drug X  PVCs Drug X increases
on ECG
mortality
Comment
POEM study
contradicts DOE
study
POEM agrees
Antihypertensive Antihypertensive Antihypertensive
therapy  BP therapy  mortality with DOE
therapy
Prostate
Screening
PSA screening ? whether PSA
detects prostate screening 
cancer early
mortality
DOE exists, but
the important
POEM is
unknown
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
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”!
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”
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!
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
InfoPOEMs - The Clinical Awareness System
Alendronate prevents multiple fractures in osteoporotic women
over 55
Clinical question
Does alendronate prevent multiple fractures from occurring in women with osteoporosis?
Setting: Outpatient (any)
Study design: Randomized controlled trial (double-blinded)
Synopsis
The 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 line
Women 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?
LOE
2bReference
Levis 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.
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•LOE
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
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.
Translational Validity
Can 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
Translational Validity
Can 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
Drilling for the Best Information
Cochrane Library
Clinical Evidence
Specialty-specific
Usefulness
POEMs
Best Evidence
Textbooks, Up-toDate, 5-Minute
Clinical Consult
Journals/ Medline
InfoRetriever 2003
Windows 95/98/NT/ME/2000, PocketPC and Web
1500 short research synopses
(400 added per year)
5 Minute Clinical
Consult
Cochrane Database
of Systematic Reviews:
over 1200 abstracts
Bayesian
diagnostic
test / H&P
calculator
102 clinical
prediction
rules
Basic drug
info by class
and cost for
1200 drugs
Key evidencebased
treatment
guidelines
650 critical reviews
of recent research
from the Journal of
Family Practice
POEMs section
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
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.
Information Mastery
An Evidence-Based Approach
to Medical Education
University of Virginia, Charlottesville, VA
April 2 - 5, 2003