Transcript What is Clinical Decision Support? - Faculty Virginia

I'm All Shook Up … How to Stay
Ahead of the Constantly Changing
Medical Information Business
Scott M. Strayer, MD, MPH
Associate Professor
Department of Family Medicine
University of Virginia Health
System
Objectives
1. Apply a practical, evidence-based framework for
evaluating medical information tools.
2. Understand how clinicians use point of care technology to
“hunt” for evidence-based information that can be applied
to clinical decision making on a daily basis.
3. Understand how clinicians use “foraging” tools to
systematically sift through new medical information that is
valid and relevant to clinical practice.
4. Evaluate “hunting” and “foraging” tools to determine the
validity and relevance of their information sources.
Scientific discoveries will
require technological solutions
that allow physicians to
access the latest findings 24
hours a day, 7 days a week,
online and on demand, as
medical learning becomes a
nonstop process
Newt Gingrich, AAFP Assembly,
Sep 28, 2006
Medical Information is Big Business
Now!
New EPS Research Forecasts The Scientific, Technical & Medical (STM)
Information Market To Reach Nearly $11 Billion Dollars By 2008
·Publicly-traded STM publishers grew 8.6% in their reported currencies in 2005;
aggregate profit margins held steady at 25% ·Thomson posted the strongest increase
in profits with a year-over-year gain of 20.5%, outperforming its peers and the market
average of 17.7% ·Elsevier achieved the strongest organic growth: 5% and 6% in its
Science & Technology and Health Sciences divisions, respectively ·The five largest
players (Reed Elsevier, Thomson, Wolters Kluwer, Springer and Wiley) continued to
acquire scale, and now account for over half (52.3%) of total market revenues
·Revenues from digital content distribution may be nearing a tipping point: 60% of STM
First Wave of Acquisitions in
Medical Information Business
Wiley publishers now owns InfoRetriever
and Info Poems, now “Essential Evidence”
Ebsco publishers owns Dynamed
Recent Changes
Skyscape acquired by Physicians
Interactive, Inc. (2009)
Wolters Kluwers acquired UpToDate
(2008)
Large publishers and other businesses
focused on profitability will continue to
acquire evidence based sources
How did most physicians
find out about that new
smoking cessation drug?
Varenicline, an 4 2 Nicotinic Acetylcholine Receptor Partial Agonist, vs Sustained-Release Bupropion and
Placebo for Smoking Cessation
A Randomized Controlled Trial
David Gonzales, PhD; Stephen I. Rennard, MD; Mitchell Nides, PhD; Cheryl Oncken, MD; Salomon Azoulay, MD;
Clare B. Billing, MS; Eric J. Watsky, MD; Jason Gong, MD; Kathryn E. Williams, PhD; Karen R. Reeves, MD; for
the Varenicline Phase 3 Study Group
JAMA. 2006;296:47-55.
Context The 4 2 nicotinic acetylcholine receptors (nAChRs) are linked to the reinforcing effects of nicotine and
maintaining smoking behavior. Varenicline, a novel 4 2 nAChR partial agonist, may be beneficial for smoking
cessation.
Objective To assess efficacy and safety of varenicline for smoking cessation compared with sustained-release
bupropion (bupropion SR) and placebo.
Design, Setting, and Participants Randomized, double-blind, parallel-group, placebo- and active-treatment–
controlled, phase 3 clinical trial conducted at 19 US centers from June 19, 2003, to April 22, 2005. Participants
were 1025 generally healthy smokers ( 10 cigarettes/d) with fewer than 3 months of smoking abstinence in the
past year, 18 to 75 years old, recruited via advertising.
Intervention Participants were randomly assigned in a 1:1:1 ratio to receive brief counseling and varenicline
titrated to 1 mg twice per day (n = 352), bupropion SR titrated to 150 mg twice per day (n = 329), or placebo
(n = 344) orally for 12 weeks, with 40 weeks of nondrug follow-up.
Main Outcome Measures Primary outcome was the exhaled carbon monoxide–confirmed 4-week rate of
continuous abstinence from smoking for weeks 9 through 12. A secondary outcome was the continuous
abstinence rate for weeks 9 through 24 and weeks 9 through 52.
Results For weeks 9 through 12, the 4-week continuous abstinence rates were 44.0% for varenicline vs 17.7% for
placebo (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.70-5.50; P<.001) and vs 29.5% for bupropion SR
(OR,
95%9CI,
1.40-2.68;
Bupropion SR
was also significantly
more 21.9%
efficacious
placebo (OR,
For 1.93;
weeks
through
52,P<.001).
the continuous
abstinence
rates were
forthan
varenicline
2.00; 95% CI, 1.38-2.89; P<.001). For weeks 9 through 52, the continuous abstinence rates were 21.9% for
vs 8.4% vs
for8.4%
placebo
(OR,(OR,
3.09;
95%
1.95-4.91;
P<.001)
vsfor16.1%
for SR (OR, 1.46;
varenicline
for placebo
3.09;
95% CI,
CI, 1.95-4.91;
P<.001)
and vsand
16.1%
bupropion
95%
CI, 0.99-2.17;
P = .057).
Varenicline
reduced
craving P
and=withdrawal
bupropion
SR (OR,
1.46;
95% CI,
0.99-2.17;
.057). and, for those who smoked while
receiving study drug, smoking satisfaction. No sex differences in efficacy for varenicline were observed.
Varenicline was safe and generally well tolerated, with study drug discontinuation rates similar to those for
placebo. The most common adverse events for participants receiving active-drug treatment were nausea (98
participants receiving varenicline [28.1%]) and insomnia (72 receiving bupropion SR [21.9%]).
Conclusion Varenicline was significantly more efficacious than placebo for smoking cessation at all time points
and significantly more efficacious than bupropion SR at the end of 12 weeks of drug treatment and at 24 weeks.
For weeks 9 through 52, the continuous abstinence rates were 21.9% for varenicline
vs 8.4% for placebo (OR, 3.09; 95% CI, 1.95-4.91; P<.001) and vs 16.1% for
bupropion SR (OR, 1.46; 95% CI, 0.99-2.17; P = .057).
95% C.I.
Since the 95% CI
crosses 1.0, the
difference is not
significant
0.99
Difference could
be this minimal
(1% decrease)
1.0
1.46
2.17
Difference
could be this
high
(117%
increase)
How Well Do We Distribute
New Information?
Left to our own devices

1987: Of 28 Landmark trials, only 2 had
an immediate (1-2 year) effect on
clinical practice Fineberg HV. Clinical evaluation: how
does it influence medical practice? Bull Cancer 1987;74:333-46.

1992: Thrombolytic therapy for acute
MI: 13 years after proof of benefit
before review articles suggest it for
routine use
Antman EM, et al. A comparison of results of meta-analyses of
randomized control trials and recommendations of clinical experts.
Treatments for myocardial infarction. JAMA 1992;268:240-8.
How Well Do We Distribute
New Information?
1996: Little effect of publication of the ISIS-2
(Aspirin works post-MI) and diltiazem postinfarction trial (diltiazem doesn’t work).---ASA
and Diltiazem use---no change after trial
Col NF, et al. The impact of clinical trials on the use of medications for acute myocardial
infarction. Arch Int Med 1996; 156: 54 - 60.
Majumdar 2003:

HOPE study –  in ramipril prescribing by 5% per
month without advertising, 12%  per month with
advertising over the next 2 years
Majumdar SR, et al. Synergy between publication and promotion: Comparing
adoption of new evidence in Canada and the United States. Am J Med
2003;115:467-72.
How Well Do We Distribute
New Information?
Bottom Line:

Change occurs quickly
When supported by lots of publicity
or pharmaceutical company
marketing (like any consumer
product)

Change is much slower
When left up to publications or word
of mouth for dissemination of
information
Two Tools Needed to Master
Information- BMJ 1999
A method of being alerted to new information (a
“foraging” or “push” tool)
A tool for finding the information again when you
need it. (a “hunting” or “pull” tool)
Without both:


You don’t know that new info. is available
You can’t find it when you do
Clinical example- Anticholinergics for COPD
Shaughnessy AF, Slawson DC. Are we providing doctors with the training and tools
for lifelong learning? British Medical Journal 1999 (13 Nov): www.bmj.com.
(http://bmj.com/cgi/reprint/319/7220/1280.pdf)
Information Mastery in a
Nutshell
Clinically useful information can be defined by:
Usefulness = Relevance x Validity
Work
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.
Effect on Patient-Oriented
Outcomes
Symptoms
Functioning
Quality of Life
Lifespan
Valid PatientOriented
Evidence
Effect on Disease Markers
Diabetes
Arthritis
Peptic Ulcer
Effect on Risk Factors for
Disease
Improvement in markers
(blood pressure, cholesterol)
Uncontrolled Observations
&
Conjecture
Physiologic Research
Preliminary Clinical
Research
Case reports
Observational studies
Validity of Evidence
Highly Controlled Research
Randomized Controlled
Trials
Systematic Reviews
Strayer’s Corollary: Information
Mastery and Computers
Not always assessed by software
Usefulness = Relevance x Validity
Work
Can be reduced by
computers
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.
Clinicians demand “just-in-time”
resources
48 randomly selected generalist physicians in
ambulatory care
Asked 1062 questions but only answered 585
(55%)
Obstacles:




Doubt that answer exists (11%)
Selected source doesn’t have answer (26%)
Requested comprehensive sources that answer
questions likely to occur in clinical practice with
emphasis on treatment and bottom-line advice
Help locating information quickly with lists, bolded
sub-headings, algorithms….avoid lengthy text
Ely et al J Am Med Inform Assoc. 2005 Mar-Apr;12(2):217-24.
Quality Hunting and Foraging
Systems---A New Definition
1. How is the information filtered?




Patient- vs disease- oriented?
Specialty-specific?
Comprehensive? Which journals?
Does it matter (change my practice?) or is it
simply news?
2. Is the information valid?


must have levels of evidence labels
Beware “Trojan Horse”!
Quality Hunting and Foraging
Foraging Systems
3. How well is information summarized?

2000 - 3000 words accurately in 200 words
4. Is the information placed into context?


Much more than abstracts
“Translational Validity”
Hunting Tools
Hunting







First Consult—www.firstconsult.com
Essential Evidence
Up To Date---www.uptodateonline.com
DynaMed---www.dynamicmedical.com/
Medscape---www.medscape.com
Database of Abstracts of Reviews of Effectiveness
DARE---http://agatha.york.ac.uk/darehp.htm
Translating Research Into Practice (TRIP)--www.tripdatabase.com
Foraging Tools
Systematically identified tools between MayAugust 2007
Searched Internet for all medical content sites
(e.g. Medscape, WebMD, etc.)
Searched well-known evidence-based
databases (e.g. Cochrane, TRIP, DARE)
Monitored List-serves for Health IT and PDA
tools (e.g. Palm-Med, Wireless Medical
Applications, STFM EBM)
Consulted with experts and practicing physicians
Sent invitations to list-serves for suggestions
tool
Abbrev.
URL
American College of Physicians Journal Club
AC
www.acpjc.org
American Family Physician Tips
AF
www.aafp.org
BMJ Clinical Evidence
CE
http://clinicalevidence.bmj.com/ceweb/index.jsp
Cochrane for Clinicians
CC
http://www.aafp.org/afp/20070501/cochrane.html
Doctor’s Guide
DG
www.docguide.com
Dynamed Weekly Update
DM
http://www.ebsconewsletter.com/dmweeklyupdate/index000
242960.cfm?x=b11,0,w
Epocrates DocAlerts
EP
www.epocrates.com
Essential Evidence Plus (formerly InfoPoems)
EE
http://infopoems.com
FPIN Clinical Inquiries
FP
http://www.aafp.org/afp/20070101/fpin.html
Global Family Doctor Daily Alerts
GF
www.globalfamilydoctor.com
Journal Abstracts Delivered Electronically
(JADE)
JD
www.biodigital.org/jade
Journal Watch
JW
www.jwatch.org
MD Linx Network
LX
www.mdlinx.com
Medscape Best Evidence (also BMJ Updates
and McMaster Plus)
ME
www.medscape.com
PeerView Institute
PV
www.peerview-institute.org
Physician’s First Watch
PW
http://firstwatch.jwatch.org/misc/about.dtl?q=etoc
Skyscape ARTbeat
SA
www.skyscape.com/Estore/ProductDetail.aspx?ProductID=
924
Treatment Guidelines
TG
www.medicalletter.org
Hunting and Foraging System
Risks
“Spyware”: May be tracking your usage
“Trojan Horse”: who’s paying when it’s free?
Abstracts only: Journal Watch, Journal Rack,
Tips from other Journals, Clinical Updates,
etc.

No relevance/ validity filter
You can have information “free” and you can
have it “uncensored”, but you can’t have it both
ways. No Free Lunch!
Not All Information Tools
are Created Equal!
Quality of Drug Foraging and
Hunting Tools
Strayer, SM, Slawson, DC, Shaugnessy, AM, Disseminating Drug Prescribing
Information: The COX-2 Inhibitor Withdrawals. JAMIA 2006. 13:396-398.
A Few Foraging Tools…
Beware of the Trojan
Horse
Will Skyscape Become a new
Trojan Horse Information
Source?
A Few Hunting Tools…
Rating Hunting and
Foraging Tools
Rating Hunting and Foraging Tools
Hunting Tool Evaluation Worksheet
Foraging Tool Evaluation Worksheet
BMJ Updates
Hunting and Foraging Tools
Foraging

InfoPoems---www.infopoems.com

Peer View Institute--www.peerview-institute.org/

Journal Alerts--www.globalfamilydoctor.com/daily
alerts/main.htm

Medscape Best Evidence
(http://hiru.mcmaster.ca/MORE/Ho
wRatingsAreUsed.htm)

MDLinx

BMJ Updates
(http://bmjupdates.mcmaster.ca)

First Watch (www.jwatch.org)

Cochrane PEARLS
Hunting







First Consult—
www.firstconsult.com
InfoPoems
Up To Date--www.uptodateonline.com
DynaMed--www.dynamicmedical.com/
Medscape--www.medscape.com
Database of Abstracts of
Reviews of Effectiveness
DARE--http://agatha.york.ac.uk/dareh
p.htm
Translating Research Into
Practice (TRIP)--www.tripdatabase.com
Foraging Tools Results
Only seven tools had specific criteria for
both relevance and validity







American College of Physicians Journal Club
BMJ Clinical Evidence
Cochrane for Clinicians
DynaMed
Essential Evidence (formerly InfoRetriever)
FPIN Clinical Inquiries
Treatment Guidelines (Medical Letter)
Summarize
Evidence-based clinical decision making
requires a coordinated “hunting” and
“foraging” tool.
Use the principles of Information Mastery
to evaluate your information tools.
Not all information tools are created alike--evaluate using worksheets.
Contact Information
E-mail: [email protected]
Information Mastery Course:
http://www.healthsystem.virginia.edu/inter
net/familymed/information_mastery/inform
ation_mastery_course.cfm
Center for Information Mastery:
http://www.healthsystem.virginia.edu/inter
net/familymed/information_mastery/info_m
astery.cfm