Information Mastery. Objectives At the end of this seminar, participants should be able to:...

Information Mastery

ObjectivesAt the end of this seminar, participants should be

able to: Incorporate information mastery principles into daily

learning and patient care activitiesFormulate focused foreground questions in PICO formatDistinguish between disease-oriented and patient-

oriented evidence Identify high quality evidence based on study designUse evidence-based medical databases to research

clinical queries and to stay up to date with medical literature

DisclosuresNo financial disclosuresMuch of the material and ideas were developed

by David Slawson, MD, and Alan Shaughnessy, PharmD, MMedEd

What is EBM?“Evidence-based medicine is the conscientious,

explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”David Sackett, 1996

Why read literature?Answer clinical questionsKeep up to dateFollow your interestsBe the best advocate possible for patients

Limitations of EBMLimited evidencePoor quality evidenceIndividual patient differences

What determines medical decisions?

Decision

Medical Evidence

Prior clinical

experienceIndividual

patient characterist

ics

Classic EBM5 step approach

AskSearchCritically appraise ImplementEvaluate

EBMInformation MasteryTraditional EBM = basic science, primary article

appraisalInformation Mastery = applied science

1994, Slawson and ShaughnessyGather valid, relevant, patient-oriented

information that is critically appraised and apply it to practice.

Use tools that appraise evidence for youAllows you to stay up do date without drowning in

the vast sea of primary journal articles.

UsefulnessUsefulness = (relevance * validity)/workRelevance: Does it matter to my patient?Validity: How well does the study reflect the

truth? Less work is better

Maximize reading high quality information without sifting through poor quality information

Clinical QuestionsType of question determines sources to useBackground (basic science)Foreground (specific clinical question)

PICOPatient population/problemInterventionComparisonOutcome

ACTIVITY 1Write a PICO for each case: Patient population/problem,

Intervention, Comparison, OutcomeCase 1: “A 65 year old man with T2DM checks his blood

sugar daily and does his best to control his blood sugar with exercise and nutrition. He wonders if having well-controlled blood sugars overtime will increase his lifespan.”  

Case 2: “A 40 year old woman presents with migraine headaches that are becoming more She is reluctant to use medications other than herbal supplements and tells you that she just read an article about the possible benefits of riboflavin for preventing migraines.

DOE vs POEDisease-oriented evidence/outcomes

Focused around diseases/labs.Patient-oriented outcomes

Focused on outcomes patients care about: Quality of lifeMorbidityMortality

Disease-Oriented Outcome

Patient-Oriented Outcome

Intensive glucose lowering can decrease A1c

Intensive glucose lowering does not decrease mortality

Beta-carotene, Vit E are good antioxidants

Neither prevents cancer or CV disease

Varenicline is effective for helping patients quit smoking

Varenicline increases the risk of adverse CV events

POEMPatient Oriented Evidence that MattersIs information relevant & does it matter? 3

criteria:Do patients care about the outcomes/is it patient-

oriented (quality of life, morbidity, mortality)? Is the intervention feasible? If true, will it require you to change your practice?

Yes to all 3 = POEM

ACTIVITY 2Read 2 evidence summariesDiscuss in small groups to determine if they are

POEMS3 criteria of POEMS

Do patients care about the outcomes/is it patient-oriented (quality of life, morbidity, mortality)?

Is the intervention feasible? If true, will it require you to change your practice?

Evidence Hierarchy

Graded EvidenceSORT

Developed by AAFPTakes POEM into consideration

USPSTF Graded recommendationsGRADE

Developed by international group of physiciansLevel of Evidence

11 categoriesDeveloped at Oxford

SORT (Strength Of Recommendation Taxonomy)

Code DefinitionA Consistent, good-quality patient-oriented evidenceB Inconsistent or limited-quality patient-oriented evidenceC Consensus, disease-oriented evidence, usual practice,

expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

Highly Controlled Research·Randomized Controlled Trials·Systematic Reviews

Physiologic ResearchPreliminary Clinical Research·Case reports·Observational studies

Uncontrolled Observations&

Conjecture

Effect on Patient-Oriented Outcomes·Symptoms (drivers license)·Functioning (visual loss)·Quality of Life (leg ulcers)·Lifespan

Effect on Disease Markers·Diabetes (Photocoagulation, GFR, NCV)·Arthritis (x-ray, sed rate)·Peptic Ulcer (endoscopic ulcer)

Effect on Risk Factors for Disease·Improvement in markers (blood pressure, HBA1C, cholesterol)

SORTA

Validity of Evidence

Rel

evan

ce o

f Out

com

e

SORTB

SORTC

USPSTF GradesGrade DefinitionA The USPSTF recommends the service. There is high certainty that

the net benefit is substantialB The USPSTF recommends the service. There is high certainty that

the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

GRADE (Grade of Recommendations, Assessment, Development, and Evaluation)

Code

Quality of Evidence

Definition

A High Further research is very unlikely to change our confidence in the estimate of effect. Several high quality studies with consistent results or one large high quality multi-center trial

B Moderate Further research is likely to have an important impact on our confidence in the estimate of the effect and may change the estimate. One high quality study, several studies with some limitations

C Low Further research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. One or more studies with severe limitations

D Very low Any estimate of effect is very uncertain Expert opinion, no direct research evidence, onre or more studies with very severe limitations.

Level of EvidenceDeveloped by Centre for Evidence-Based

Medicine in Oxford, EnglandMore detailed and complex

11 levels1a-c (systematic reviews), 2a-c, 3a-c, 4, 5 (expert

opinion)http://www.cebm.net/oxford-centre-evidence-bas

ed-medicine-levels-evidence-march-2009/ (see for a table)

Information Mastery Toolkit

Journals (2-3)Foraging services (summaries of new

information)Hunting tools (find answers to questions)

“Foraging” ServicesAnalyze articles/evidence for you and send you

summariesDynaMed AlertsEE Plus POEMSBMJ Clinical EvidenceFPIN Clinical InquiriesACP Journal Club

Characteristics of an Ideal Foraging/Alert Tool

How is the information filtered? Specialty specific Patient-oriented (relevance)

Is the information valid? Backed-up by evidence (level of evidence, SORT is always best)

Is the information summarized and easy to access? Comprehensive but summarized (2000-3000 words accurately

in 200 words) Point of care (work) Coordinated with a hunting tool

Is the information placed into context? Translational validity More than abstracts

Characteristics of an Ideal Foraging/Alert Tool

Specialty-specificPatient-oriented (relevance)Backed up by levels of evidence, SORT is best

(validity)Comprehensive but summarized (2000-3000

words accurately in 200 words)Point of care (work)Coordinated with a hunting tool

Foraging/Alert Tool RisksWho’s paying when it is free?

Possibly pharmaceutical companiesAbstracts only contain no relevance/validity filter

Examples are Journal Watch, Clinical Updates

TAKE HOME POINT: If it’s free there may be something wrong with it. Quality often doesn’t come free!

Foraging Tool OverviewTool Less work More workACP Journal Club -Specialty Specific (IM) -Validity assessment but

no LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool

BMP Updates -Specialty Specific (various)

-Validity assessment but no LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool

DynaMed Alerts -Specialty specific (various)-Validity assessment-LOE-Relevance: focuses on patient-oriented evidence-Coordinated hunting tool

Foraging Tool OverviewTool Less work More workJournal Watch -Specialty Specific

(various)-No validity assessment -No LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool

Medscape -Specialty Specific (various)

-No validity assessment-No LOE-Relevance: no POE vs DOE, no “matters” factor-No hunting tool

Fig 1 Updating curves for relevant evidence (128 systematic reviews) by point of care information summaries (log rank χ2=404, P<0.001).

©2011 by British Medical Journal Publishing Group

Banzi R et al. BMJ 2011;343:bmj.d5856

Summary of Foraging Tools

DynaMed: Fastest to update with new information

BMJ Clinical Evidence: Only sends valid articlesUpToDate: e-mails article authors every 6

months to ask for updates No one has looked at how accurately information

is summarized/said in the tools (are summaries valid?)

EBM “Hunting” ToolsPoint of care evidence-based tools (30-40

seconds)Best tools = useful = (relevance*validity)/work

DynaMedCochrane databaseEssential Evidence PlusBMJ Clinical EvidenceFPIN Clinical InquiriesTrip databasePub Med

Drilling for the Best Information

BMJ Clinical Evidence (therapy)

Dynamed

UpToDate

TRIP Database

TextbooksUs

eful

ness

Medline

Usefulness = Relevance X validityWork

R WV R WV

R WV

R WV

R WV

R WV

R

W

V

Essential EvidencePlus

PIERR WV R WV

Clinical JazzScience (EBM/structure) + Art (improvisation) =

Clinical JazzBoth structure and improvisation are necessary,

but there’s not good evidence for many areas of medicine, so we have a lot of liberty to improvise!

ACTIVITY 3Review use of the following tools:

DynaMedEssential Evidence PlusTRIP DatabaseBMJ Clinical evidence

ACTIVITY: Medical Myths

ACTIVITY: Look-up conference

Some Studies that I Like to Quotehttp://www.youtube.com/watch?v=Ij8bPX8IINg

James McCormack, MD