Clinical Decision Making in Clinical Decision Making in Three Minutes or Less: Three Minutes or Less:

Information Mastery at the Information Mastery at the Point of CarePoint of Care

Scott M. Strayer, MD, MPHScott M. Strayer, MD, MPH

Assistant ProfessorAssistant Professor

Department of Family MedicineDepartment of Family Medicine

University of Virginia Health SystemUniversity of Virginia Health System

ObjectivesObjectives

1. Apply a practical, evidence-based framework for 1. Apply a practical, evidence-based framework for evaluating new medical information. evaluating new medical information. 2. Understand how to use point of care technology to 2. Understand how to use point of care technology to "hunt" for evidence-based information that can be "hunt" for evidence-based information that can be applied to clinical decision making on a daily basis. applied to clinical decision making on a daily basis. 3. Understand how to use "foraging" tools to 3. Understand how to use "foraging" tools to systematically sift through new medical information that systematically sift through new medical information that is valid and relevant to clinical practice. is valid and relevant to clinical practice. 4. Evaluate "hunting" and "foraging" tools to determine 4. Evaluate "hunting" and "foraging" tools to determine the validity and relevance of their information sources. the validity and relevance of their information sources.

SLU Residency Teach BoardSLU Residency Teach Board

How Many People Have How Many People Have Heard of the “ABCD Heard of the “ABCD

Criteria”?Criteria”?

Do We Really Need Help With Do We Really Need Help With Clinical Decision Making?Clinical Decision Making?

Clinical QuestionsClinical Questions

They’re commonThey’re common Physician recall: 0.1 information needs per encounter Physician recall: 0.1 information needs per encounter Direct observation: 0.5 information needs per Direct observation: 0.5 information needs per

encounter encounter

They’re importantThey’re important Only 30% pursued, 75% of those satisfiedOnly 30% pursued, 75% of those satisfied Of those not pursued, half were “important”Of those not pursued, half were “important” Journals only used to answer 2 of 1101 questions in Journals only used to answer 2 of 1101 questions in

busy practicebusy practice ((J Ely, BMJ 99J Ely, BMJ 99))

Clinical QuestionsClinical Questions

Internal Medicine ResidentsInternal Medicine Residents 2 for every 3 patients2 for every 3 patients 29% pursued29% pursued textbook (31%); journals (21%); attendings (17%)textbook (31%); journals (21%); attendings (17%)

Patient expectation, fear of malpractice Patient expectation, fear of malpractice associated with seeking answerassociated with seeking answer

Lack of time (60%), forgot (29%).Lack of time (60%), forgot (29%).Am J Med Am J Med

2000;109:218-33.2000;109:218-33.

How Well Do We Distribute How Well Do We Distribute New InformationNew Information??

Left to our own devicesLeft to our own devices 1987: Of 28 Landmark trials, only 2 had 1987: Of 28 Landmark trials, only 2 had

an immediate (1-2 year) effect on clinical an immediate (1-2 year) effect on clinical practice practice Fineberg HV. Clinical evaluation: how does it Fineberg HV. Clinical evaluation: how does it influence medical practice? Bull Cancer 1987;74:333-46.influence medical practice? Bull Cancer 1987;74:333-46.

1992: Thrombolytic therapy for acute MI: 1992: Thrombolytic therapy for acute MI: 13 years after proof of benefit before 13 years after proof of benefit before review articles suggest it for routine usereview articles suggest it for routine useAntman EM, et al. A comparison of results of meta-analyses Antman EM, et al. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA experts. Treatments for myocardial infarction. JAMA 1992;268:240-8.1992;268:240-8.

How Well Do We Distribute How Well Do We Distribute New InformationNew Information? ?

1996: Little effect of publication of the ISIS-2 1996: Little effect of publication of the ISIS-2 (Aspirin works post-MI) and diltiazem post-(Aspirin works post-MI) and diltiazem post-infarction trial (diltiazem doesn’t work).---ASA infarction trial (diltiazem doesn’t work).---ASA and Diltiazem use---no change after trialand Diltiazem use---no change after trialCol NF, et al. The impact of clinical trials on the use of medications for 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.acute myocardial infarction. Arch Int Med 1996; 156: 54 - 60.

Majumdar 2003:Majumdar 2003: HOPEHOPE study – study – in ramipril prescribing by 5% per month in ramipril prescribing by 5% per month

without advertising, 12% without advertising, 12% per month per month withwith advertising advertising over the next 2 yearsover the next 2 yearsMajumdar SR, et al. Synergy between publication and promotion: Comparing Majumdar SR, et al. Synergy between publication and promotion: Comparing adoption of new evidence in Canada and the United States. Am J Med adoption of new evidence in Canada and the United States. Am J Med

2003;115:467-72.2003;115:467-72.

How Well Do We Distribute How Well Do We Distribute New InformationNew Information??

Bottom Line:Bottom Line: Change occurs quicklyChange occurs quickly

When supported by lots of publicity or When supported by lots of publicity or pharmaceutical company marketing pharmaceutical company marketing (like any consumer product)(like any consumer product)

Change is much slowerChange is much slowerWhen left up to publications or word of When left up to publications or word of mouth for dissemination of informationmouth for dissemination of information

Two Tools Needed to Master Two Tools Needed to Master Information- BMJ 1999Information- BMJ 1999

A method of being A method of being alertedalerted to new information (a to new information (a “foraging” tool)“foraging” tool)A tool for A tool for findingfinding the information again when you the information again when you need it. (a “hunting” tool)need it. (a “hunting” tool)Without both:Without both: You don’t know that new info. is availableYou don’t know that new info. is available You can’t find it when you doYou can’t find it when you do

Clinical example- Riboflavin for migrainesClinical example- Riboflavin for migraines

Shaughnessy AF, Slawson DC. Are we providing doctors with the training and tools Shaughnessy AF, Slawson DC. Are we providing doctors with the training and tools for lifelong learning? British Medical Journal 1999 (13 Nov): for lifelong learning? British Medical Journal 1999 (13 Nov): www.bmj.comwww.bmj.com. . (http://bmj.com/cgi/reprint/319/7220/1280.pdf)(http://bmj.com/cgi/reprint/319/7220/1280.pdf)

Hunting and Foraging ToolsHunting and Foraging Tools

ForagingForaging InfoPoems---InfoPoems---

www.infopoems.comwww.infopoems.com Peer View Institute---Peer View Institute---

www.peerview-institute.org/www.peerview-institute.org/ Journal Alerts---Journal Alerts---

www.globalfamilydoctor.cowww.globalfamilydoctor.com/dailyalerts/main.htmm/dailyalerts/main.htm

Medscape Daily UpdateMedscape Daily Update MDLinxMDLinx

HuntingHunting InfoPoemsInfoPoems Up To Date---Up To Date---

www.uptodateonline.comwww.uptodateonline.com DynaMed---DynaMed---

www.dynamicmedical.com/www.dynamicmedical.com/ Medscape---Medscape---

www.medscape.comwww.medscape.com

Information Mastery in a Information Mastery in a NutshellNutshell

Clinically useful information can be defined by:Clinically useful information can be defined by:

Usefulness = Usefulness = Relevance x ValidityRelevance x Validity WorkWork

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a Medical Slawson DC, Shaughnessy AF, Bennett JH. Becoming a Medical Information Master:Feeling Good About Not Knowing Everything. Information Master:Feeling Good About Not Knowing Everything. The Journal of Family Practice 1994;38:505-13.The Journal of Family Practice 1994;38:505-13.

Information Mastery and Information Mastery and ComputersComputers

Slawson DC, Shaughnessy AF, Bennett JH. Becoming a Medical Information Master:Feeling Good About Not 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.Knowing Everything. The Journal of Family Practice 1994;38:505-13.

Can be reduced bycomputers

Usefulness = Relevance x Validity Work

Not always assessed by software

Highly Controlled ResearchRandomized Controlled TrialsSystematic Reviews

Physiologic ResearchPreliminary Clinical ResearchCase reportsObservational studies

Uncontrolled Observations&

Conjecture

Effect on Patient-Oriented OutcomesSymptomsFunctioningQuality of LifeLifespan

Effect on Disease MarkersDiabetes (GFR, albumin, HbA1C, photocoagulation)Arthritis (sed rate, X-ray)Peptic Ulcer (endoscopic ulcers)

Effect on Risk Factors for DiseaseImprovement in markers (blood pressure, glucose, cholesterol)

SORTA

Validity of Evidence

Re

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of O

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SORTB

SORTC

Drilling for the Best InformationDrilling for the Best Information

Cochrane LibraryEB Practice Guideline

Specialty-specificPOEMs

Best Evidence

Clinical EvidenceClinical Inquiries

Reviews: Textbooks, Up-to-Date, 5-Minute Clinical Consult

Use

fuln

ess

Medline

Computers to Drill for the Best InformationComputers to Drill for the Best Information

Web, InfoRetriever

InfoRetriever, JournalWatch, AFP Online

Best Evidence

CogniQ, BMJ, FPIN

Unbound, SkyscapeOnline Textbooks

Use

fuln

ess

CogniQ, SkyscapePubMed, OVIDMedline

Reviews/Textbooks

POEMs

Clinical EvidenceClinical Inquiries

Cochrane

POEMPOEMPatient-OrientedPatient-OrientedEvidenceEvidence

that Mattersthat Mattersmatters to the clinician, because if valid, matters to the clinician, because if valid,

will will requirerequire a a changechange in practice in practice

Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.

Relevance: Type of EvidenceRelevance: Type of Evidence

POEPOE: Patient-oriented evidence : Patient-oriented evidence mortality, morbidity, quality of lifemortality, morbidity, quality of life Longer, better or bothLonger, better or both

DOEDOE: Disease-oriented evidence: Disease-oriented evidence pathophysiology, pharmacology, etiologypathophysiology, pharmacology, etiology

POEMs:The “Change” FactorPOEMs:The “Change” Factor

Bextra Causes More Heart Attacks and Bextra Causes More Heart Attacks and StrokesStrokesALLHAT study---HCTZ is best first agent ALLHAT study---HCTZ is best first agent in hypertensive patientsin hypertensive patients3 questions:3 questions:

A. Is it an outcome patients care about?A. Is it an outcome patients care about?B. Is it common to your practice and the B. Is it common to your practice and the intervention feasible?intervention feasible?C. C. IfIf valid, would it valid, would it requirerequire you to change your you to change your practice?practice?

Comparing DOES and Comparing DOES and POEMsPOEMs

Example

Disease-Oriented Evidence

Patient-Oriented Evidence that

Matters

Comment Antiarrhythmic Therapy

Drug X PVCs on ECG

Drug X increases mortality

POEM study contradicts DOE study

Antihypertensive therapy

Antihypertensive therapy BP

Antihypertensive therapy mortality

POEM agrees with DOE

Prostate Screening

PSA screening detects prostate cancer early

? whether PSA screening mortality

DOE exists, but the important POEM is unknown

Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60.

ValidityValidity

The hard part of Information MasteryThe hard part of Information Mastery

Technique: EBM working group Technique: EBM working group

Did the researchers find what they think they Did the researchers find what they think they

found?found?

Do the results apply to Do the results apply to youryour patients? patients?

Self vs delegation- Take Self vs delegation- Take responsibilityresponsibility

Determining ValidityDetermining Validity

Levels of Evidence (LOE):Levels of Evidence (LOE): 1a, b, c; 2a, b, c; etc., 5- expert opinion1a, b, c; 2a, b, c; etc., 5- expert opinion

A, B, C, DA, B, C, D

SORT CriteriaSORT Criteria

Therapy, diagnosis, prognosis, reviews, etc. Therapy, diagnosis, prognosis, reviews, etc.

A “moving target” A “moving target”

Treatment Validity Treatment Validity WorksheetsWorksheets

Diagnosis Validity WorksheetsDiagnosis Validity Worksheets

WorkWork

Not all information sources are Not all information sources are created equalcreated equal

Two type of information sourcesTwo type of information sources ““Just-in-case” sources: high workJust-in-case” sources: high work ““Just-in-time” sources: low workJust-in-time” sources: low work

Minimizing Work: Types of Minimizing Work: Types of Archived Information SourcesArchived Information Sources

““Just-in-Case” informationJust-in-Case” information Libraries, Medline, MDConsult, WebMd, MedSites, Libraries, Medline, MDConsult, WebMd, MedSites,

StatRef, other databases StatRef, other databases

A “superstore” of informationA “superstore” of information

Focus: a complete “inventory” of informationFocus: a complete “inventory” of information

Benefit: Much information is always “in stock” to meet Benefit: Much information is always “in stock” to meet

many needsmany needs

Detriments: Even the simplest needs require time to Detriments: Even the simplest needs require time to

access the informationaccess the information

Minimizing Work: Types of Minimizing Work: Types of Archived Information SourcesArchived Information Sources

““Just-in-Time” informationJust-in-Time” information Highly filtered information sources with rapid Highly filtered information sources with rapid

access: InfoRetriever, Up To Date, Dynamedaccess: InfoRetriever, Up To Date, Dynamed A “Seven-Eleven” -- not everything, but quick and A “Seven-Eleven” -- not everything, but quick and

what you need most of the timewhat you need most of the time Focus: the best, most commonly needed Focus: the best, most commonly needed

informationinformation Benefit: Rapid access (less than one minute); Benefit: Rapid access (less than one minute);

ease of useease of use Detriments: Reliance on the filtering mechanism---Detriments: Reliance on the filtering mechanism---

what is the quality of the filtering mechanims?what is the quality of the filtering mechanims?

Quality Hunting and Foraging Quality Hunting and Foraging SystemsSystems

1. How is the information filtered?1. How is the information filtered? Patient- vs disease- oriented?Patient- vs disease- oriented? Specialty-specific?Specialty-specific? Comprehensive? Which journals?Comprehensive? Which journals? Does it matter (change my practice?) or is it Does it matter (change my practice?) or is it

simply news?simply news?

2. Is the information valid?2. Is the information valid? must have levels of evidence labelsmust have levels of evidence labels Beware “Trojan Horse”!Beware “Trojan Horse”!

Quality Hunting and Foraging Quality Hunting and Foraging Foraging SystemsForaging Systems

3. How well is information summarized?3. How well is information summarized? 2000 - 3000 words 2000 - 3000 words accuratelyaccurately in 200 words in 200 words

4. Is the information placed into context?4. Is the information placed into context? Much more than abstractsMuch more than abstracts ““Translational Validity”Translational Validity”

Hunting and Foraging SystemHunting and Foraging SystemRisksRisks

““Spyware”: Spyware”: May be tracking your usageMay be tracking your usage

““Trojan Horse”: Trojan Horse”: who’s paying when it’s free?who’s paying when it’s free?

Abstracts only: Abstracts only: Journal Watch, Journal Rack, Journal Watch, Journal Rack, Tips from other JournalsTips from other Journals, , ClinicalClinical UpdatesUpdates, , etc. etc. No relevance/ validity filterNo relevance/ validity filter

You can have information “free” and you can You can have information “free” and you can have it “uncensored”, but you can’t have it both have it “uncensored”, but you can’t have it both ways. No Free Lunch!ways. No Free Lunch!

Not All Information Tools Not All Information Tools are Created Equal!are Created Equal!

Translation of UKPDS into PracticeTranslation of UKPDS into Practice

Shaughnessy AF, Slawson DC. What happened to the valid POEMs? A survey of review articles on the treatment of type 2 diabetes. BMJ 2003; 327:266-269.

Review Criteria for Study of Review Criteria for Study of Information ToolsInformation Tools

What Happened to the Valid What Happened to the Valid Reviews?Reviews?

Quality of Drug Foraging and Quality of Drug Foraging and Hunting ToolsHunting Tools

Valdecoxib Withdrawal Notification

020406080

100120

Drug Information Sources

Tim

e (d

ays)

A Few Foraging Tools…A Few Foraging Tools…

Beware of the Trojan Beware of the Trojan HorseHorse

A Few Hunting Tools…A Few Hunting Tools…

Rating Hunting and Rating Hunting and Foraging ToolsForaging Tools

Rating Hunting and Foraging ToolsRating Hunting and Foraging Tools

Hunting Tool Evaluation WorksheetHunting Tool Evaluation Worksheet

Foraging Tool Evaluation WorksheetForaging Tool Evaluation Worksheet

Hunting and Foraging ToolsHunting and Foraging Tools

ForagingForaging InfoPoems---InfoPoems---

www.infopoems.comwww.infopoems.com Peer View Institute---Peer View Institute---

www.peerview-institute.org/www.peerview-institute.org/ Journal Alerts---Journal Alerts---

www.globalfamilydoctor.cowww.globalfamilydoctor.com/dailyalerts/main.htmm/dailyalerts/main.htm

Medscape Daily UpdateMedscape Daily Update MDLinxMDLinx

HuntingHunting InfoPoemsInfoPoems Up To Date---Up To Date---

www.uptodateonline.comwww.uptodateonline.com DynaMed---DynaMed---

www.dynamicmedical.com/www.dynamicmedical.com/ Medscape---Medscape---

www.medscape.comwww.medscape.com

SummarizeSummarize

Evidence-based clinical decision making Evidence-based clinical decision making requires a coordinated “hunting” and requires a coordinated “hunting” and “foraging” tool.“foraging” tool.

Use the principles of Information Mastery Use the principles of Information Mastery to evaluate your information tools.to evaluate your information tools.

Not all information tools are created Not all information tools are created alike---evaluate using worksheets.alike---evaluate using worksheets.