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The pace of change inpractice-driving medical knowledge
in new models of publishing
May 5, 2013
Brian S. Alper, MD, MSPH, FAAFPEditor-in-Chief, DynaMed
Medical Director, EBSCO Publishing
Introduction/Disclosures
Rural family medicine in 1995
Mission to provide most useful informationto healthcare professionals at point of care
Now working full-time as
Editor-in-Chief, DynaMed
Medical Director, EBSCO Publishing
Half of what is taught in medical education is wrong, but we don’t
know which half.
Attributed to Dr. C. Sidney Burwell, Dean of Harvard Medical School 1935-1949, in Pickering GW. The purpose of medical education. BMJ 1956 Jul 21;2:113
45 highly-cited original research publications
16%
16%
24%
16% contradicted by subsequent studies16% found to have smaller ef-fects24% remain un-replicated
Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA. 2005;294(2):218-228
124 original articles in NEJM in 2009
Prasad V, Gall V, Cifu A. The frequency of medical reversal. Archives of Internal Medicine 2011 Oct 10;171(18):1675-1676
49%
13%
49% present new prac-tice surpassing current care
13% reverse previosly accepted care
The pace of change is accelerating. “Medicine will change more in the
next 20 years than it has in the past 2000.”
Smith R. Thoughts for new medical students at a new medical school. BMJ 2003 Dec 20;327(7429):1430-1433
How quickly does core evidence change?
• Management overviews of top DynaMed topics evaluated
- Maintained via 7-step evidence-based methodology
- Updated daily
- Standardized templates with outline format (overviews represent most important evidence and guideline for practice)
• Compared to 1-2 years ago, how many lines have changed (addition, deletion, modification)?
• Classify change due to
- New evidence
- New guidance
- External feedback
- Internal quality improvement
How quickly does core evidence change? Interim results: 80 topics (mean time 1.5 years)
0%20%40%60%80%
100%
Examples of new evidence changing overviews
Dyspnea: midazolam may reduce unexplained dyspnea more than morphine in advanced cancer
Gallstones: cholecystectomy within 48 hours in mild gallstone pancreatitis may safely reduce hospital stay
MS: dextromethorphan/quinidine sulfate may reduce frequency/severity of pseudobulbar affect episodes
MRSA: comparative efficacy for linezolid, telavancin, vancomycin
PE: Pulmonary Embolism Rule out Criteria (PERC)
PE: less bleeding with oral rivaroxaban vs. LMWH/warfarin
Stroke: graduated compression stockings do not appear to reduce DVT and may cause skin damage
How quickly does core evidence change?
Interim results: 4,411 lines, 2,532 lines changed (mean time 1.5 years)
1160 modified 474 deleted 898 added0%
5%
10%
15%
20%
25%
30%
Of 2,532 lines changed
How quickly does core evidence change?
0%
10%
20%
30%
40%
50%
60%
How quickly does core evidence change?Interim results: 4,411 lines (mean time 1.5 years)
0%
10%
20%
30%
Adjusted for 1-year timeframe:
16.2% practice-guiding information changes in 1 year due to
new evidence or guidance
Questions?
Brian S. Alper, MD, MSPHEditor-in-Chief, DynaMed
Medical Director, EBSCO Publishing