Title: Online information resources for evidencebased clinical care: their evolution and the special role o
1Online information resources for evidence-based
clinical care their evolution and the special
role of librarians in their development and
dissemination.
- Brian Haynes
- McMaster University
2Objectives
- Review the evolution of information resources for
evidence-based clinical decisions - Review strategies for
- Having evidence find you/your clients (PUSH)
- Finding evidence (PULL)
- Integrating evidence into workflow (PROMPT)
- Apply these strategies to learning about Lantus
Insulin
3Clinical case
- 48 year old male with type 1 diabetes mellitus
for 9 years, collapses on factory loading dock,
unrousable. Admitted to hospital with severe
hypoglycemia. No recollection of antecedent
warning symptoms, but had been engaged in
increased physical activity just before onset. - 3 weeks after hospital discharge, wife calls 911
during nocturnal bout of hypoglycemia no
warning, unusual activity. (Glucagon on hand but
not used.) - Admits that others notice he is not right
before he recognizes low sugars - Regimen Humalog with meals Humulin N 25 U am
and pm - What about Lantus?
- His doctor asks a librarian for help.
4The History of Thrombolysis
Grimes et al, NEJM 1993 Immediate Percutaneous
Coronary Intervention (PCI) is more effective
than thrombolysis for acute MI
Antman, Lau, Kupelnick, Mosteller, and T
Chalmers, JAMA 1992.
5The Slippery Slope
100
r -0.54 plt0.001
. .. . . .... .
knowledge of current best care
Choudhry, Fletcher and Soumerai, Ann Intern Med
2005142260-73 94 of 62 studies found
decreasing competence for at least some tasks,
with increasing physician age.
...
... ...
50
... ..
.... ....
0
years since graduation
6How to use Evidence-Based Medicine Resources to
Keep on Top of the Game
- Evidence-based medicine is...
- ...a set of resources to support clinical
decisions based on current best evidence.
research-enhanced health care
7Early Realization
- EBHC wont work unless backed up by effective
information tools and resources
8Doing EBM Push-Pull-Prompt
- PUSH - having evidence find end-user
- PULL - seeking evidence when needed
- PROMPT evidence-based reminders in clinical
practice settings and preferably in electronic
medical records
9PUSH Resources for Keeping Up-to-Date
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12Evidence-Based Journals
Critical Appraisal Filters
2,500 articles/yr meet critical appraisal and
content criteria (95 noise reduction)
50,000 articles/yr from 120 journals
13Jennifer Holland
Ann McKibbon
Angela Eady
Cindy Walker
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15McMaster PLUS Project
Clinical Relevancy Filter (MORE)
25 articles/yr for clinicians (99.95 noise
reduction)
2,500 articles/yr meet critical appraisal and
content criteria (95 noise reduction)
5-50 articles/yr for authors of evidence-based
clinical topic reviews
16Did I mention that its free?
http//bmjupdates.mcmaster.ca
17PULL Resources for Finding Evidence When You
Need it
18Examples
Computerized Decision Support System (CDSS)
Evidence-based textbooks
Systems
Evidence-based journals
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
19Systems Clinical Evidence
http//www.clinicalevidence.com
20Systems Up-to-Date
21Systems Physicians Information and Education
Resource
22EBM Systems vs Traditional Textbook Model
- Traditional textbook
- Author is an authority
- Author selects, reports on own
- One-year production line from manuscript to
bookstand - Three-year production schedule
23Updating in EBM Systems
- Authors are provided with new studies and reviews
that are - Assessed for validity
- Rated by clinicians for relevance
- Rated by clinicians for newsworthiness
- Within a month of original publication
244S Smorgasbord Ovids EBMR
25Examples
Computerized Decision Support System (CDSS)
Evidence-based textbooks
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
26Synopses ACP Journal Club
27Synopses Evidence-Based Medicine
28Examples
Computerized Decision Support System (CDSS)
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
29Syntheses The Cochrane Library
30Examples
Computerized Decision Support System (CDSS)
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
31Studies General Resource PubMed
Filters also available on Ovid and Skolar
32Patients with Type 1 Diabetes and Hypoglycemia
Unawareness
33Examples
Computerized Decision Support System (CDSS)
Systems
Evidence-based textbook
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
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35From Up-to-Date
36Examples
Computerized Decision Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
37http//bmjupdates.mcmaster.ca
38(No Transcript)
39CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal hypoglycaemic
episodes, especially when compared with
once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal
hypoglycaemic episodes, especially when compared
with once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
40Examples
Computerized Decision Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
41PubMed Clinical Queries Search for Syntheses
42(No Transcript)
43CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal hypoglycaemic
episodes, especially when compared with
once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal
hypoglycaemic episodes, especially when compared
with once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
44Examples
Computerized Decision Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
45PubMed Clinical Queries Search for Studies
46Patients with Type 1 Diabetes and Hypoglycemia
Unawareness Resolution of Case
- Cut back on total insulin dose
- Evening glargine instead of intermediate (or
long-acting) insulin - Close monitoring of glucose
- Scrupulous avoidance of hypoglycemia
- Type 1 class for review and retraining
47Tomorrow...Prompt
- Computerized decision support systems that
include - Instant access to current best evidence
- Reminders for indicated care
- Warnings for contraindicated care
48Personal digital internet libraries with wireless
PDA access, linked to individual patient records,
with a database of current best evidence, new
evidence alerts, and links to other resources
(patient information product monographs
continuing education with feedback)
Tomorrow...
49To keep on top
- Push
- Pull
- Prompt..some labs and med orders
systems
synopses
summaries
studies