Information Mastery: EvidenceBased Medicine in Everyday Practice

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Information Mastery Evidence-Based Medicine in
Everyday Practice

• David C. Slawson, MD
• Allen F. Shaughnessy, PharmD

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The Medical Information Business

Production

• Original Research
• Clinical experience

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)
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The Medical Information Business


Production

• Systematic reviews
• POEM Alert System

Refinement


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The Medical Information Business

Production

• Clinician-centered
• Just-in-time information
• Hunting/foraging tools

Refinement

Distribution

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The Medical Information Business


Production

• Information Mastery
• The Applied Science of Clinical Medicine

Sales Marketing
Refinement
Distribution
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How do we learn?

• Adults learn by solving problems
• Our problems clinical questions
• CME can highlight advances and make us aware of
  our deficits
• 120 studies, short term benefit to testing, but
  no patient benefit to traditional lecture
• Answering clinical questions at the point of care
  is how we learn and improve outcomes

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Clinical questions

• Theyre common Average 1 question for every
  other patient
• Theyre important
• Only 1 in 3 questions pursued
• Found answer 80 of time
• Guess at 70-80 of information needs!
• Journals only used to answer 2 of 1101 questions
• Books, colleagues used most often
• Average search time 1 minute or less.
• Ely JE. Analysis of questions asked by family
  doctors regarding patient care. BMJ
  1999319358-61

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Clinical Questions

• Internal Medicine Residents
• 2 for every 3 patients
• 29 pursued
• textbook (31) journals (21) attendings (17)
• Patient expectation, fear of malpractice
  associated with seeking answer
• Lack of time (60), forgot (29).
• Am J Med 2000109218-33.

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Information Sources for the Point of Care

• Everything is based on the usefulness equation
• Usefulness Relevance x Validity
• Work
• Slawson DC, Shaughnessy AF, Bennett JH. Becoming
  a Medical Information MasterFeeling Good About
  Not Knowing Everything. The Journal of Family
  Practice 199438505-13.

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Validity

• The hard part of Information Mastery
• Technique EBM working group
• Guyatt G, Rennie D, ed. Users guides to the
  medical literature. A manual for evidence-based
  clinical practice. Chicago AMA, 2002.
• Did the researchers find what they think they
  found?
• Do the results apply to your patients?
• Self vs delegation- Take responsibility

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Work

• Not all information sources are created equal
• Two type of information sources
• Just-in-case sources high work
• Just-in-time sources low work

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Relevance Type of Evidence

• POE Patient-oriented evidence
• mortality, morbidity, quality of life
• Live longer and/or better
• DOE Disease-oriented evidence
• pathophysiology, pharmacology, etiology

Shaughnessy AF, Slawson DC, Bennett JH. Becoming
an Information Master A Guidebook to the Medical
Information Jungle. The Journal of Family
Practice 199439(5)489-99.
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POEM

• Patient-Oriented
• Evidence
• that Matters
• matters to you, the clinician, because if valid,
  will require you to change your practice

Shaughnessy AF, Slawson DC, Bennett JH. Becoming
an Information Master A Guidebook to the Medical
Information Jungle. The Journal of Family
Practice 199439(5)489-99.
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POEMs The Change Factor

• Pen G prevents rheumatic fever
• Would a study showing this require a change?
• ALLHAT study (ALLHAT Officers and Coordinators.
  Major outcomes in high-risk hypertensive patients
  randomized to angiotensin-converting enzyme
  inhibitor or calcium channel blocker vs diuretic.
  The Antihypertensive and Lipid-Lowering Treatment
  to prevent Heart Attack Trial (ALLHAT). JAMA
  20022882981-97).
• Diuretics gt effective than other treatments to
  prevent mortality and morbidity associated with
  hypertension, including type 2 diabetes
• Would this study require a change in behavior?

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Determining Validity

• Levels of Evidence (LOE)
• 1a, b, c 2a, b, c etc., 5- expert opinion
• A, B, C, D,
• Therapy, diagnosis, prognosis, reviews, etc.
• A moving target
• The best way to ascertain trust in the process

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Was allocation assignment concealed?

• Did investigators know to which group the
  potential subject would be assigned before
  enrolling them?

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Importance of concealed allocation

• Trials with unconcealed allocation consistently
  overestimate benefit by 40
• Schulz KF, Chalmers I, Hayes RJ, et al. JAMA
  1995273408-12
• Schulz KF, Grimes DA. Lancet 2002359614-18.

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Was allocation assignment concealed?

• Concealed allocation ? blinding
• Blinding can occur without concealed allocation
• UVA example- surfactant in the NICU
• Allocation can be concealed in an unblinded study
• PT vs surgery for knee DJD
• Moseley JB, O'Malley K, Petersen NJ, et al. N
  Engl J Med 2002 34781-8.

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Importance of concealed assignment

• Meta-analysis of trials evaluating screening
  mammography
• In studies in which allocation wasnt concealed
• Higher SE status, education level in screened
  group
• Age disparity (average 6 mo older in the
  unscreened group)
• Richer, smarter, younger live longer!
• Trials with concealed allocation screening
  harmful!
• No effect or increased mortality
• 20 more mastectomies
• Lancet Jan 8, 2000 Oct 20, 2001

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Should we use a new test? Levels of Valid
POEMness

• Sensitivity specificity
• Does it change diagnoses?
• Does it change treatment?
• Does it change outcomes?
• Is it worthwhile (to patients and/or society)?
• (examples T4/PKU in newborns, BNP for CHF, HbA1C
  for DM, electron beam tomography for CAD, CRP,
  BMD)
• Fryback DG, Thornbury JR. The efficacy of
  diagnostic imaging. Med Decis Making 1991
  1188-94

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• Mundus Vult Decipi- The world wishes to be
  deceived
• People would rather be deceived that have the
  truth cause anxiety
• Caleb Carr, Killing Time

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Two Tools Needed to Master Information- BMJ 1999

• A method of being alerted to new information (a
  foraging tool)
• A tool for finding the information again when you
  need it. (a hunting tool)
• Without both
• You dont know that new info. is available
• You cant find it when you do
• Clinical example- Riboflavin for migraines
• 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)

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Can we trust reviews (Hunting Tools)?

• Study of 36 review articles using 10 criteria for
  determining rigor
• Overall rating of rigor
• Experts correlation 0.23
• Non-experts correlation 0.78
• ? expertise of writer stronger prior opinion ?
  less time spent on review ? lower quality
• Study of quality of 35 review articles on type 2
  DM
• Ave. score 1/15 best score 5/15
• Experts should do research
• Non-experts should write due to less bias
• Oxman AD, Guyatt GH. The science or reviewing
  research. Ann N Y Acad Sci 1993703125-33.
  Shaughnessy AF, Slawson DC. What happened to the
  valid POEMs? A survey of review articles on the
  treatment of type 2 diabetes. British Medical
  Journal 2003327266-9.

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Typical Flow of Information in Medicine
Medical Research Published
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Flow of Information from the UKPDS
Results Selectively Presented by Experts
Patient Care Based on Wrong/Incomplete Information
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Translational ValidityCan We Trust Review
Articles?

• Reporting of the UKPDS by 35 review articles
• 85 of reviews readers not told that good
  glucose control alone doesnt decrease mortality
  (NNR 7) Important Non-Valid POEM
• All reported that good control decreased
  complications
• None reported that almost all (84) benefit due
  to decreased rates of retinal photocoagulation
  (no change in blindness rate, the Important
  Non-Valid POEM)
• Valid POEM Only 18 (NNR 6) reported that
  metformin decreased mortality, independent of BS
  control

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Translational ValidityCan We Trust Review
Articles?

• None reported lack of any benefit (micro- or
  macrovascular) of insulin/ sulfonylureas in obese
  diabetics- Important Non-Valid POEM
• Valid POEM Only 13 (NNR 8) reported that blood
  pressure control is more important than BG
  control
• None of the reviews reported all Valid and
  Important Non-Valid POEMs (NNR gt 35).
• Including significant EB databases
• Shaughnessy AF, Slawson DC. What happened to the
  valid POEMs? A survey of review articles on the
  treatment of type 2 diabetes. BMJ
  2003327266-271.

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Lending a Hand to Patients with Type 2 Diabetes
Metformin/?ASA
Blood pressure
Cholesterol
Glucose control?
Smoking
Vijan S. Treatment of hypertension in type 2
diabetes mellitus blood pressure goals, choice
of agents, and setting priorities in diabetes
care. Ann Intern Med 2003 138593-602.
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Drilling for the Best Information
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InfoRetriever 2005 Windows 95/98/NT/ME/2000/XP,
PocketPC, Palm and Web
1900 short research synopses (400 added per year)
Cochrane Database of Systematic Reviews over
1300 abstracts
5 Minute Clinical Consult
Bayesian diagnostic test / HP calculator
150 clinical prediction rules
Basic drug info by class and cost for 1200 drugs
Key evidence-based treatment guidelines
www.InfoPOEMs.com
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Characteristics of an Ideal Clinical Awareness
System

• Specialty-specific
• Comprehensive
• Coordinated hunting and foraging tools
• Specific and reproducible criteria for relevance
  and validity
• Available at the point-of-care
• All backed up by levels of evidence

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The Clinician of the Future

• I know a lot, therefore I am
• Replaceable by a computer
• I think, therefore I am
• Never replaceable by computer
• Travel agent should they memorize schedules?
• Would you trust them?
• How do you know?
• Hand held computer stethoscope of the future

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Take-Home Points

• Confidence through information
• Hunting foraging tools providing relevant and
  valid information when needed
• Focus on valid POEMs Patient-Oriented Evidence
  that Matters

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• Effect on Patient-Oriented Outcomes
• Symptoms
• Functioning
• Quality of Life
• Lifespan

SORT A
SORT B

• Effect on Disease Markers
• Diabetes
• Arthritis
• Peptic Ulcer

SORT C
Relevance of Outcome

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

• Highly Controlled Research
• Randomized Controlled Trials
• Systematic Reviews

• Physiologic Research
• Preliminary Clinical Research
• Case reports
• Observational studies

Uncontrolled Observations Conjecture
Validity of Evidence
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Take-Home Points

• Clinicians will be/are valued by how they think
  and not by what they know
• The information age is about information
  management, not information acquisition

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