Information Mastery Objectives At the end of this

Information Mastery

Objectives At the end of this seminar, participants should be able to: Incorporate information mastery principles into daily learning and patient care activities Formulate focused foreground questions in PICO format Distinguish between disease-oriented and patient-oriented evidence Identify high quality evidence based on study design Use evidence-based medical databases to research clinical queries and to stay up to date with medical literature

Disclosures No financial disclosures Much of the material and ideas were developed by David Slawson, MD, and Alan Shaughnessy, Pharm. D, MMed. Ed

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 questions Keep up to date Follow your interests Be the best advocate possible for patients

Limitations of EBM Limited evidence Poor quality evidence Individual patient differences

What determines medical decisions? Prior clinical experience Individual patient characteristics Medical Evidence Decision

Classic EBM 5 step approach Ask Search Critically appraise Implement Evaluate

EBM Information Mastery Traditional EBM = basic science, primary article appraisal Information Mastery = applied science 1994, Slawson and Shaughnessy Gather valid, relevant, patient-oriented information that is critically appraised and apply it to practice. Use tools that appraise evidence for you Allows you to stay up do date without drowning in the vast sea of primary journal articles.

Usefulness = (relevance * validity)/work Relevance: 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 Questions Type of question determines sources to use Background (basic science) Foreground (specific clinical question) PICO Patient population/problem Intervention Comparison Outcome

ACTIVITY 1 Write a PICO for each case: Patient population/problem, Intervention, Comparison, Outcome Case 1: “A 65 year old man with T 2 DM 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 POE Disease-oriented evidence/outcomes Focused around diseases/labs. Patient-oriented outcomes Focused on outcomes patients care about: Quality of life Morbidity Mortality

Disease-Oriented Outcome Patient-Oriented Outcome Intensive glucose lowering can Intensive glucose lowering decrease A 1 c 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

POEM Patient Oriented Evidence that Matters Is 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 2 Read 2 evidence summaries Discuss in small groups to determine if they are POEMS 3 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 Evidence SORT Developed by AAFP Takes POEM into consideration USPSTF Graded recommendations GRADE Developed by international group of physicians Level of Evidence 11 categories Developed at Oxford

SORT (Strength Of Recommendation Taxonomy) Code Definition A Consistent, good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

Relevance of Outcome 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) SORT B SORT A SORT C Effect on Risk Factors for Disease ·Improvement in markers (blood pressure, HBA 1 C, cholesterol) Uncontrolled Observations & Conjecture Physiologic Research Preliminary Clinical Research ·Case reports ·Observational studies Validity of Evidence Highly Controlled Research ·Randomized Controlled Trials ·Systematic Reviews

USPSTF Grades Grade Definition A The USPSTF recommends the service. There is high certainty that the net benefit is substantial B 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 Evidence Developed by Centre for Evidence-Based Medicine in Oxford, England More detailed and complex 11 levels 1 a-c (systematic reviews), 2 a-c, 3 a-c, 4, 5 (expert opinion) http: //www. cebm. net/oxford-centre-evidence-basedmedicine-levels-evidence-march-2009/ table) (see for a

Information Mastery Toolkit Journals (2 -3) Foraging services (summaries of new information) Hunting tools (find answers to questions)

“Foraging” Services Analyze articles/evidence for you and send you summaries Dyna. Med Alerts EE Plus POEMS BMJ Clinical Evidence FPIN Clinical Inquiries ACP 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-specific Patient-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 Risks Who’s paying when it is free? Possibly pharmaceutical companies Abstracts 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 Overview Tool Less work More work ACP 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 Dyna. Med Alerts -Specialty specific (various) -Validity assessment -LOE -Relevance: focuses on patient-oriented evidence -Coordinated hunting tool

Foraging Tool Overview Tool Less work More work Journal 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). Banzi R et al. BMJ 2011; 343: bmj. d 5856 © 2011 by British Medical Journal Publishing Group

Summary of Foraging Tools Dyna. Med: Fastest to update with new information BMJ Clinical Evidence: Only sends valid articles Up. To. Date: 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” Tools Point of care evidence-based tools (30 -40 seconds) Best tools = useful = (relevance*validity)/work Dyna. Med Cochrane database Essential Evidence Plus BMJ Clinical Evidence FPIN Clinical Inquiries Trip database Pub Med

Drilling for the Best Information BMJ Clinical Evidence (therapy) R V W PIER R V W TRIP Database R V W Usefulness Essential Evidence Plus R V Usefulness = Relevance X validity Work W Dynamed Up. To. Date Textbooks Medline

Clinical Jazz Science (EBM/structure) + Art (improvisation) = Clinical Jazz Both 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 3 Review use of the following tools: Dyna. Med Essential Evidence Plus TRIP Database BMJ Clinical evidence

ACTIVITY: Medical Myths

ACTIVITY: Look-up conference

Some Studies that I Like to Quote http: //www. youtube. com/watch? v=Ij 8 b. PX 8 IINg James Mc. Cormack, MD