Kick Your Textbooks to the Curb: Finding Clinically Relevant Information Quickly Adrian Banning, MMS, PA-C Gary M. Childs, MS Too much info, too little time, chatter and hyperbole (!) • • • • We are bombarded with information. You have to sift the good from the bad. You can’t give up and read nothing. Where would you prefer to get your daily news? Your sources count • • • • • • Morning news? Journal in the office? Colleagues? Buzz? Patients? Conferences? Walter Cronkite Walter Cronkite was a real news anchor. http://www.theatlantic.co m/international/archive/20 12/07/is-it-waltercronkites-fault-whyolympic-announcers-keepsaying-beizhing/260556/ Ron Burgundy Not a real news anchor, even though he looks like one. Source: http://cdn.sheknows.com/a rticles/2013/08/ronburgundy-memoir.jpg The difference is VALIDITY In desperation, you may listen to buzz as factthat’s how rumors get started and we don’t have time or leeway for that. Something has to be relevant to you, be good info and take little time to find. No free lunch: You need a level of evidence (LOE) • Beware things that are mailed to you for free or that can’t account for their levels of evidence (LOE). • You’ll need to search out what you have at your disposal and the quality of it-or else you’re just doing more of the same • Look at free mailers with lots of ads skeptically. • Pharm reps Making Decisions • How do we know what to do? • Knowledge>Fear • Find good evidence (and experience and opinions), combine with patient risk and values to give us options • We then weigh the options with the patient and make a decision • Science and Art • How do we do this. . . in reality? Need answers at point-of-care Internal med residents had 2 questions for every 3 pts seen Background = epi, pathophys, presentation, requires textbooks Foreground information is testing, diagnosis, treatment, Need EBM summaries or research Residents asked mostly about therapy and diagnosis and asked more foreground than background questions as training progressed Pursued 29% of their questions Used textbooks, original articles, and attendings Pursued an answer if they thought pt wanted it for in fear of malpractice Information Mastery Slawson and Shaugnessy, et al. • Finding high quality information to answer YOUR question, quickly. • You may not be an appraisal expert, but they exist • You need a level of evidence (LOE) Information sources are not all equal(different databases, journals, experts) • Go for patient-oriented evidence first • POEM vs DOE • Hunting vs foraging Information Mastery Usefulness of Info= (Relevance x Validity) Work Critical appraisal is a total drag, but. . . Ask, find, assess validity, synthesize • RECRUITEMENT, Randomized ALLOCATION, ACCOUNTED (ITT), MAINTENANCE/MEASURMENT • BLINDING, OUTCOME IM lets the experts assess for you. Are you sure you can assess this expertly? Allocation concealment? You must stay an expert on the interpretations AND how to interpret AND see patients AND eat AND sleep AND. . . Evidence Based Medicine Steps • Have a question (put it into PICO) • Search the literature from the top of the pyramid (next slide) • Find a study/find evidence • Perform appraisal /find level of evidence and look for bias • Determine how the results help you-how will you use them with your patient in their lives using your/others’ experience • Are the above steps working? The Evidence Hierarchy From: http://www.dartmouth.edu/~biomed/services.htmld/EBP_docs/pyramid-loaded.pdf Levels of Evidence Pyramid Example http://www.hsl.virginia.edu/collections/ebm/pyramid.cfm Patient Oriented Evidence that Matters: POEMs DOE = Disease Oriented Evidence You will likely have to differentiate POEMs vs DOE yourself Specialists and researchers may need DOE as well if highly specialized, but DOE doesn’t change your immediate clinical decision with a patient. POEM Requirement Number 1: Address a frequently encountered clinical question (in your realm of medicine-family/cardio/oncology). Not too rare and about something you’ll need to a make a decision on POEM Requirement Number 2: • Measures a patient oriented outcome like: mortality morbidity quality of life reduction in symptoms other endpoints that are important to the patient and you. • Not a disease-oriented outcome like LV pumping or neuronal death. • Intermediate or premature evidence is not helpful here-too early in the process. POEM Requirement Number 3: Results will require a change in your practice (M) Confirming what you already know and do is a waste of time. One person’s POEM may be another’s POE depending on your practice. DOE Increase our knowledge of a disease DOE= prognosis, prevalence, pathophysiology, pharmacology, etiology, etc. DOEs are crucial to medicine and we can’t dx, tx or prevent a disease before we understand it. “Comparing DOES and POEMs” Slawson, D.C. & Shaughnessy, A. 2003. Information Mastery: Evidence-Based Medicine in Everyday Practice. PowerPoint file retrieved February 17, 2011 from http://www.bmj.com. Slide 12. Example Antiarrhythmic Therapy DiseaseOriented Evidence Patient-Oriented Evidence that Matters Drug X PVCs Drug X increases on ECG mortality Comment POEM study contradicts DOE study POEM agrees Antihypertensive Antihypertensive Antihypertensive therapy BP therapy mortality with DOE therapy Prostate Screening PSA screening detects prostate cancer early ? whether PSA screening mortality DOE exists, but the important POEM is unknown Hunting and Foraging • Forage- have information come to you • POEM of the Week Podcast! Emails! • Hunting-looking for evidence • Databases Tips on keeping validity • Go to trusted sources (use the pyramid). • Go to relevant items (POEMs). • Look for LEVELS OF EVIDENCE, resources, someone who is accountable. • A.K.A. “WHO WROTE THIS?” • Don’t contribute to chatter if you haven’t checked the facts. Read the article. • Brush-up on how to read a research article. It’s ok. We all forget some things, sometimes. Immediate Gratification Many resources can provide an immediate answer at the point-of-care! Yes! Part 1: Summary • Find a realistic way to use evidence • You DO need the skills to be able to read technical medical information • type of article, type of research, PPV/NPV, odds and risk ratios • Does the patient see the difference-can you bring them the evidence and make them part of their own team? • Application of EBM is not cookbook Part 2, Hunting Sources: Finding Clinically Relevant Information Quickly Cochrane Systematic Reviews A study done in 1972 showed inexpensive corticosteroids beneficial in preterm delivery. No systematic review of the literature was done until 1989. Had it been it would have shown that infant mortality is reduced 30-50% using this evidence that was already on hand. VERY comprehensive analysis of the research Links To Video Tutorial Playlist http://tinyurl.com/m22fosh -ORhttps://www.youtube.com/playlist?list=PLkr8XTH_bktjgj4V9mxfl VvBz7wAkAPIL Clinical Question • Suzy, the mother of a 2 y/o girl with asthma is concerned about the upcoming cold and flu season. She’s interested in having her child receive the influenza vaccine, but she’s afraid that the vaccine could trigger her daughter’s asthma. What does the current available evidence suggest? PICO(T) Format • • • • • P: Patient, population, “problem” I: Intervention C: Comparison Intervention O: Outcome (T): Time Clinical Question in PICO format • • • • • P: 2 y/o girl with asthma I: influenza vaccine C: no influenza vaccine O: possible asthma exacerbation risk (T): immediately following vaccination Cochrane Library: Search Terms CDSR: Systematic Review Length CDSR: Plain Language Summary CDSR: Conclusions CDSR: References TRIP: Turning Research Into Practice TRIP: Article Abstracts DynaMed DynaMed: Search Autocomplete DynaMed: Search With Records & Level of Evidence (LOE) DynaMed: LOE Defined DynaMed: Calculators National Guideline Clearinghouse (NGC) NGC: Search Terms NGC: Results NGC: Guideline Summaries NGC: LOE (not standardized!) NGC: Not All Guidelines Include LOE MEDLINE (PubMed) MEDLINE: Clinical Queries Search Terms MEDLINE: Limits MEDLINE: Display Settings -Abstract Questions? ? References Claude Moore Health Sciences Library. Information mastery: navigating the maze. University of Virginia Health System Web site. www.hsl.virginia.edu/collections/ebm/pyramid.cfm. Accessed May 11, 2012. Dartmouth Biomedical Libraries. Evidence-based medicine (EBM) Resources. Dartmouth College Library Web site. http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_resources.shtml. Accessed May 11, 2012. Ebell MH, Barry HC, Slawson DC, & Shaughnessy AF. Finding POEMs in the medical literature. J Fam Pract. 1999;48(5):350-355. Ebell M, Shaughnessy A. Information mastery: integrating continuing medical education with the information needs of clinicians. J Cont Ed Health Prof [serial online]. April 2, 2003;23:S53-62. Available from: CINAHL with Full Text, Ipswich, MA. Accessed May 30, 2013. Johnson CA. The Information Diet. Sebastopol, CA; O’Reilly Media, Inc.; 2011 Marks S, McKibbon KA. Posing clinical questions: Framing the question for scientific inquiry. AACN Clin Issues. 2001;12(4):477-481. Mayer, D. (2009). Essential Evidence-Based Medicine. Oxford, UK. Oxford University Press. McConaghy JR. Evolving medical knowledge: moving toward efficiently answering questions and keeping current. Prim Care: Clin in Office Prac. 2006 December; 33(4): 831-837 References Pearce-Smith N, Hunter J. The introduction of librarian tutors into the teaching evidencebased medicine week in Oxford, UK. Health Info Libr J. 2005;22(2):146-149. Shaughnessy A, Gupta P, Erlich D, Slawson D. Ability of an information mastery curriculum to improve residents' skills and attitudes. Fam Med. 2012 April; 44(4): 259-64. Shaughnessy AF, Slawson DC, & Bennett JH. Becoming an information master: A guidebook to the medical information jungle. J Fam Pract. 1994;39(5):489-499. Slawson DC, Shaughnessy AF, & Bennett JH. Becoming a medical information master: Feeling good about not knowing everything. J Fam Pract. 1994;38(5):505-513. Slawson, D.C. & Shaughnessy, A. Information mastery: evidence-based medicine in everyday practice. 2003. Accessed May 11, 2012 from http://www.bibalex.org/supercourse/bmj/bmj.htm. Slawson, D.C. & Shaughnessy, A. 2003. Information Mastery: Evidence-Based Medicine in Everyday Practice. PowerPoint file retrieved February 17, 2011 from http://www.bmj.com. http://www.theatlantic.com/international/archive/2012/07/is-it-walter-cronkites-faultwhy-olympic-announcers-keep-saying-beizhing/260556/ http://cdn.sheknows.com/articles/2013/08/ron-burgundy-memoir.jpg Bonus! http://www.thennt.com/ The NNT Groups • Thennt.com • How many people without heart disease need to be on the Mediterranean diet for 5 years before one person doesn’t have a CVA, MI or die? http://www.thennt.com 61 and no one gets hurt More on Information Mastery? • Tufts Health Care Institute Conference: • http://www.thci.org/educationalactivities/conferences/information-mastery • UVA School of Medicine: • http://www.medicine.virginia.edu/clinical/departments/familym ed/information_mastery/info_mastery-page More Foraging-many are both: sign up for emails to forage. Journal Watch (NEJM) ACCESSSS Federated Search, free, register. Hunting and foraging: http://plus.mcmaster.ca/accessss/Default.aspx?Page=1 ACP Journal Club (Annals of Internal Medicine) http://www.essentialevidenceplus.com/ National Prescribing Centre (UK): http://www.npc.nhs.uk/ EssentialEvidencePlus POEM of the week podcasts (iTunes) Agency for Healthcare Research and Quality subscriptions http://www.ahrq.gov/ National Guidelines Clearinghouse: http://www.guidelines.gov/