Evidence on the Internet Mark A. Goedecker, MD mgoedecker@yorkhospital.edu York Hospital Department of Family Medicine May, 17, 2007

Why Is This Important? Information mastery is the key to the future of medicine Being able to answer clinical questions quickly at the point-of-care is a necessary skill Physicians are already being “graded” on the care they provide If you provide care based on the best evidence, your reimbursement will be greater Pay for performance programs

Why Is This Important? Today’s residents and students are very skillful with computers Learners challenge you to have ALL the answers and are disappointed when you don’t

Objectives By the end of this lecture the audience should be able to: List 5 web sites where point-of-care evidence can be obtained Use an “evidenced-based website” to answer a clinical question at the point-of care

The Evidence on Evidence Only half of the interventions used in routine clinical practice are supported by the results from randomized controlled trials – InfoPOEMS (LOE 2b) https://www.infopoems.com/irsearch/display_article.cfm?resource=E&article=20506

The Evidence on Evidence Teaching critical appraisal skills to health professionals improves knowledge but there is a lack of evidence that it changes the process of care or patient outcomes. – The Cochrane Collaboration SORT A http://www.cochrane.org/reviews/en/ab001270.html

Formulating a Good Question is the Best Place to Start

Formulating a Question Does the question ask only one point? Is the question answerable? Can the question be entered into standard web-based search engine?

Formulating a Question: An Example You are seeing a 17 year old male with pustular acne. Your question might be: “What is the most effective treatment for pustular acne based on the most current evidence?”

Types of Evidence Original articles Evidence based synopses Systematic reviews Clinical questions E-textbooks Guidelines

Original Articles Pros: Cons: You actually read the article and make your own interpretation Cons: Very time intensive – requires a literature search, pulling articles, reviewing of articles This is key for original research but not practical at the point-of-care (especially in the outpatient setting) Meta-analyses are part of this

Evidenced-Based Synopses Reviews of article(s) of significance Pros: To the point Usually have a “bottom-line” Very quick Cons: Quality may be variable May not find the answer to your question

Systematic Reviews Exhaustive evidence reviews on a certain topic Examples include Cochrane reviews and USPSTF reviews

Systematic Reviews Pros: Cons: Complete Usually answer several questions Very high quality Cons: There may not be an answer if the evidence is inconclusive, contradictory, or absent

Clinical Questions Also called query answering services You ask a question and a research team does the work for you and gives you the answer

Clinical Questions Pros: Cons: You can ask almost anything There may not be an evidenced-based answer to your question

E-Textbooks (Up-To-Date), FP Notebook, E Medicine Pros: Cons: Quick, extensive Cons: Not usually based on the best current available evidence May not be “UpToDate”

Guidelines Pros: Cons: Most are well done and have done a thorough evidence review Cons: Reliability of the source This can be a way of pushing an agenda

EBM Search Engines It’s Google for EBM These sites search other sites for answers to your questions Like Google, you have to sort out the good from the bad Some of the sites it searches have restricted access

Trip Database http://www.tripdatabase.com/ Searches Medline for you Easy to use FREE

SUMSearch http://sumsearch.uthscsa.edu/ Searches PubMed, National Guidelines Clearinghouse, DARE, WikiPedia FREE

Systematic Review Sites

Agency for Healthcare Research and Quality http://www.ahrq.gov/ Part of the Department of Health and Human Services United States Preventive Services Task Force National Guidelines Clearinghouse Reviews of evidence on certain topics FREE

Cochrane Database http://www.cochrane.org Abstracts are available for free These abstracts are also available as part of InfoPOEMS (more to come) Great evidence reviews on over 2000 topics in medicine Considered the “Gold Standard” in EBM FREE

Clinical Evidence http://clinicalevidence.com/ceweb/conditions/index.jsp Very concise reviews of topics Sponsored by the BMJ Free access can be obtained at this site for six months if you have a hard copy of the Clinical Evidence book Yearly subscription cost $239/year online or $49.95 handheld version

DARE http://www.crd.york.ac.uk/crdweb/ Database of Abstracts of Reviews of Effects FREE

Evidence-based Synopses

InfoPOEMs http://infopoems.com/ Excellent site, but you must pay a yearly fee ($249) You can register for a free 30 day trial A good place to get answers fast Can download entire database to handheld Can sign up for daily “InfoPOEMS”

DynaMed http://www.dynamicmedical.com/ Similar to InfoPOEMS Also has yearly fee ($349) If you agree to be a reviewer, you can get the service for free Can download database to handheld

Bandolier http://www.jr2.ox.ac.uk/bandolier/ UK site Not the most user-friendly, but useful data can still be gleaned FREE

BestBETs http://www.bestbets.org/index.html Similar to DynaMed and InfoPOEMS, but it’s free (as far as I can tell) Contains evidence-based synopses of certain clinical questions Another UK based site (they seem to be a little ahead of us in this area) FREE

E-Textbooks

UpToDate www.utdol.com An on-line textbook which is updated quarterly Reviews relevant topics in medicine A good place to start – be careful of the evidence quality Recent move to make this an evidence-based resource (February 2006) Good place to get answers fast

Other E-textbooks Family Practice Notebook GP Notebook (UK) http://www.fpnotebook.com/ GP Notebook (UK) http://www.gpnotebook.co.uk/homePage.cfm Merck Manual http://www.merck.com/mmpe/index.html

Original Literature Searches

National Library of Medicine – Pub Med http://www.nlm.nih.gov/nlmhome.html Allows you to search the entire database of medical literature More useful when doing original research – more time intensive FREE

Query-Answering Services You submit a question, they find an answer ATTRACT – UK site http://www.attract.wales.nhs.uk/index.cfm Family Physicians Inquiry Network http://www.fpin.org/ National Library of Health UK http://www.clinicalanswers.nhs.uk/index.cfm Previous answers can be searched for free

Hitting the Headlines http://www.library.nhs.uk/rss/newsAndRssArchive.aspx?storyCategory=0 From the National Electronic Library for Health (UK) Reviews the evidence behind the news your patients may be reading or seeing on TV http://www.nlm.nih.gov/medlineplus/newsbydate.html NIH/National Library of Health Site for patients that reviews important medically related news articles from the past 30 days At the end of the article, a reference is noted

Immunization Information STFM Group on Immunizations www.immunizationed.org Online and handheld versions of Shots 2007 FREE Rapid answers to questions regarding immunizations which are based on CDC/ACIP recommendations (and therefore the best evidence)

The CDC www.cdc.gov Information on travelers health, environmental health, diseases and conditions, etc…

National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov/ BMI Calculator 10-Year Heart Attack Risk Calculator (based on Framingham data)

Complimentary and Alternative Medicine Resource National Center for Complimentary and Alternative Medicine (NIH) http://nccam.nih.gov/ Sloan-Kettering http://www.mskcc.org/mskcc/html/11570.cfm

Keys to Using Web Based Evidence at the Point-of-Care Formulate a good question Use sites that are easy to use and can give you the answer you are looking for quickly Practice makes perfect (use the sites every chance you have)