Information Mastery: Evidence-Based Medicine in Everyday Practice David C. Slawson, MD Allen Shaughnessy, PharmD

The Medical Information Business Original Research Clinical experience Production

Refinement The Medical Information Business Systematic reviews (Cochrane) Meta-analysis Practice guidelines POEM Alert System

Production Refinement Distribution Clinician centered informatics “Just-in-time” info Hand-held computers Internet/Intranet Hunting/Foraging tools The Medical Information Business

Production Refinement Distribution Sales & Marketing The Medical Information Business Evidence-Based Medicine Information Mastery

Information Sources for the point of care Everything is based on the usefulness equation: Usefulness = Relevance x Validity Work

Validity The hard part of Information Mastery Technique: EBM working group Apply to other information sources Responsibility: Self vs. Delegation

Work Basic law of human behavior: lowest amount of work you can get away with Varies with source and your need Recognizing the balance “Informatics”- “Just -in-time” vs “just-in-case”

Relevance: Type of Evidence POE: Patient-oriented evidence –mortality, morbidity, quality of life DOE: Disease-oriented evidence –pathophysiology, pharmacology, etiology

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

Comparing DOES and POEMs

Two Tools to Get the Job Done Hunting and Foraging go together like horse and carriage (fish and chips, London and fog, Americans and bad manners... ) Without both, you don’t know what you are looking for and can’t find it when you do. Clinical example- Riboflavin for migraines

Quality Foraging Tools 1. What is the filter? Is it relevant? –Patient- vs disease- oriented? –Common (specialty-specific?) –Comprehensive-which journals? –Will it change behavior (POEM)? 2. Is it valid (must have LOE labels)? –Beware “Trojan Horse”!

Quality Foraging Tools 3. How well is information summarized? – words accurately in 200 words 4. Bottom Line: Put in context with rest of information and clinical practice –Much more than “abstracts”/current content –Must be experienced clinician in specialty, well versed in current and past literature –“Translational Validity”

Quality Foraging Tools: Beware “free” software Spyware (e.g. Epocrates, PDR for the Pocket PC) Trojan Horse (e.g. Journals-to-Go, others) Abstracts/ Current Contents/ Journal Watch/ “Journal Rack”/ “Tips”/ etc. None of these have relevance/ validity criteria (LOEs) You can have information “free” and you can have it “uncensored”, but you can’t have it both ways- No Free Lunch!

Quality Foraging Tools IR/IP = “The Clinical Awareness System” –Criteria: specialty-specific, comprehensive, specific and reproducible criteria for relevance and validity available at the point-of-care –All backed up by LOEs –POEMs for Primary Care, Pediatrics, Internal Medicine –Soon to be others!

InfoPOEMs - The Clinical Awareness System Alendronate prevents multiple fractures in osteoporotic women over 55 Clinical question Does alendronate prevent multiple fractures from occurring in women with osteoporosis? Setting: Outpatient (any) Study design: Randomized controlled trial (double-blinded) Synopsis The investigators enrolled women between the age of 55 and 81 who had a vertebral fracture or whose bone mineral density (BMD) met the WHO criteria for osteoporosis. They were randomly assigned (allocation method concealed) to receive alendronate (Fosamax, 5 mg/d for 2 years followed by 10 mg/d; n=1841) or placebo (n=1817). All patients with insufficient dietary calcium also received daily supplements of 500 mg of elemental calcium plus 250 IU cholecalciferol (a low dose of vitamin D, by the way). The authors followed the patients for an average of 4 years and analyzed the data based upon the initial group assignment. During this follow-up period, they found a total of 789 symptomatic fractures. 471 of the fractures occurred in 341 patients receiving placebo compared to 308 fractures in 248 of the women receiving alendronate. Two or more fractures occurred in 86 (4.7%) women on placebo compared to 51 (2.8%; NNT= 51 for 4.3 years) on alendronate. Some poor souls had three or more fractures (27 and 7, respectively; NNT=91 for 4.3 years). Since they followed the patients over time, they were able to see how soon any benefit might occur, finding that after 6 months, benefits were already apparent. Bottom line Women with established osteoporosis taking alendronate (Fosamax) will have fewer symptomatic fractures than women taking placebos. This study should not be extrapolated to women without established osteoporosis. In a randomized trial (N Engl J Med 1997; 337: 670-6) of primary prevention using 500 mg calcium and 700 IU vitamin D, the NNT to prevent one fracture was 15 for 3 years. Wouldn't it be nice to see a REAL study comparing these expensive drugs to a reasonable dose of calcium and vitamin D? LOE 2b- Reference Levis S, Quandt SA, Thompson D, et al. Alendronate reduces the risk of multiple symptomatic fractures: results from the Fracture Intervention Trial. J Am Geriatr Soc 2002;50: Visit us Online Online InfoRetriev erInfoRetriev er InfoPOEMS ©InfoPOEMS © Tour Purchase Support Downloads Contact Us LOE Please do not reply to this . If you wish to receive this plain text format, please click here. Copyright © InfoPOEM, Inc. All rights reserved.here

Relevance first, validity second Comparison with ACP Journal Club, Best Evidence 13% of POEMs (in Evidence Based Practice) were in ACP JC 70% of abstracts in ACP JC were not POEMs. Many were DOEs without commentary. Gold Standard = Valid POEMs (only 2.6%), 25 – 30/ month

Quality of Review (Hunting) Information 10 methodological criteria for rigor of 36 published review articles Overall rating: intraclass correlation lowest (0.23) for experts vs non-experts (0.78) trained to do critique More expertise = stronger prior opinion, less time spent on review, lower quality –Avg score 1/15; best score 5/15; No LOEs! UTD = 2/15 “evidence-based” –Translational validity- worse yet! Experts = original research; Non-experts = refinement/ synthesis due to less bias Oxman AD, Guyatt GH. The science or reviewing research. Ann N Y Acad Sci 1993;703:

Translational Validity Can We Trust Review Articles? Reporting of the UKPDS by 40 review articles –85% of reviews: readers not told that good glucose control doesn’t decrease mortality –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 POEM) –Only 18% (NNR = 6): metformin decreased mortality, independent of BS control

Translational Validity Can We Trust Review Articles? –None reported lack of any benefit (micro- or macrovascular) of insulin/ sulfonylureas in obese diabetics –Only 13% (NNR = 8) reported that blood pressure control is more important than BG control

Drilling for the Best Information Cochrane Library Specialty-specific POEMs Best Evidence Clinical Evidence Textbooks, Up-to- Date, 5-Minute Clinical Consult Usefulness Journals/ Medline

InfoRetriever 2003 Windows 95/98/NT/ME/2000, PocketPC and Web 650 critical reviews of recent research from the Journal of Family Practice POEMs section Bayesian diagnostic test / H&P calculator Basic drug info by class and cost for 1200 drugs Key evidence- based treatment guidelines Cochrane Database of Systematic Reviews: over 1200 abstracts 102 clinical prediction rules 1500 short research synopses (400 added per year) 5 Minute Clinical Consult

Take – Home Points 1. Overall mission of Information mastery: Answer at least 80% of clinicians’ information needs in 50 seconds or less. 2. In order to survive in the information age (the "future" already at hand): every clinician will need a specialty-specific hunting and foraging tool, based on the information mastery equation: Usefulness = Relevance x Validity/ Work

Take-Home Points 3. Clinicians in the information age will be valued by how they "think" and not by what they "know". 4. (This one is specific for academia) The information age is about information, not research. We need to see ourselves as part of a team: the production of new information is only part of it. Refinement, distribution, and sales/marketing are also necessary components. Only when we have all four do we have sufficiency.

Information Mastery An Evidence-Based Approach to Medical Education University of Virginia, Charlottesville, VA April 2 - 5, 2003