1. Evaluating Foraging Tools for Keeping Up with New, Relevant and Valid Information 1

2. A Bigger Problem? “It’s not what you don’t know that hurts you (your patients), it’s what you think you know that’s not so” Important to answer practice-based questions with best source Equally important to make sure the necessary questions are being asked

3. Sorting Out Information The Usefulness Equation Usefulness = Relevance x Validity of any sourceWork Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle. The Journal of Family Practice 1994;39(5):489-99.

4. Two Tools Needed to Master Information 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 don’t know that new info. is available You can’t 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)www.bmj.com

5. 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

6. Information Overload Foraging clip

9. Real World Medicine Two patients in first week with mild COPD, minimal symptoms, history of CAD/MI, secondary prevention. Currently on Spiriva- should I stop it? Doc not seeing study would never ask question!!! (no known link)

10. Bottom line: Adults with chronic obstructive pulmonary disease (COPD) treated with inhaled anticholinergics, including ipratropium (Atrovent) and tiotropium (Spiriva), are at an increased risk of adverse major cardiovascular events including myocardial infarction (MI) and cardiovascular death. However, anticholinergics do improve the important patient oriented outcome of quality of life while not increasing the risk of all-cause mortality. Clinicians should assess the individual risk and benefit of treatment for each patient (e.g. withhold anticholinergics from patients with mild to moderate symptoms of COPD at high risk of CVD and strongly consider treating patients with life-altering symptoms from COPD at medium or low risk of CVD). (Common POEM)

11. Chest 2010 : Celli B, et al. Cardiovascular safety of tiotropium in patients with COPD. Bottom line This study finds some support for the safety of tiotropium (Spiriva) in patients with chronic obstructive pulmonary disease (COPD). However, an important limitation of the study was that the authors only looked at studies sponsored by the manufacturer, and the results were heavily weighted by a single large, long study that excluded patients with recent evidence of heart disease. Studies of ipratropium have found different results (Chest 2010;137(1):13-19), and it is unclear why there would be an important difference in risk given the similarity of these drugs.

12. Singh S, Loke YK, Enright PL, et al. Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. BMJ 2011 Jun 14;342:d3215. RESULTS: Five randomised controlled trials were eligible for inclusion. Tiotropium mist inhaler was associated with a significantly increased risk of mortality (90/3686 v 47/2836; relative risk 1.52, 95% confidence interval, 1.06 to 2.16; P=0.02; I(2)=0%). Both 10 microg (2.15, 1.03 to 4.51; P=0.04; I(2)=9%) and 5 microg (1.46, 1.01 to 2.10; P=0.04; I(2)=0%) doses of tiotropium mist inhaler were associated with an increased risk of mortality. The overall estimates were not substantially changed by sensitivity analysis of the fixed effect analysis of the five trials combined using the random effects model (1.45, 1.02 to 2.07; P=0.04), limiting the analysis to three trials of one year`s duration each (1.50, 1.05 to 2.15), or the inclusion of additional data on tiotropium mist inhaler from another investigational drug programme (1.42, 1.01 to 2.00). The number needed to treat for a year with the 5 microg dose to see one additional death was estimated to be 124 (95% confidence interval 52 to 5682) based on the average control event rate from the long term trials. CONCLUSIONS: This meta-analysis explains safety concerns by regulatory agencies and indicates a 52% increased risk of mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease.

13. Foraging Tool Work Sheet Key Points: Specialty specific, POC (work) Disease vs Patient Oriented (relevance) LOE rating, best if SORT (validity) Coordinated with HQ hunting tool

15. Reflections/Questions

16. Quality First-Alert Systems 1. How is the information filtered? Patient- vs disease- oriented? Specialty-specific? Comprehensive? Which journals? Does it matter (change my practice?) or is it simply news? 2. Is the information valid? must have levels of evidence (LOE) labels Beware “Trojan Horse”!

17. Quality First-Alert Systems 3. How well is information summarized? 2000 - 3000 words accurately in 200 words 4. Is the information placed into context? Much more than abstracts “Translational Validity”

18. First-Alert System Risks “Spyware”: Doc Alerts “Trojan Horse”: who’s paying when it’s free? Abstracts only: Journal Watch,Tips from other Journals, ClinicalUpdates, No relevance/ validity filter You can have information “free” and you can have it “uncensored”, but you can’t have it both ways. No Free Lunch!

19. Clinical Quandry Black box warning on Avandia (rosiglitazone) NEJM, then JAMA Blood sugar still too high, what about Actos (pioglitazone) ? Should I still be recommending Actos? (did my foraging tool keep me UTD?)

21. 1. www.google.com www.google.com 2. www.bmjupdates.com (user ID: dcs6e; password: marnie www.bmjupdates.com 3. www.medscape.com (user: slawson44; pass: andrew www.medscape.com

26. Cochrane Review Twenty-two trials which randomised approximately 6200 people to pioglitazone treatment were identified. Longest duration of therapy was 34.5 months. Published studies of at least 24 weeks pioglitazone treatment in people with type 2 diabetes mellitus did not provide convincing evidence that patient-oriented outcomes like mortality, morbidity, adverse effects, costs and health-related quality of life are positively influenced by this compound. Metabolic control measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint did not demonstrate clinically relevant differences to other oral antidiabetic drugs. Occurrence of oedema was significantly raised. The results of the single trial with relevant clinical endpoints (Prospective Pioglitazone Clinical Trial In Macrovascular Events - PROactive study) have to be regarded as hypothesis- generating and need confirmation.

27. Foraging tool overview ToolLess workMore work ACP Journal ClubSpecialty specific (IM)Validity assessment but no LOE Relevance: No POE vs. DOE, no “matters” factor No hunting tool Journal WatchSpecialty specific (various)Validity: No assessment, no LOE Relevance: No POE vs. DOE, no “matters” factor No hunting tool Dynamed AlertsSpecialty specific Validity assessment, LOE Relevance: Focuses on evidence that matters Coordinated hunting tool,

28. Foraging tool overview ToolLess workMore work MedscapeSpecialty specific (various)Validity: No assessment, no LOE Relevance: No POE vs. DOE, no “matters” factor No hunting tool BMJ UpdatesSpecialty specific (various)Validity assessment but no LOE Relevance: No POE vs. DOE, no “matters” factor (example: breast size=DM2 risk) No hunting tool

29. Comparison of Various Email Alert Services for Clinical Knowledge Updates Stacy Hom MD, Scott Strayer MD MPH, and David Slawson MD

30. Email Alert Services free subscription alerts sent out at least monthly in frequency automatic push service (user did not have to take additional steps to receive email updates) Measured Translational Accuracy (MTA): Time to Diffusion and Quality of Assessment.

31. Emails were collected continuously from September 2008 to September 2010 We using the search terms “Tiotropium” and “Spiriva” Search results were reviewed and only those related to Tiotropium’s impact on cardiovascular health were included This was confirmed by checking online archives of email updates sent We limited our search to a six month period from the date of article publication

32. Email Alert Services Compared 1. BMJ Evidence Updates 2. Doctor’s Guide 3. Dynamed 4. Essential Evidence POEMs 5. Global Family Doctor 6. Peerview Institute 7. Physician’s First Watch 8. Cochrane Pearls

34. Time to Diffusion

35. Did NOT send out 2010 article 1. Doctor’s Guide 2. Dynamed 3. Peerview Institute 4. Cochrane Pearls 5. Essential Evidence POEMs: 6 months later

36. Quality of Assessment Results 6 out of 8 email services looked at were missing updates on one or both articles. Physician’s First Watch & Wonca Global Family Doctor alerted clinicians on both articles. Average time to update was 12 days for the 2008 study, and 37 days for the 2010 study

37. Quality of Assessment Essential Evidence was the only email service to make the distinction that the 2010 study largely excluded patients with recent heart disease.

38. Measured Translational Accuracy (MTA) of Foraging Tools Time to Diffusion Quality of Assessment Just like getting to Fenway Park for Game 7 World Series