2. Online information resources for evidence-based clinical care: their evolution and the special role of librarians in their development and dissemination. Brian Haynes McMaster University

3. Objectives Review the evolution of information resources for evidence-based clinical decisions Review strategies for –Having evidence find you/your clients (“PUSH”) –Finding evidence (“PULL”) –Integrating evidence into workflow (“PROMPT”) Apply these strategies to learning about “Lantus Insulin”

4. Clinical case 48 year old male with type 1 diabetes mellitus for 9 years, collapses on factory loading dock, unrousable. Admitted to hospital with severe hypoglycemia. No recollection of antecedent warning symptoms, but had been engaged in increased physical activity just before onset. 3 weeks after hospital discharge, wife calls 911 during nocturnal bout of hypoglycemia – no warning, unusual activity. (Glucagon on hand but not used.) Admits that others notice he is “not right” before he recognizes low sugars Regimen: Humalog with meals; Humulin N 25 U am and pm “What about Lantus?” His doctor asks a librarian for help.

5. The History of Thrombolysis* *Antman, Lau, Kupelnick, Mosteller, and T Chalmers, JAMA 1992. 1975Trials show life-saving benefits 1985Most textbooks state benefits – few patients are offered thrombolysis 1990Textbooks uniformly state benefits – 40% of patients are offered thrombolytics Grimes et al, NEJM 1993 Immediate Percutaneous Coronary Intervention (PCI) is more effective than thrombolysis for acute MI

6. The Slippery Slope years since graduation r = -0.54 p<0.001............... knowledge of current best care 100% 0% 50%

7. How to use Evidence-Based Medicine Resources to Keep on Top of the Game Evidence-based medicine is......a set of resources to support clinical decisions based on current best evidence. research-enhanced health care

8. Early Realization… …EBHC won’t “work” unless backed up by effective information tools and resources

9. “Doing EBM”: Push-Pull-Prompt PUSH - having evidence find end-user PULL - seeking evidence when needed PROMPT – evidence-based reminders in clinical practice settings – and preferably in electronic medical records

10. PUSH: Resources for Keeping Up-to-Date

13. 50,000 articles/yr from 120 journals ~2,500 articles/yr meet critical appraisal and content criteria (95% noise reduction) Evidence-Based Journals Critical Appraisal Filters

14. Angela Eady Jennifer HollandAnn McKibbon Cindy Walker

16. ~2,500 articles/yr meet critical appraisal and content criteria (95% noise reduction) McMaster PLUS Project Clinical Relevancy Filter (MORE) ~25 articles/yr for clinicians (99.95% noise reduction) ~5-50 articles/yr for authors of evidence- based clinical topic reviews

17. http://bmjupdates.mcmaster.ca Did I mention that it’s free?

18. PULL: Resources for Finding Evidence When You Need it

19. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journals Computerized Decision Support System (CDSS) Evidence-based textbooks

20. http://www.clinicalevidence.com Systems: Clinical Evidence

21. Systems: Up-to-Date

22. Systems: Physicians’ Information and Education Resource

23. EBM “Systems” vs Traditional Textbook Model Traditional textbook: Author is an “authority” Author selects, reports on own One-year production line from manuscript to bookstand Three-year production schedule

24. Updating in EBM Systems Authors are provided with new studies and reviews that are: Assessed for validity Rated by clinicians for relevance Rated by clinicians for newsworthiness Within a month of original publication

25. 4S Smorgasbord – Ovid’s EBMR

26. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS) Evidence-based textbooks

27. Synopses – ACP Journal Club

28. Synopses – Evidence-Based Medicine

29. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS)

30. Syntheses: The Cochrane Library

31. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS)

32. Studies – General Resource: PubMed Filters also available on Ovid and Skolar

33. Patients with Type 1 Diabetes and Hypoglycemia Unawareness What about Lantus?

34. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS) Evidence-based textbook

36. From Up-to-Date

37. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS) Evidence-based textbook

38. http://bmjupdates.mcmaster.ca

40. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes.

41. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS) Evidence-based textbook

42. PubMed Clinical Queries: Search for Syntheses

44. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes. CONCLUSIONS: The evidence suggests that, compared with NPH insulin, insulin glargine is effective in reducing the number of nocturnal hypoglycaemic episodes, especially when compared with once-daily NPH. There appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes.

45. Studies Syntheses Synopses Systems Examples Original published articles Cochrane reviews Evidence-based journal abstract Computerized Decision Support System (CDSS) Evidence-based textbook

46. PubMed Clinical Queries: Search for Studies

47. Patients with Type 1 Diabetes and Hypoglycemia Unawareness: Resolution of Case Cut back on total insulin dose Evening glargine instead of intermediate (or long- acting) insulin Close monitoring of glucose Scrupulous avoidance of hypoglycemia Type 1 class for review and retraining

48. Tomorrow...Prompt Computerized decision support systems that include… Instant access to current best evidence Reminders for indicated care Warnings for contraindicated care

49. Personal digital internet libraries with wireless PDA access, linked to individual patient records, with a database of current best evidence, new evidence alerts, and links to other resources (patient information; product monographs; continuing education with feedback…) Tomorrow...

50. To keep on top Push Pull Prompt…..some labs and med orders systems synopses summaries studies