1. Evidence on the Internet
Mark A. Goedecker, MD
York Hospital
Department of Family Medicine
May, 17, 2007

2. 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

3. 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

4. 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

5. 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)

6. 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

7. Formulating a Good Question is the Best Place to Start

8. 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?

9. 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?”

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

11. 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

12. 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

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

14. 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

15. 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

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

17. 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”

18. 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

19. 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

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

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

22. Systematic Review Sites

23. Agency for Healthcare Research and Quality
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

24. 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

25. Clinical Evidence
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

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

27. Evidence-based Synopses

28. 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”

29. 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

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

31. 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

32. E-Textbooks

33. 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

34. Other E-textbooks Family Practice Notebook GP Notebook (UK)
GP Notebook (UK)
Merck Manual

35. Original Literature Searches

36. National Library of Medicine – Pub Med
Allows you to search the entire database of medical literature
More useful when doing original research – more time intensive
FREE

37. Query-Answering Services
You submit a question, they find an answer
ATTRACT – UK site
Family Physicians Inquiry Network
National Library of Health UK
Previous answers can be searched for free

38. Hitting the Headlines
From the National Electronic Library for Health (UK)
Reviews the evidence behind the news your patients may be reading or seeing on TV
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

39. Immunization Information
STFM Group on Immunizations
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)

40. The CDC
Information on travelers health, environmental health, diseases and conditions, etc…

41. National Heart, Lung and Blood Institute
BMI Calculator
10-Year Heart Attack Risk Calculator (based on Framingham data)

42. Complimentary and Alternative Medicine Resource
National Center for Complimentary and Alternative Medicine (NIH)
Sloan-Kettering

43. 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)