1. Information Mastery

2. Objectives At the end of this seminar, participants should be able to: Incorporate information mastery principles into daily learning and patient care activities Formulate focused foreground questions in PICO format Distinguish between disease-oriented and patient-oriented evidence Identify high quality evidence based on study design Use evidence-based medical databases to research clinical queries and to stay up to date with medical literature

3. Disclosures No financial disclosures Much of the material and ideas were developed by David Slawson, MD, and Alan Shaughnessy, PharmD, MMedEd

4. What is EBM? “Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” David Sackett, 1996

5. Why read literature? Answer clinical questions Keep up to date Follow your interests Be the best advocate possible for patients

6. Limitations of EBM Limited evidence Poor quality evidence Individual patient differences

7. What determines medical decisions? Decision Medical Evidence Prior clinical experience Individual patient characteristics

8. Classic EBM 5 step approach Ask Search Critically appraise Implement Evaluate

9. EBM  Information Mastery Traditional EBM = basic science, primary article appraisal Information Mastery = applied science 1994, Slawson and Shaughnessy Gather valid, relevant, patient-oriented information that is critically appraised and apply it to practice. Use tools that appraise evidence for you Allows you to stay up do date without drowning in the vast sea of primary journal articles.

10. Usefulness Usefulness = (relevance * validity)/work Relevance: Does it matter to my patient? Validity: How well does the study reflect the truth? Less work is better Maximize reading high quality information without sifting through poor quality information

11. Clinical Questions Type of question determines sources to use Background (basic science) Foreground (specific clinical question) PICO Patient population/problem Intervention Comparison Outcome

12. ACTIVITY 1 Write a PICO for each case: Patient population/problem, Intervention, Comparison, Outcome Case 1: “A 65 year old man with T2DM checks his blood sugar daily and does his best to control his blood sugar with exercise and nutrition. He wonders if having well-controlled blood sugars overtime will increase his lifespan.” Case 2: “A 40 year old woman presents with migraine headaches that are becoming more She is reluctant to use medications other than herbal supplements and tells you that she just read an article about the possible benefits of riboflavin for preventing migraines.

13. DOE vs POE Disease-oriented evidence/outcomes Focused around diseases/labs. Patient-oriented outcomes Focused on outcomes patients care about: Quality of life Morbidity Mortality

14. Disease-Oriented Outcome Patient-Oriented Outcome Intensive glucose lowering can decrease A1c Intensive glucose lowering does not decrease mortality Beta-carotene, Vit E are good antioxidants Neither prevents cancer or CV disease Varenicline is effective for helping patients quit smoking Varenicline increases the risk of adverse CV events

15. POEM Patient Oriented Evidence that Matters Is information relevant & does it matter? 3 criteria: Do patients care about the outcomes/is it patient-oriented (quality of life, morbidity, mortality)? Is the intervention feasible? If true, will it require you to change your practice? Yes to all 3 = POEM

16. ACTIVITY 2 Read 2 evidence summaries Discuss in small groups to determine if they are POEMS 3 criteria of POEMS Do patients care about the outcomes/is it patient-oriented (quality of life, morbidity, mortality)? Is the intervention feasible? If true, will it require you to change your practice?

17. Evidence Hierarchy

18. Graded Evidence SORT Developed by AAFP Takes POEM into consideration USPSTF Graded recommendations GRADE Developed by international group of physicians Level of Evidence 11 categories Developed at Oxford

19. SORT (Strength Of Recommendation Taxonomy) CodeDefinition AConsistent, good-quality patient-oriented evidence BInconsistent or limited-quality patient-oriented evidence CConsensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

20. Highly Controlled Research  Randomized Controlled Trials  Systematic Reviews Physiologic Research Preliminary Clinical Research  Case reports  Observational studies Uncontrolled Observations & Conjecture Effect on Patient-Oriented Outcomes  Symptoms (drivers license)  Functioning (visual loss)  Quality of Life (leg ulcers)  Lifespan Effect on Disease Markers  Diabetes (Photocoagulation, GFR, NCV)  Arthritis (x-ray, sed rate)  Peptic Ulcer (endoscopic ulcer) Effect on Risk Factors for Disease  Improvement in markers (blood pressure, HBA1C, cholesterol) SORT A Validity of Evidence Relevance of Outcome SORT B SORT C

21. USPSTF Grades GradeDefinition AThe USPSTF recommends the service. There is high certainty that the net benefit is substantial BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. CThe USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. DThe USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. IThe USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

22. GRADE (Grade of Recommendations, Assessment, Development, and Evaluation) CodeQuality of EvidenceDefinition AHighFurther research is very unlikely to change our confidence in the estimate of effect. Several high quality studies with consistent results or one large high quality multi-center trial BModerateFurther research is likely to have an important impact on our confidence in the estimate of the effect and may change the estimate. One high quality study, several studies with some limitations CLowFurther research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate. One or more studies with severe limitations DVery lowAny estimate of effect is very uncertain Expert opinion, no direct research evidence, onre or more studies with very severe limitations.

23. Level of Evidence Developed by Centre for Evidence-Based Medicine in Oxford, England More detailed and complex 11 levels 1a-c (systematic reviews), 2a-c, 3a-c, 4, 5 (expert opinion) http://www.cebm.net/oxford-centre-evidence-based- medicine-levels-evidence-march-2009/ (see for a table) http://www.cebm.net/oxford-centre-evidence-based- medicine-levels-evidence-march-2009/

24. Information Mastery Toolkit Journals (2-3) Foraging services (summaries of new information) Hunting tools (find answers to questions)

25. “Foraging” Services Analyze articles/evidence for you and send you summaries DynaMed Alerts EE Plus POEMS BMJ Clinical Evidence FPIN Clinical Inquiries ACP Journal Club

26. Characteristics of an Ideal Foraging/Alert Tool How is the information filtered? Specialty specific Patient-oriented (relevance) Is the information valid? Backed-up by evidence (level of evidence, SORT is always best) Is the information summarized and easy to access? Comprehensive but summarized (2000-3000 words accurately in 200 words) Point of care (work) Coordinated with a hunting tool Is the information placed into context? Translational validity More than abstracts

27. Characteristics of an Ideal Foraging/Alert Tool Specialty-specific Patient-oriented (relevance) Backed up by levels of evidence, SORT is best (validity) Comprehensive but summarized (2000-3000 words accurately in 200 words) Point of care (work) Coordinated with a hunting tool

28. Foraging/Alert Tool Risks Who’s paying when it is free? Possibly pharmaceutical companies Abstracts only contain no relevance/validity filter Examples are Journal Watch, Clinical Updates TAKE HOME POINT: If it’s free there may be something wrong with it. Quality often doesn’t come free!

29. Foraging Tool Overview ToolLess workMore work ACP Journal Club-Specialty Specific (IM)-Validity assessment but no LOE -Relevance: no POE vs DOE, no “matters” factor -No hunting tool BMP Updates-Specialty Specific (various) -Validity assessment but no LOE -Relevance: no POE vs DOE, no “matters” factor -No hunting tool DynaMed Alerts-Specialty specific (various) -Validity assessment -LOE -Relevance: focuses on patient-oriented evidence -Coordinated hunting tool

30. Foraging Tool Overview ToolLess workMore work Journal Watch-Specialty Specific (various) -No validity assessment -No LOE -Relevance: no POE vs DOE, no “matters” factor -No hunting tool Medscape-Specialty Specific (various) -No validity assessment -No LOE -Relevance: no POE vs DOE, no “matters” factor -No hunting tool

31. Fig 1 Updating curves for relevant evidence (128 systematic reviews) by point of care information summaries (log rank χ2=404, P<0.001). ©2011 by British Medical Journal Publishing Group Banzi R et al. BMJ 2011;343:bmj.d5856

32. Summary of Foraging Tools DynaMed: Fastest to update with new information BMJ Clinical Evidence: Only sends valid articles UpToDate: e-mails article authors every 6 months to ask for updates No one has looked at how accurately information is summarized/said in the tools (are summaries valid?)

33. EBM “Hunting” Tools Point of care evidence-based tools (30-40 seconds) Best tools = useful = (relevance*validity)/work DynaMed Cochrane database Essential Evidence Plus BMJ Clinical Evidence FPIN Clinical Inquiries Trip database Pub Med

34. Drilling for the Best Information BMJ Clinical Evidence (therapy) Dynamed UpToDate TRIP Database Textbooks Usefulness Medline Usefulness = Relevance X validity Work RWVRW V R WV RWV RWV RWV R W V Essential Evidence Plus PIER RWVR WV

35. Clinical Jazz Science (EBM/structure) + Art (improvisation) = Clinical Jazz Both structure and improvisation are necessary, but there’s not good evidence for many areas of medicine, so we have a lot of liberty to improvise!

36. ACTIVITY 3 Review use of the following tools: DynaMed Essential Evidence Plus TRIP Database BMJ Clinical evidence

37. ACTIVITY: Medical Myths

38. ACTIVITY: Look-up conference

39. Some Studies that I Like to Quote http://www.youtube.com/watch?v=Ij8bPX8IINg James McCormack, MD