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Kick Your Textbooks to the Curb: Finding Clinically Relevant Information Quickly. Adrian Banning, MMS, PA-C Gary M. Childs, MS. Too much info, too little time, chatter and hyperbole (!). We are bombarded with information. You have to sift the good from the bad.
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Kick Your Textbooks to the Curb: Finding Clinically Relevant Information Quickly Adrian Banning, MMS, PA-C Gary M. Childs, MS
Too much info, too little time, chatter and hyperbole (!) • We are bombarded with information. • You have to sift the good from the bad. • You can’t give up and read nothing. • Where would you prefer to get your daily news?
Your sources count • Morning news? • Journal in the office? • Colleagues? • Buzz? • Patients? • Conferences?
Walter Cronkite Walter Cronkite was a real news anchor. http://www.theatlantic.com/international/archive/2012/07/is-it-walter-cronkites-fault-why-olympic-announcers-keep-saying-beizhing/260556/
Ron Burgundy Not a real news anchor, even though he looks like one. Source: http://cdn.sheknows.com/articles/2013/08/ron-burgundy-memoir.jpg
The difference is VALIDITY In desperation, you may listen to buzz as fact-that’s how rumors get started and we don’t have time or leeway for that. Something has to be relevant to you, be good info and take little time to find.
No free lunch: You need a level of evidence (LOE) • Beware things that are mailed to you for free or that can’t account for their levels of evidence (LOE). • You’ll need to search out what you have at your disposal and the quality of it-or else you’re just doing more of the same • Look at free mailers with lots of ads skeptically. • Pharm reps
Making Decisions • How do we know what to do? • Knowledge>Fear • Find good evidence (and experience and opinions), combine with patient risk and values to give us options • We then weigh the options with the patient and make a decision • Science and Art • How do we do this. . . in reality?
Need answers at point-of-care • Internal med residents had 2 questions for every 3 pts seen • Background = epi, pathophys, presentation, requires textbooks • Foreground information is testing, diagnosis, treatment, Need EBM summaries or research • Residents asked mostly about therapy and diagnosis and asked more foreground than background questions as training progressed • Pursued 29% of their questions • Used textbooks, original articles, and attendings • Pursued an answer if they thought pt wanted it for in fear of malpractice
Information MasterySlawson and Shaugnessy, et al. • Finding high quality information to answer YOUR question, quickly. • You may not be an appraisal expert, but they exist • You need a level of evidence (LOE) Information sources are not all equal(different databases, journals, experts) • Go for patient-oriented evidence first • POEM vs DOE • Hunting vs foraging
Information Mastery Usefulness of Info= (Relevance x Validity) Work
Critical appraisal is a total drag, but. . . • Ask, find, assess validity, synthesize • RECRUITEMENT, Randomized ALLOCATION, ACCOUNTED (ITT), MAINTENANCE/MEASURMENT • BLINDING, OUTCOME • IM lets the experts assess for you. • Are you sure you can assess this expertly? • Allocation concealment? • You must stay an expert on the interpretations AND how to interpret AND see patients AND eat AND sleep AND. . .
Evidence Based Medicine Steps • Have a question (put it into PICO) • Search the literature from the top of the pyramid (next slide) • Find a study/find evidence • Perform appraisal /find level of evidence and look for bias • Determine how the results help you-how will you use them with your patient in their lives using your/others’ experience • Are the above steps working?
The Evidence HierarchyFrom: http://www.dartmouth.edu/~biomed/services.htmld/EBP_docs/pyramid-loaded.pdf
Levels of Evidence Pyramid Example http://www.hsl.virginia.edu/collections/ebm/pyramid.cfm
Patient Oriented Evidence that Matters: POEMs • DOE = Disease Oriented Evidence • You will likely have to differentiate POEMs vs DOE yourself • Specialists and researchers may need DOE as well if highly specialized, but DOE doesn’t change your immediate clinical decision with a patient.
POEM Requirement Number 1: • Address a frequently encountered clinical question (in your realm of medicine-family/cardio/oncology). • Not too rare and about something you’ll need to a make a decision on
POEM Requirement Number 2: • Measures a patient oriented outcome like: • mortality • morbidity • quality of life • reduction in symptoms • other endpoints that are important to the patient and you. • Not a disease-oriented outcome like LV pumping or neuronal death. • Intermediate or premature evidence is not helpful here-too early in the process.
POEM Requirement Number 3: • Results will require a change in your practice (M) • Confirming what you already know and do is a waste of time. • One person’s POEM may be another’s POE depending on your practice.
DOE • Increase our knowledge of a disease • DOE= prognosis, prevalence, pathophysiology, pharmacology, etiology, etc. • DOEs are crucial to medicine and we can’t dx, tx or prevent a disease before we understand it.
“Comparing DOES and POEMs”Slawson, D.C. & Shaughnessy, A. 2003. Information Mastery: Evidence-Based Medicine in Everyday Practice. PowerPoint file retrieved February 17, 2011 from http://www.bmj.com. Slide 12.
Hunting and Foraging • Forage- have information come to you • POEM of the Week Podcast! Emails! • Hunting-looking for evidence • Databases
Tips on keeping validity • Go to trusted sources (use the pyramid). • Go to relevant items (POEMs). • Look for LEVELS OF EVIDENCE, resources, someone who is accountable. • A.K.A. “WHO WROTE THIS?” • Don’t contribute to chatter if you haven’t checked the facts. Read the article. • Brush-up on how to read a research article. It’s ok. We all forget some things, sometimes.
Immediate Gratification Many resources can provide an immediate answer at the point-of-care! Yes!
Part 1: Summary • Find a realistic way to use evidence • You DO need the skills to be able to read technical medical information • type of article, type of research, PPV/NPV, odds and risk ratios • Does the patient see the difference-can you bring them the evidence and make them part of their own team? • Application of EBM is not cookbook
Part 2, Hunting Sources: Finding Clinically Relevant Information Quickly
Cochrane Systematic Reviews • A study done in 1972 showed inexpensive corticosteroids beneficial in preterm delivery. • No systematic review of the literature was done until 1989. • Had it been it would have shown that infant mortality is reduced 30-50% using this evidence that was already on hand. • VERY comprehensive analysis of the research
Links To Video Tutorial Playlist http://tinyurl.com/m22fosh -OR- https://www.youtube.com/playlist?list=PLkr8XTH_bktjgj4V9mxflVvBz7wAkAPIL
Clinical Question • Suzy, the mother of a 2 y/o girl with asthma is concerned about the upcoming cold and flu season. She’s interested in having her child receive the influenza vaccine, but she’s afraid that the vaccine could trigger her daughter’s asthma. What does the current available evidence suggest?
PICO(T) Format • P: Patient, population, “problem” • I: Intervention • C: Comparison Intervention • O: Outcome • (T): Time
Clinical Question in PICO format • P: 2 y/o girl with asthma • I: influenza vaccine • C: no influenza vaccine • O: possible asthma exacerbation risk • (T): immediately following vaccination
