current best evidence sources

Where can you find “current best evidence”? Advances in the quest for access to high

quality evidence, ready for clinical application.

Brian HaynesMcMaster University

Presenter

Muir Gray, the architect of the UK National Electronic Library of Health, classifies information resources into 3 categories, PUSH, PULL, PROMPT. I’m going to spend a few minutes this morning relating the evolution of ACP information services according to this model, including the way that the PLUS project has evolved from ACP Journal Club.

Objectives

! To review the emerging hierarchy of pre-appraised “best evidence”resources

! To consider the complementary roles of “push” and “pull” evidence services (and “prompt”)

! To illunstrate the use of current sources of “pre-appraised” evidence

Systems

Summaries

Synopses

Syntheses

Studies

Examples

Computerized decision support

Evidence-based textbooks

Evidence-based journal abstracts

Systematic reviews

Original journal articles

Olde School EBHC

New School EBHC

The evolution of information resources for evidence-based decisions

All of these resources require that clinicians link the evidence with individual patient problems...Systems are needed to

link directly from patient problems to evidence

Presenter

This slide summarizes the evolution of information resources for evidence-based care over the past 15 years. EBM began at the bottom of this pyramid, teaching clinicians how to appraise original articles. In the mid-1990s, led by the Cochrane Collaboration, systematic reviews – here labelled syntheses – became available in increasing numbers. Beginning about this time as well, synopses of premier research became available, in the form of evidence-based journals such ACP Journal Club. Most recently, evidence-based texts were created, including PIER and BMJ Clinical Evidence which I’ve shown you, and UpToDate and Dynamed, along with a substantial number of specialty texts, and Harrison’s Practice is about to join these ranks. Thus, the original version of EBM has become Olde School and the New School EBM is growing towards the top of this pyramid. All of these resources require that clinicians link the evidence with individual patient problems. Ultimately, I hope that all these resources will make it possible to provide current best evidence in the context of individual patient features, the links being automated. The prospects for this I will leave to my Clem McDonald to provide.

Evolution of EBM Info

! PreEBM: Passive diffusion (“publish it and they will come”)

! Early EBM: Pull diffusion (“teach them to read it and they will come”)

Evolution of EBM Info

! Current EBM: Push diffusion (“read it for them and send it to them”)

! Future EBM: Prompt diffusion (“read it for them, connect it to their individual patients, prompt them and their patients”)

Finding best evidence for healthcare decisions

! Push, Pull, Prompt! of Pre-appraised evidence

Push:

Presenter

ACP Journal Club was the first evidence-based information service, using a systematic and explicit approach to evaluating new research and a structured, rigorous approach to summarizing high quality evidence for internal medicine.

70,000 articles/yrfrom 160 journals

~4,500 articles/yrmeet critical appraisaland content criteria(94% ‘noise’ reduction)

Evidence!Based"Journals

Critical Appraisal FiltersReliability (kappa) >90% beyond chance

Includes all Cochrane Reviews,CADTH Reviews, NHS HTA Reviews, AHRQ Reviews

Presenter

This figure depicts what happens ‘behind the scenes’ or ‘under the hood’ of the evidence-based journals. For these, we begin with about 60,000 articles per year in 120+ journals of established relevance for a broad range of medical and nursing practice ***highly trained and calibrated research staff apply basic “critical appraisal” filters that select studies and reviews that are scientifically strong and possibly ready for clinical attention, ***these filters shrink 60,000 articles down to about 3500 articles per year – a 94% noise reduction from a clinical perspective, but still too many articles for a clinician to read

The McMaster PLUS project

! only a tiny proportion of all research is “ready for application”

! only a tiny fraction of the “ready” research is “relevant” to the practice of a given clinician

! only a tiny proportion of the “relevant”research for a given practitioner is “interesting” in the sense of being something new, important, and actionable.

Presenter

My group has developed and tested a new approach to making new evidence as “available as tap water”. The basic ideas are these: ***only a tiny proportion of all research is ready for application and ***only a tiny fraction of the “ready” research is relevant to the practice of a given clinician, and then again, ***only a tiny proportion of the relevant research for a given practitioner is interesting in the sense of being something important, new, and actionable.

McMaster Online Rating of Evidence: >5000 clinicians

RELEVANCE

To become a rater, e-mail us at [email protected](must be in current clinical practice)

~4,500 articles/y meet critical appraisal and content criteria

McMaster PLUS Project

Clinical Relevancy Filter (MORE)

~20 articles/yr for clinicians (99.96%noise reduction)

~5-50 articles/y for authors of evidence- based guidelines and reviews

Health Knowledge Refinery

Predicts citation counts (p<0.001)

Presenter

The PLUS project then takes this to the next level. We take the 2500 methodologically OK articles and add a clinical relevancy filter, the MORE (McMaster Online Rating of Evidence) service, engaging over 2000 practicing physicians around the world. This determines which (if any) practice disciplines the 2500 articles are relevant to. This distills the 2500 articles down to about 20 important articles per year for a given clinical discipline (an overall noise reduction of 99.96%, not to put to fine a point on it) and, depending on the clinical problem, we can also identify between 5 and 50 articles per year that would be relevant to the author of a clinical topic in an evidence-based publication such as PIER in the US or Clinical Evidence in the UK. Using this approach, I think we can make keeping up to date tractable for practitioners, and updating evidence-based resources. Practical for publishers and authors.

With biomedical research articles published @ 2,000,000/yr, a clinician reading 2 articles/day will be 55 centuries behind each year.

Bernier & Yerkey, 1979

The evidence base for clinical effectiveness has become so vast that it is essentially unmanageable for individual providers.

Institute of Medicine, 2001

Presenter

There are many scary predications concerning the rapid growth of new biomedical knowledge. Here are 2 of them. Bernier and Yerkey in 1979 provided figures that led to the calculation that a practitioner reading 2 articles per day would end up 55 centuries behind in their reading each year, given the 2,000,000 articles published annually in the biomedical literature. The Institute of Medicine declared in 2001 that the evidence base for clinical effectiveness has become so vast that it is essentially unmanageable for individual providers. What I’ve just shown you concerning new developments in medical literature processing puts the lie to these dire pronouncements.

User End

! Users sign up according to discipline! Users control relevance and flow! Users can change disciplines at any time,

and can sign up for as many as they wish! Users can search according to discipline –

or not! Users can access many fulltext articles for

free! Users can access PubMed Clinical Queries

McMaster PLUS Trial Findings: % of participants using evidence-based resources by month

Perc

enta

ge U

sing

PLU

S

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

03 03 04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05Month

70

60

50

40

30

20

10

0

Baseline (5 mo) Self-serve vs Full-serve Full-Serve

Self-serve Full-Serve

Relative increase 58.7%, P=0.001

RCT begins Control cross-over begins

Presenter

The McMaster PLUS service was evaluated in a cluster randomized trial sponsored by the Canadian Institutes of Health Research and increased the use of evidence-based information services by physicians in the sparsely populated area of Northern Ontario by about 58%, sustained over 18 months of follow-up. During the ***baseline period of 5 months for this study, the 2 groups were indistinguishable in accessing the digital library. In the second***, randomized phase of the trial, we see divergence of the Self Serve and Full Serve groups, with about 58% relative increase in use by the group receiving alerts. In April 2005,*** participants receiving the control, self-serve group were crossed over to the full serve intervention, and showed an immediate increase in use that has been sustained.

You can sign up for free at

http://plus.mcmaster.ca/EvidenceUpdates

Medscape"Best"Evidence"Alerts

Free!at! https://profreg.medscape.com/px/newsletter.do!

PULL: Resources for finding evidence when you need it

…is there an alternative to insulin?

Patient: A 36 year old white woman with gestational diabetes and elevated bloods sugars despite exercise and dietary measures asks...

Did I miss any important evidence with my search?

Is there any way I could have retrieved less “junk”?

What is the best current evidence?

Presenter

Screen the results and list the potentially relevant ones Also state how many are definitely not relevant But, makes you wonder, how many actual relevant studies are we missing

SystemsSummariesSynopsesSyntheses

Studies

Search for Evidence

! Systems – none that I know of! Summaries – Clinical Evidence,

UpToDate, ! Traditional texts – MD Consult,

ACP Medicine! Pull resources: EvidenceUpdates,

ACPJC+, Nursing PLUS

MEDICAL THERAPY — If normoglycemia cannot be maintained by medical nutritional therapy, then anti-hyperglycemic agents should be initiated [43]. There are two options in pregnant patients who require medical therapy aimed at controlling blood glucose: insulin (and some insulin analogs), which is the only recommended approach in the United States [11]; and oral anti-hyperglycemic agents, which are used in some other countries.

Currently, the ADA and the American College of Obstetricians and Gynecologists do not endorse the use of oral anti-hyperglycemic agents during pregnancy and such therapy has not been approved by the Unites States Food and Drug Administration for treatment of GDM [5,11]. [references are from 2001 and 2004]

http://www.uptodate.com/online/content/abstract.do?topicKey=pregcomp/27083&refNum=5,11

http://www.uptodate.com/online/content/abstract.do?topicKey=pregcomp/27083&refNum=43

http://www.uptodate.com/online/content/abstract.do?topicKey=pregcomp/27083&refNum=11

RATIONALE FOR TREATMENT — Identifying women with GDM is important because appropriate therapy can decrease fetal and maternal morbidity, particularly macrosomia [1,2]. An effective treatment regimen consists of dietary therapy, self blood glucose monitoring, and the administration of insulin if target blood glucose values are not met with diet alone.

http://www.uptodate.com/online/content/abstract.do?topicKey=pregcomp/27083&refNum=1,2

CONCLUSIONS!

There!is!little!evidence!available!on!the!benefits!and!harmsof!screening!for!gestational!diabetes.!Limited!evidence!suggests

that!treatment!!of!gestational!

diabetes!after!24!weeks!of!gestation

may!improve!!maternal!and!neonatal!

outcomes.


Studies

CONCLUSION:!No!substantial!maternal!or!neonatal!outcome!

differences!were!found!with!the!use!of!glyburide!or!metformin!

compared!with!use!of!insulin!in!women!with!GDM.


Studies


Studies

For gestational diabetes, what is the best current management?

Systems: no Computerized Decision SupportSummaries: in UTD, not CESynopses: EBM, EBN, ACPJCSyntheses: EvidenceUpdates Studies: in UTD, CE, EvidenceUpdates; more

in Clinical Queries

To keep up with evidence! Pull

! Push

! Prompt…some labs and EMRs with a credible evidence-based pedigree

Systems

Summaries

Synopses

Syntheses

Studies

Finding evidence-based guidelines

UK National Institute of Clinical Effectiveness (no guideline on GDM)

US National Guideline Clearinghouse(no guideline on GDM)

http://www.evidence.nhs.uk

DARE Synopsis of Nicholson et al. Evidence Report/Technology Assessment; 162. 2008Practice: the authors stated that clinicians should be aware that there was insufficient evidence to determine the effectiveness of alternatives to insulin for either birth weights or maternal glucose control, but use of such alternatives was unlikely to result in maternal or foetal adverse events.

http://www.guideline.gov

NGC Search ResultsYour search criteria: Keyword: gestational diabetes and oral hypoglycemic Guideline Categories: Assessment of Therapeutic Effectiveness Age Range: Adult (19 to 44 years) Gender: Female Sort Order: Relevance

No guidelines were found that matched your query.

Free at www.tripdatabase.com

(PickOne)

FREE AT www.sumsearch.uthscsa.edu

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