online information resources for evidence-based clinical care: their evolution and the special role...
TRANSCRIPT
Online information resources for evidence-based clinical care: their evolution and the special role of librarians in their development and dissemination.
Brian HaynesMcMaster University
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”
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.
The History of Thrombolysis*
*Antman, Lau, Kupelnick, Mosteller, and T Chalmers, JAMA 1992.
1975 Trials show life-saving benefits
1985 Most textbooks state benefits – few patients are offered thrombolysis
1990 Textbooks 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
The Slippery Slope
years since graduation
r = -0.54p<0.001
...
...
. ... . .... .
....
....
.....
...knowledgeof current best care
100%
0%
50%Choudhry, Fletcher and Soumerai, Ann Intern Med 2005;142:260-73
94% of 62 studies found decreasing competence for at least some tasks, with increasing physician age.
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
Early Realization…
…EBHC won’t “work” unless backed up by effective information tools and resources
“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
PUSH: Resources for Keeping Up-to-Date
50,000 articles/yrfrom 120 journals
~2,500 articles/yrmeet critical appraisaland content criteria(95% noise reduction)
Evidence-Based Journals
Critical Appraisal Filters
Angela Eady
Jennifer Holland Ann McKibbon
Cindy Walker
~2,500 articles/yr meet critical appraisaland 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
http://bmjupdates.mcmaster.ca
Did I mention that it’
s free?
PULL: Resources for Finding Evidence When You Need it
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journals
Computerized Decision Support System (CDSS)
Evidence-based textbooks
http://www.clinicalevidence.com
Systems: Clinical Evidence
Systems: Up-to-Date
Systems: Physicians’ Information and Education Resource
4S Smorgasbord – Ovid’s EBMR
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)Evidence-based textbooks
Synopses – ACP Journal Club
Synopses – Evidence-Based Medicine
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)
Syntheses: The Cochrane Library
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)
Studies – General Resource: PubMed
Filters also available on Ovid and Skolar
Patients with Type 1 Diabetes and Hypoglycemia Unawareness
What about Lantus?
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)Evidence-based textbook
From Up-to-Date
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)Evidence-based textbook
http://bmjupdates.mcmaster.ca
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.
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)Evidence-based textbook
PubMed Clinical Queries: Search for Syntheses
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.
Studies
Syntheses
Synopses
Systems
Examples
Original published articles
Cochrane reviews
Evidence-based journal abstract
Computerized Decision Support System (CDSS)Evidence-based textbook
PubMed Clinical Queries: Search for Studies
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
Tomorrow...Prompt
Computerized decision support systems that include…
• Instant access to current best evidence
• Reminders for indicated care
• Warnings for contraindicated care
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...
To keep on top
• Push
• Pull
• Prompt…..some labs and med orders
systems
synopses
summaries
studies