The pace of change inpractice-driving medical knowledge

in new models of publishing

May 5, 2013

Brian S. Alper, MD, MSPH, FAAFPEditor-in-Chief, DynaMed

Medical Director, EBSCO Publishing

Introduction/Disclosures

Rural family medicine in 1995

Mission to provide most useful informationto healthcare professionals at point of care

Now working full-time as

Editor-in-Chief, DynaMed

Medical Director, EBSCO Publishing

Half of what is taught in medical education is wrong, but we don’t

know which half.

Attributed to Dr. C. Sidney Burwell, Dean of Harvard Medical School 1935-1949, in Pickering GW. The purpose of medical education. BMJ 1956 Jul 21;2:113

45 highly-cited original research publications

16%

16%

24%

16% contradicted by subsequent studies16% found to have smaller ef-fects24% remain un-replicated

Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA. 2005;294(2):218-228

124 original articles in NEJM in 2009

Prasad V, Gall V, Cifu A. The frequency of medical reversal. Archives of Internal Medicine 2011 Oct 10;171(18):1675-1676

49%

13%

49% present new prac-tice surpassing current care

13% reverse previosly accepted care

The pace of change is accelerating. “Medicine will change more in the

next 20 years than it has in the past 2000.”

Smith R. Thoughts for new medical students at a new medical school. BMJ 2003 Dec 20;327(7429):1430-1433

How quickly does core evidence change?

• Management overviews of top DynaMed topics evaluated

- Maintained via 7-step evidence-based methodology

- Updated daily

- Standardized templates with outline format (overviews represent most important evidence and guideline for practice)

• Compared to 1-2 years ago, how many lines have changed (addition, deletion, modification)?

• Classify change due to

- New evidence

- New guidance

- External feedback

- Internal quality improvement

How quickly does core evidence change? Interim results: 80 topics (mean time 1.5 years)

0%20%40%60%80%

100%

Examples of new evidence changing overviews

Dyspnea: midazolam may reduce unexplained dyspnea more than morphine in advanced cancer

Gallstones: cholecystectomy within 48 hours in mild gallstone pancreatitis may safely reduce hospital stay

MS: dextromethorphan/quinidine sulfate may reduce frequency/severity of pseudobulbar affect episodes

MRSA: comparative efficacy for linezolid, telavancin, vancomycin

PE: Pulmonary Embolism Rule out Criteria (PERC)

PE: less bleeding with oral rivaroxaban vs. LMWH/warfarin

Stroke: graduated compression stockings do not appear to reduce DVT and may cause skin damage

How quickly does core evidence change?

Interim results: 4,411 lines, 2,532 lines changed (mean time 1.5 years)

1160 modified 474 deleted 898 added0%

5%

10%

15%

20%

25%

30%

Of 2,532 lines changed

How quickly does core evidence change?

0%

10%

20%

30%

40%

50%

60%

How quickly does core evidence change?Interim results: 4,411 lines (mean time 1.5 years)

0%

10%

20%

30%

Adjusted for 1-year timeframe:

16.2% practice-guiding information changes in 1 year due to

new evidence or guidance

Questions?

Brian S. Alper, MD, MSPHEditor-in-Chief, DynaMed

Medical Director, EBSCO Publishing