Transcript Comprehensive version - Tufts University School of Medicine

Information Mastery
The Applied Science of EvidenceBased Practice
Allen F. Shaughnessy, PharmD, MmedEd
Tufts University School of Medicine
Department of Family Medicine
David C. Slawson, MD
The University of Virginia,
Department of Family Medicine
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According to the Bible, how many
antelopes did Noah take into the Ark?
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Of every clean beast thou shalt take to
sevens
thee by
, the male and his
female: and of beasts that are not
clean by two, the male and his female.
Of fowls also of the air by sevens, the
male and the female; to keep seed
alive upon the face of all the earth.
 Genesis. Ch 7; v2
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How we acquire and use
information
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Where did you get the information from
to make that snap decision?
If you had had time (and interest), what
would you have done to make sure you
had the right answer?
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Evidence and Decision-Making
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Most decisions are based on what we
think is the evidence, not what we know
is the evidence
We use brief reading and talking to
other people as our information sources
No one has time to appraise all of the
evidence
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This workshop has been presented
in:
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Most of the US
Canada
Israel
Saudi Arabia
England
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Wales
Hong Kong
Taiwan
Denmark
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Where are we going?
EBM/EBP applied to everyday practice
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Main message of conference: Not all evidence is
ready for clinical application
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How to distinguish must-know from nice-to-know information
How to identify information that may not be valid
Sources of information vary in their usefulness
Evidence at the point of care requires the use of
appropriate information tools
The future of healthcare relies on the appropriate
use of resources
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Avoiding underuse, overuse, misuse
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How we will get there?
Concepts, practice, modeling
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Introduction of the ideas behind EBM/EBP and
information mastery
Practice applying the ideas
Modeling different ways of teaching the material
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Modified problem-based learning
Lecture presentations
Hands-on practice
• Evaluating information
• Using evidence tools
You are all teachers and leaders of the
“revolution/solution”!!!!
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Lee RV, Eimerl S. The Physician. New York, NY: Time Inc; 1967:154.
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Focusing on outcomes that matter
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POE: Patient-oriented evidence
• mortality, morbidity, quality of life
• Live longer and/or better
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DOE: Disease-oriented evidence
• pathophysiology, pharmacology, etiology
Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A Guidebook to the Medical Information Jungle.
The Journal of Family Practice 1994;39(5):489-99.
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Patient-oriented evidence contradicts diseaseoriented evidence
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
Erythropoeitin in patients with chronic
renal failure increases Hemoglobin
Erythropoietin increases mortality in
patients with chronic renal failure
Telmisartan (Benicar) lowers blood
pressure
Telmisartan increases the risk of
adverse cardiovascular events
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Determining whether information is
relevant and does it matter?
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Does it address an outcome people care
about (Patient-oriented evidence)?
Is the intervention feasible?
If it is true, will it require you to change your
practice?
Yes to all three –
Patient-Oriented Evidence that Matters
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The new paradigm: probabilistic
thinking
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Current paradigm: the biomedical model
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The body can be approached as an engineering problem
• External fetal monitoring
Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic
fetal monitoring in predicting cerebral palsy. N Engl J Med 1996;334:613-8.
• Right heart catheterization
Shah MR, et al. Impact of the pulmonary artery catheter in critically ill patients:
meta-analysis of randomized clinical trials. JAMA. 2005 Oct 5;294(13):1693-4.
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The new paradigm: Probabilities
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What can we do for people that, on average, will help most of
them most of the time?
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What is Evidence-Based Medicine?
“The judicious use of the best current evidence in making
decisions about the care of the individual patient.”
--EBM working group
“An acknowledgment that there is a hierarchy of evidence and
that conclusions related to evidence from controlled
experiments are accorded greater credibility than conclusion
grounded in other sorts of evidence.”
-- Brian Hurwitz. BMJ 2004;329:1024-8.
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The Hierarchy of Evidence
Credibility
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Results from controlled trials
Results from case-control studies
Results from case series
Expert consensus or opinion
Pathophysiologic reasoning
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The Place of EBM in Medicine
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Goals of medicine: Relieve/prevent suffering;
maintain/provide hope; prevent, treat, or cure disease
The science of medicine: knowing the best way to
prevent, treat, or cure disease (EBM can address this
aspect)
The art of medicine: Determining, using intuition,
experience, and judgment, what patients need the
most
Combining the art and science  Clinical Jazz
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Feeling Good About Not Knowing
Everything: Information Mastery
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Prioritize efforts to identify, validate,
and apply common POEMs
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Responsibility: less to read, but more
important to find and evaluate
The Information Mastery Traffic Light
Red: Don’t for most people most of the time
Yellow: Benefit/harm uncertain
Green: Most of the time for most people
The Information Mastery Traffic Light
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But the lights may change . . .
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Red to Green: B-blockers for CHF
Green to Red: HRT for postmenopausal women
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Why? Practice before valid POEMs were known
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Yellow: Keep an open mind — be ready to update DOEs
and ? valid POEMs (low LOE)
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If it’s not a valid POEM, it’s not necessarily so
Keeping Up in the Real World
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Read few original articles, only if forced
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Get rid of the bedside stack
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Use Foraging Tools
• Sources of valid information filtered for relevance to
practice
• Foraging session
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Goal: “Confidence through Information”
Relevance
Frequency of Problem
Common
Patient-Oriented
Evidence
Best
Type of
Evidence
Disease-Oriented
Evidence
Caution
Rare
Only if
Time
Worst
POEMs
Finding Answers in the Real World:
Hunting Tools
Use summary sources that filter for relevance &
validity:
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Dynamed
Clinical Evidence
The Cochrane Library
Essential Evidence Plus
The Clinician of the Future (NOW!)
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“I know a lot, therefore I am”
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Replaceable by a computer
“I think, therefore I am”
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Never replaceable by computer
Travel agent – should they memorize schedules?
• Would you trust them?
• “How do you know?”
Bedside computer = “stethoscope of the present”
Take-Home Points
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Confidence through information
Hunting & foraging tools providing relevant
and valid information when needed
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Focus on valid POEMs – Patient-Oriented
Evidence that Matters
Take-Home Points
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Clinicians will be/are valued by how they think
and not by what they know
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The information age is about information
management, not information acquisition
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Thinking in probabilities, not mechanics