Transcript Cochrane Library - Physician Assistant Education Association

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 (!)
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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
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Morning news?
Journal in the office?
Colleagues?
Buzz?
Patients?
Conferences?
Walter Cronkite
Walter Cronkite was a real
news anchor.
http://www.theatlantic.co
m/international/archive/20
12/07/is-it-waltercronkites-fault-whyolympic-announcers-keepsaying-beizhing/260556/
Ron Burgundy
Not a real news anchor,
even though he looks like
one.
Source:
http://cdn.sheknows.com/a
rticles/2013/08/ronburgundy-memoir.jpg
The difference is VALIDITY
In desperation, you may listen to buzz as factthat’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 Mastery
Slawson 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 Hierarchy
From: 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:
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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.
Example
Antiarrhythmic
Therapy
DiseaseOriented
Evidence
Patient-Oriented
Evidence that
Matters
Drug X  PVCs Drug X increases
on ECG
mortality
Comment
POEM study
contradicts DOE
study
POEM agrees
Antihypertensive Antihypertensive Antihypertensive
therapy  BP
therapy  mortality with DOE
therapy
Prostate
Screening
PSA screening
detects prostate
cancer early
? whether PSA
screening 
mortality
DOE exists, but
the important
POEM is
unknown
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
-ORhttps://www.youtube.com/playlist?list=PLkr8XTH_bktjgj4V9mxfl
VvBz7wAkAPIL
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
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P: Patient, population, “problem”
I: Intervention
C: Comparison Intervention
O: Outcome
(T): Time
Clinical Question in PICO format
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P: 2 y/o girl with asthma
I: influenza vaccine
C: no influenza vaccine
O: possible asthma exacerbation risk
(T): immediately following vaccination
Cochrane Library: Search Terms
CDSR: Systematic Review Length
CDSR: Plain Language Summary
CDSR: Conclusions
CDSR: References
TRIP: Turning Research Into
Practice
TRIP: Article Abstracts
DynaMed
DynaMed: Search Autocomplete
DynaMed: Search With Records & Level
of Evidence (LOE)
DynaMed: LOE Defined
DynaMed: Calculators
National Guideline
Clearinghouse (NGC)
NGC: Search Terms
NGC: Results
NGC: Guideline Summaries
NGC: LOE (not standardized!)
NGC: Not All Guidelines Include
LOE
MEDLINE (PubMed)
MEDLINE: Clinical Queries
Search Terms
MEDLINE: Limits
MEDLINE: Display Settings -Abstract
Questions?
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References

Claude Moore Health Sciences Library. Information mastery: navigating the maze. University of
Virginia Health System Web site. www.hsl.virginia.edu/collections/ebm/pyramid.cfm. Accessed
May 11, 2012.
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Dartmouth Biomedical Libraries. Evidence-based medicine (EBM) Resources. Dartmouth College
Library Web site.
http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_resources.shtml. Accessed
May 11, 2012.
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Ebell MH, Barry HC, Slawson DC, & Shaughnessy AF. Finding POEMs in the medical literature. J
Fam Pract. 1999;48(5):350-355.
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Ebell M, Shaughnessy A. Information mastery: integrating continuing medical education with the
information needs of clinicians. J Cont Ed Health Prof [serial online]. April 2, 2003;23:S53-62.
Available from: CINAHL with Full Text, Ipswich, MA. Accessed May 30, 2013.

Johnson CA. The Information Diet. Sebastopol, CA; O’Reilly Media, Inc.; 2011
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Marks S, McKibbon KA. Posing clinical questions: Framing the question for scientific inquiry. AACN
Clin Issues. 2001;12(4):477-481.
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Mayer, D. (2009). Essential Evidence-Based Medicine. Oxford, UK. Oxford University Press.
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McConaghy JR. Evolving medical knowledge: moving toward efficiently answering questions and
keeping current. Prim Care: Clin in Office Prac. 2006 December; 33(4): 831-837
References
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Pearce-Smith N, Hunter J. The introduction of librarian tutors into the teaching evidencebased medicine week in Oxford, UK. Health Info Libr J. 2005;22(2):146-149.
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Shaughnessy A, Gupta P, Erlich D, Slawson D. Ability of an information mastery curriculum to
improve residents' skills and attitudes. Fam Med. 2012 April; 44(4): 259-64.
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Shaughnessy AF, Slawson DC, & Bennett JH. Becoming an information master: A guidebook
to the medical information jungle. J Fam Pract. 1994;39(5):489-499.
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Slawson DC, Shaughnessy AF, & Bennett JH. Becoming a medical information master:
Feeling good about not knowing everything. J Fam Pract. 1994;38(5):505-513.

Slawson, D.C. & Shaughnessy, A. Information mastery: evidence-based medicine in
everyday practice. 2003. Accessed May 11, 2012 from
http://www.bibalex.org/supercourse/bmj/bmj.htm.
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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.
 http://www.theatlantic.com/international/archive/2012/07/is-it-walter-cronkites-faultwhy-olympic-announcers-keep-saying-beizhing/260556/
 http://cdn.sheknows.com/articles/2013/08/ron-burgundy-memoir.jpg
Bonus!
http://www.thennt.com/
The NNT Groups
• Thennt.com
• How many people without heart disease need
to be on the Mediterranean diet for 5 years
before one person doesn’t have a CVA, MI or
die?
http://www.thennt.com
61 and no one gets hurt
More on Information Mastery?
• Tufts Health Care Institute Conference:
• http://www.thci.org/educationalactivities/conferences/information-mastery
• UVA School of Medicine:
• http://www.medicine.virginia.edu/clinical/departments/familym
ed/information_mastery/info_mastery-page
More Foraging-many are both:
sign up for emails to forage.
Journal Watch (NEJM)
ACCESSSS Federated Search, free, register. Hunting and
foraging:
http://plus.mcmaster.ca/accessss/Default.aspx?Page=1
ACP Journal Club (Annals of Internal Medicine)
http://www.essentialevidenceplus.com/
National Prescribing Centre (UK):
http://www.npc.nhs.uk/
EssentialEvidencePlus POEM of the week podcasts
(iTunes)
Agency for Healthcare Research and Quality
subscriptions http://www.ahrq.gov/
National Guidelines Clearinghouse:
http://www.guidelines.gov/