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Improving Evidence Based Clinical Decision Making Larissa Lucas, MD, FACP Instructor, Harvard Medical School 5th Simposio Internacional de Seguridad del Paciente Cali, Colombia March 13, 2014 Conflict of Interest Senior Deputy Editor of DynaMed, an educational product of EBSCO Information Services Objectives Explain the connection between cognitive processes and errors in medical decision making Identify the challenges to answering clinical questions and making evidence based clinical decisions Describe the pros and cons of available tools Identifies strategies for a better system of information management According To Traditional Stories, How Many Goats Did Noah Take Into The Ark? The Answer? 2? 7? 10? 14? 20? According To Traditional Stories, How Many Goats Did Noah Take Into The Ark? O f e v e r y c le a n b e a s t t h o u s h a lt t a k e t o sevens thee by , t h e m a le a n d h is f e m a le : a n d o f b e a s t s t h a t a r e n o t c le a n b y t w o , t h e m a le a n d h is f e m a le . O f f o w ls a ls o o f t h e a ir b y s e v e n s , t h e m a le a n d t h e f e m a le ; t o k e e p s e e d a liv e u p o n t h e f a c e o f a ll t h e e a r t h . G e n e sis. Ch 7 ; v 2 How Do You Approach A Problem? Intuition – everyone knows this one Ask an “expert” – haven’t read about this in a while Look for the answer in reliable sources – never heard of this type of problem before Everyone Knew The Answer Other Historic TRUTHS in medicine Post menopausal hormone replacement therapy Increased breast cancer and MI Anti-arrhythmic medications for premature ventricular complexes (PVC) post MI Increased Newborns Increased Reduce mortality in CAST trial should sleep prone (on their stomachs) SIDS, now all newborns sleep on their backs HbA1c as low as possible Increased mortality in ACCORD trial Things We Do Differently Now Wear gloves, wash hands, universal precautions Surgery checklists Double check a patient’s identification before dispensing prescriptions Double check a patient’s blood type before transfusion Operating room device counts before and after surgery No One Is Exempt We are all human “To Err is Human” We all make cognitive errors To Err is Human… Early 1990s: errors were either due to “ignorance” or “implementation” 1999: To Err is Human, IOM report shifted focus from individuals to systems of care Now errors are: Systemic Cognitive Croskerry P. Diagnostic Failure: A Cognitive and Affective Approach. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Conditions for Cognitive Errors Ambient conditions Affective state Past experience Patient factors Team factors Fatigue Violation producing factors Croskerry P. Diagnostic Failure: A Cognitive and Affective Approach. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Errors of Knowledge We don’t know what we don’t know Our current knowledge is wrong or outdated We don’t know where or how to get the information we need Cognitive Errors in Oncology Cases 56 cases retrospectively reviewed 95% of cases had at least 1 cognitive error Common cognitive errors Work up strategy Interpretation of results Determining whether symptoms had resolved Application of guidelines would have prevented an error in 66% J Gen Intern Med. 2012 Nov;27(11):1416 Why Didn’t They Follow The Guideline? Didn’t think they had to follow the guideline Couldn’t find the guideline Didn’t know which guideline to read Didn’t know how to evaluate the guideline How to Keep Up with Guidelines? Rely on your institution to provide algorithms Monitor guideline-producing organizations yourself Too much work Government-run guideline websites Decision support systems Free access Online reference resources Alerts Valid trustworthy process Presented in relevant context Cognitive Errors in ER Cases 79 claims reviewed missed diagnoses were cognitive factors in 96% Error of judgment in 87% Lack of knowledge in 58% Lapse in vigilance or memory in 41% Ann Emerg Med. 2007 Feb;49(2):196 How do you maintain your knowledge base? Consult a colleague Attend courses Regularly refer to an online reference Easy to use and navigate Valid and relevant Comprehensive Strategies To Reduce Cognitive Error Provide adequate resources to make good decisions Step back and reflect Decrease reliance on memory Simplify tasks to reduce cognitive effort Minimize time pressure Croskerry P. Diagnostic Failure: A Cognitive and Affective Approach. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb. Technology To Reduce Errors Decision alerts within the EMR Does Evidence based reference resources Do this cause alert fatigue? they provide too much, take too much time? Evidence based algorithms How do you know if they are current and valid? How do you address variances? Not every patient fits a checklist Not every disease fits an algorithm What Resources Do You Currently Use? Colleagues Online resources: DynaMed, UpToDate, EMedicine, MDConsult, Harrisons Online Mobile resources PubMed Google Others…….. Tools To Manage Information Needs Alerting Tools: send you important updates that you need to read and store “Foraging” Hunting Tools: used to search for information _________________________________________ Relevance: information must be put into clinical context or you will not remember it Validity: information must be evaluated and validated by a trustworthy process Keeping How Do Youup Keep Up With It All? up with 7 relevant ublished a family physician ed to 7.5 hours he iterature Alper BS et al, 2004 Usefulness Systems Computerized decision support Summaries Evidence-based databases Synopses Evidence-based journal abstracts Syntheses Systematic reviews Studies Original journal articles Tools Alerting tools: Keep you current Use for most common clinical scenarios Must be relevant Caution: not all new evidence should change your practice Shaughnessy, Slawson, Information Mastery Hunting tools: Help you answer questions Easy to use Comprehensive Evidence labels Caution: what is the methodology used? Using your instinct Every spring a certain pond is covered in lilly-pads The lilly-pads double in area every day If the pond is covered 100% after 48 days, how many days is it covered 50%? Case 1 59-year-old woman with >30 pack-years smoking She is very healthy otherwise and active She has just quit smoking but is concerned about her risk of lung cancer Should she be screened for lung cancer? National Lung Screening Trial Guidelines Followed American College of Chest Physicians and American Society of Clinical Oncology (ACCP/ASCO) JAMA 2012 Jun American Lung Association (ALA) ALA 2012 Apr American Cancer Society CA Cancer J Clin 2013 Mar-Apr American Association for Thoracic Surgery J Thorac Cardiovasc Surg 2012 Jul How Would You Know? Your information resource alerted you Your EMR suggested it using patient data You reviewed the information in a online resource to keep yourself current Sometimes research changes and we do more or do less……… Case 2 62-year-old man with well-controlled diabetes and hypertension well controlled on HCTZ He is having preoperative evaluation for open colectomy for colon cancer Treadmill cardiac stress test performed for chest pain 1 year ago was normal He has had no symptoms of chest pain in 1 year Would you prescribe a preoperative beta-blocker? Preoperative Beta-blockers •2009 Update driven by new research: •Harm shown in POISE Trial •Benefit shown in DECREASE Trial •2011 DECREASE Trial discredited •2013 Heart 2013 Jul Systematic Review •2013 Aug – joint statement released In 2011, however, faith in the reliability of the DECREASE trials was shattered as a result of a scientific misconduct scandal centering on the principal investigator of the studies Preoperative Beta-blockers Sometimes research changes and we and stop doing unnecessary things to our patients……… Changes To Reduce Overuse The OLD way Preoperative Chest XRAY “Whole body” diagnostic CT for all trauma patients Axillary lymph node dissection in patients with breast cancer The NEW Way Not for routine ambulatory patients without history or physical to suggest a problem Not for patients with minor trauma or single system trauma Not for stage I/II if the sentinel lymph node biopsy is negative Choosing Wisely – American College of Surgeons (http://www.choosingwisely.org/doctor-patient-lists/american-college-of-surgeons/_) MRI for Headache Government Sources Case 3 28-year-old healthy woman being seen for routine annual physical She started sexual activity at age 20 with one partner She has never been pregnant and never has had a sexually transmitted disease Her last Cervical Cytology exam was 2 years ago and normal What test does she need: Cytology, HPV, Nothing? Depends On Where You Are ACOG/ ACS/ASCCP/ASCP For women aged 21-29 Cervical cytology every 3 years NO HPV testing World Health Organization Start at age 30 Screen with HPV if resources available or Screen with cytology if colposcopy is available for follow up How global and how relevant is your online resource? Improving Your Approach To Decision Making How confident are you in what you know? How current is your information? Slow down Know when to “trust your gut” and when to investigate and confirm Verify and update your knowledge on the most common problems you see Use the information you learn Accept that you cannot know everything Online Resources There are many!! Vary in breadth and depth Some have alerting features to keep you current Some have mobile versions Evaluation Of Resources Criteria for evaluation In-line references Transparent policy for methodology Date stamp on content Indication of “new evidence” Alerting feature Federated search of external content Not included in this study but some would consider important Peer review Evidence grade labeling Haynes, RB Journal of Clinical Epidemiology 2012 Comparing Resources Reproduced with permission from Haynes, RB Journal of Clinical Epidemiology 2012 Data collected March 2011 Breadth of Coverage 100% 90% 80% % topics covered 70% 60% 50% 40% 30% 20% 10% 83% 82% 70% 63% 60% 58% 48% 47% 33% 0% Error bars: 95% Confidence Interval Reproduced with permission from Haynes, RB Journal of Clinical Epidemiology 2012 Data collected March 2011 25% Haynes, B. How Current Are Leading Evidence-Based Medical Textbooks? JMIR, December 2012 Mobile Improving Your Approach To Decision Making Technology is not the answer for all cognitive errors Technology can support the process of decision making Find a tool/tools that meets your needs Alerting to keep you updated on guidelines and practice changing evidence Breadth and depth of content when you need to look something up Evaluate yourself when you are making a decision: How confident are you in what you know? How current is your information? Verify and update your knowledge Accept that you cannot know everything Muchas Gracias!