Transcript Teaching Family Physicians To Be Information Masters

Evaluating Foraging Tools for Keeping Up
with New, Relevant and Valid Information
1
A Bigger Problem?
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“It’s not what you don’t know that hurts you
(your patients), it’s what you think you know
that’s not so”
Important to answer practice-based questions
with best source
Equally important to make sure the necessary
questions are being asked
Sorting Out Information
The Usefulness Equation
Usefulness = Relevance x Validity
of any source
Work
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.
Two Tools Needed to Master
Information
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A method of being alerted to new information (a “foraging” tool)
A tool for finding the information again when you need it. (a
“hunting” tool)
Without both:
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You don’t know that new info. is available
You can’t find it when you do
Clinical example- Riboflavin for migraines
Shaughnessy AF, Slawson DC. Are we providing doctors with the training and tools for lifelong
learning? British Medical Journal 1999 (13 Nov): www.bmj.com.
(http://bmj.com/cgi/reprint/319/7220/1280.pdf)
Characteristics of an Ideal Clinical
Awareness System
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Specialty-specific
Comprehensive
Coordinated hunting and foraging tools
Specific and reproducible criteria for relevance and
validity
Available at the point-of-care
All backed up by levels of evidence
Information Overload
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Foraging clip
Real World Medicine
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Two patients in first week with mild COPD,
minimal symptoms, history of CAD/MI,
secondary prevention.
Currently on Spiriva- should I stop it?
Doc not seeing study would never ask
question!!! (no known link)
Bottom line: Adults with chronic obstructive pulmonary disease (COPD) treated
with inhaled anticholinergics, including ipratropium (Atrovent) and tiotropium
(Spiriva), are at an increased risk of adverse major cardiovascular events
including myocardial infarction (MI) and cardiovascular death. However,
anticholinergics do improve the important patient oriented outcome of quality of
life while not increasing the risk of all-cause mortality. Clinicians should assess
the individual risk and benefit of treatment for each patient (e.g. withhold
anticholinergics from patients with mild to moderate symptoms of COPD at high
risk of CVD and strongly consider treating patients with life-altering symptoms
from COPD at medium or low risk of CVD). (Common POEM)
Chest 2010: Celli B, et al. Cardiovascular safety of
tiotropium in patients with COPD.
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Bottom line
This study finds some support for the safety of tiotropium
(Spiriva) in patients with chronic obstructive pulmonary disease
(COPD). However, an important limitation of the study was that
the authors only looked at studies sponsored by the
manufacturer, and the results were heavily weighted by a single
large, long study that excluded patients with recent evidence of
heart disease. Studies of ipratropium have found different results
(Chest 2010;137(1):13-19), and it is unclear why there would be
an important difference in risk given the similarity of these drugs.
Singh S, Loke YK, Enright PL, et al.Mortality associated with tiotropium mist
inhaler in patients with chronic obstructive pulmonary disease: systematic review and
meta-analysis of randomised controlled trials. BMJ 2011 Jun 14;342:d3215.
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RESULTS: Five randomised controlled trials were eligible for inclusion.
Tiotropium mist inhaler was associated with a significantly increased risk of
mortality (90/3686 v 47/2836; relative risk 1.52, 95% confidence interval, 1.06 to
2.16; P=0.02; I(2)=0%). Both 10 microg (2.15, 1.03 to 4.51; P=0.04; I(2)=9%)
and 5 microg (1.46, 1.01 to 2.10; P=0.04; I(2)=0%) doses of tiotropium mist
inhaler were associated with an increased risk of mortality. The overall
estimates were not substantially changed by sensitivity analysis of the fixed
effect analysis of the five trials combined using the random effects model (1.45,
1.02 to 2.07; P=0.04), limiting the analysis to three trials of one year`s duration
each (1.50, 1.05 to 2.15), or the inclusion of additional data on tiotropium mist
inhaler from another investigational drug programme (1.42, 1.01 to 2.00). The
number needed to treat for a year with the 5 microg dose to see one additional
death was estimated to be 124 (95% confidence interval 52 to 5682) based on
the average control event rate from the long term trials.
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CONCLUSIONS: This meta-analysis explains safety concerns by regulatory
agencies and indicates a 52% increased risk of mortality associated with
tiotropium mist inhaler in patients with chronic obstructive pulmonary disease.
Foraging Tool Work Sheet
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Key Points:
• Specialty specific, POC (work)
• Disease vs Patient Oriented (relevance)
• LOE rating, best if SORT (validity)
• Coordinated with HQ hunting tool
Reflections/Questions
Quality First-Alert Systems
1. How is the information filtered?
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Patient- vs disease- oriented?
Specialty-specific?
Comprehensive? Which journals?
Does it matter (change my practice?) or is it simply
news?
2. Is the information valid?
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must have levels of evidence (LOE) labels
Beware “Trojan Horse”!
Quality First-Alert Systems
3. How well is information summarized?
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2000 - 3000 words accurately in 200 words
4. Is the information placed into context?
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Much more than abstracts
“Translational Validity”
First-Alert System
Risks
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“Spyware”: Doc Alerts
“Trojan Horse”: who’s paying when it’s free?
Abstracts only: Journal Watch,Tips from
other Journals, ClinicalUpdates,
• No relevance/ validity filter
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You can have information “free” and you can
have it “uncensored”, but you can’t have it both
ways. No Free Lunch!
Clinical Quandry
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Black box warning on Avandia (rosiglitazone)
NEJM, then JAMA
Blood sugar still too high, what about Actos
(pioglitazone) ?
Should I still be recommending Actos? (did
my foraging tool keep me UTD?)
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www.google.com
www.bmjupdates.com (user ID: dcs6e;
password: marnie
www.medscape.com (user: slawson44;
pass: andrew
Cochrane Review
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Twenty-two trials which randomised approximately 6200 people to pioglitazone
treatment were identified. Longest duration of therapy was 34.5 months.
Published studies of at least 24 weeks pioglitazone treatment in people with type
2 diabetes mellitus did not provide convincing evidence that patient-oriented
outcomes like mortality, morbidity, adverse effects, costs and health-related
quality of life are positively influenced by this compound. Metabolic control
measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint
did not demonstrate clinically relevant differences to other oral antidiabetic
drugs. Occurrence of oedema was significantly raised. The results of the single
trial with relevant clinical endpoints (Prospective Pioglitazone Clinical Trial In
Macrovascular Events - PROactive study) have to be regarded as hypothesisgenerating and need confirmation.
Foraging tool overview
Tool
Less work
More work
ACP Journal Club
Specialty specific (IM)
Validity assessment but no LOE
Relevance: No POE vs. DOE, no
“matters” factor
No hunting tool
Journal Watch
Specialty specific (various)
Validity: No assessment, no LOE
Relevance: No POE vs. DOE, no
“matters” factor
No hunting tool
Dynamed Alerts
Specialty specific
Validity assessment, LOE
Relevance: Focuses on evidence that
matters
Coordinated hunting tool,
Foraging tool overview
Tool
Less work
More work
Medscape
Specialty specific (various)
Validity: No assessment, no LOE
Relevance: No POE vs. DOE, no
“matters” factor
No hunting tool
BMJ Updates
Specialty specific (various)
Validity assessment but no LOE
Relevance: No POE vs. DOE, no
“matters” factor
(example: breast size=DM2 risk)
No hunting tool
Comparison of Various Email Alert Services for
Clinical Knowledge Updates
Stacy Hom MD, Scott Strayer MD MPH,
and David Slawson MD
Email Alert Services
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free subscription
alerts sent out at least monthly in frequency
automatic push service (user did not have to
take additional steps to receive email updates)
Measured Translational Accuracy (MTA):
Time to Diffusion and Quality of Assessment.
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Emails were collected continuously from September
2008 to September 2010
We using the search terms “Tiotropium” and “Spiriva”
Search results were reviewed and only those related
to Tiotropium’s impact on cardiovascular health were
included
This was confirmed by checking online archives of
email updates sent
We limited our search to a six month period from the
date of article publication
Email Alert Services Compared
1. BMJ Evidence Updates
2. Doctor’s Guide
3. Dynamed
4. Essential Evidence POEMs
5. Global Family Doctor
6. Peerview Institute
7. Physician’s First Watch
8. Cochrane Pearls
Time to Diffusion
Did NOT send out 2010 article
1. Doctor’s Guide
2. Dynamed
3. Peerview Institute
4. Cochrane Pearls
5. Essential Evidence POEMs: 6 months later
Quality of Assessment
Results
• 6 out of 8 email services looked at were missing
updates on one or both articles.
• Physician’s First Watch & Wonca Global Family
Doctor alerted clinicians on both articles.
• Average time to update was 12 days for the 2008
study, and 37 days for the 2010 study
Quality of Assessment
• Essential Evidence was the only email service to
make the distinction that the 2010 study largely
excluded patients with recent heart disease.
Measured Translational Accuracy (MTA) of
Foraging Tools
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Time to Diffusion
Quality of Assessment
Just like getting to Fenway Park for Game 7
World Series