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Information Mastery

The Applied Science of Evidence- Based

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?

Of every clean beast thou shalt take to Of every clean beast thou shalt take to

thee by thee by sevens, the male and his , the male and his female: and of beasts that are not female: and of beasts that are not clean by two, the male and his female. clean by two, the male and his female. Of fowls also of the air by sevens, the Of fowls also of the air by sevens, the male and the female; to keep seed male and the female; to keep seed alive upon the face of all the earth.alive upon the face of all the earth.

Genesis. Ch 7; v2Genesis. Ch 7; v2

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How we acquire and use information

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

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

This workshop has been presented in:

Most of the US Canada Israel Saudi Arabia England

Wales Hong Kong Taiwan Denmark

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Where are we going?EBM/EBP applied to everyday practice

Main message of conference: Not all evidence is ready for clinical application• 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• Avoiding underuse, overuse, misuse

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How we will get there?Concepts, practice, modeling

Introduction of the ideas behind EBM/EBP and information mastery

Practice applying the ideas Modeling different ways of teaching the material

• 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

POE: Patient-oriented evidence • mortality, morbidity, quality of life

• Live longer and/or better

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 disease-oriented 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?

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

Current paradigm: the biomedical model• 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 catheterizationShah 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.

The new paradigm: Probabilities• 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

Results from controlled trials Results from case-control studies Results from case series Expert consensus or opinion Pathophysiologic reasoningC

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The Place of EBM in Medicine

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

Feeling Good About Not Knowing Everything: Information Mastery

Prioritize efforts to identify, validate,

and apply common POEMs

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

But the lights may change . . .

• Red to Green: B-blockers for CHF

• Green to Red: HRT for postmenopausal women

Why? Practice before valid POEMs were known

Yellow: Keep an open mind — be ready to update DOEs

and ? valid POEMs (low LOE)

If it’s not a valid POEM, it’s not necessarily so

Keeping Up in the Real World

Read few original articles, only if forced

Get rid of the bedside stack

Use Foraging Tools

• Sources of valid information filtered for relevance to

practice

• Foraging session

Goal: “Confidence through Information”

BestBest Only if Only if TimeTime

CautionCaution WorstWorst

POEMsPOEMs

Relevance

CommonCommon RareRareFrequency of Problem

Patient-OrientedPatient-OrientedEvidenceEvidence

Disease-OrientedDisease-OrientedEvidenceEvidence

Type ofEvidence

Finding Answers in the Real World: Hunting Tools

Use summary sources that filter for relevance &

validity:

• Dynamed

• Clinical Evidence

• The Cochrane Library

• Essential Evidence Plus

The Clinician of the Future (NOW!)

“I know a lot, therefore I am” • Replaceable by a computer

“I think, therefore I am”• 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

Confidence through information Hunting & foraging tools providing relevant

and valid information when needed• Focus on valid POEMs – Patient-Oriented

Evidence that Matters

Take-Home Points

Clinicians will be/are valued by how they think and not by what they know

The information age is about information management, not information acquisition

Thinking in probabilities, not mechanics