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Clinical Decision Making in 3 Minutes or Less

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2. Understand how to use point of care technology to 'hunt' ... Newt Gingrich, AAFP Assembly, Sep 28, 2006. Medical Information is Big Business Now! ... – PowerPoint PPT presentation

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Title: Clinical Decision Making in 3 Minutes or Less


1
Clinical Decision Making in 3 Minutes or Less
  • Scott M. Strayer, MD, MPH
  • Associate Professor
  • Department of Family Medicine
  • University of Virginia Health System

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Objectives
  • 1. Apply a practical, evidence-based framework
    for
  • evaluating new medical information.
  • 2. Understand how to use point of care technology
    to hunt
  • for evidence-based information that can be
    applied to
  • clinical decision making on a daily basis.
  • 3. Understand how to use foraging tools to
    systematically
  • sift through new medical information that is
    valid and
  • relevant to clinical practice.
  • 4. Evaluate hunting and foraging tools to
    determine the
  • validity and relevance of their information
    sources.

4
Scientific discoveries will require technological
solutions that allow physicians to access the
latest findings 24 hours a day, 7 days a week,
online and on demand, as medical learning becomes
a nonstop process
  • Newt Gingrich, AAFP Assembly, Sep 28, 2006

5
Medical Information is Big Business Now!
New EPS Research Forecasts The Scientific,
Technical Medical (STM) Information Market To
Reach Nearly 11 Billion Dollars By
2008 Publicly-traded STM publishers grew 8.6
in their reported currencies in 2005 aggregate
profit margins held steady at 25 Thomson posted
the strongest increase in profits with a
year-over-year gain of 20.5, outperforming its
peers and the market average of 17.7 Elsevier
achieved the strongest organic growth 5 and 6
in its Science Technology and Health Sciences
divisions, respectively The five largest players
(Reed Elsevier, Thomson, Wolters Kluwer, Springer
and Wiley) continued to acquire scale, and now
account for over half (52.3) of total market
revenues Revenues from digital content
distribution may be nearing a tipping point 60
of STM
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Recent Changes
  • Wiley publishers now owns InfoRetriever and Info
    Poems
  • Ebsco publishers owns Dynamed
  • Large publishers will continue to acquire
    evidence based sources

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  • How did you find out about that new smoking
    cessation drug?

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  • Varenicline, an 4 2 Nicotinic Acetylcholine
    Receptor Partial Agonist, vs Sustained-Release
    Bupropion and Placebo for Smoking Cessation
  • A Randomized Controlled Trial
  • David Gonzales, PhD Stephen I. Rennard, MD
    Mitchell Nides, PhD Cheryl Oncken, MD Salomon
    Azoulay, MD Clare B. Billing, MS Eric J.
    Watsky, MD Jason Gong, MD Kathryn E. Williams,
    PhD Karen R. Reeves, MD for the Varenicline
    Phase 3 Study Group
  • JAMA. 200629647-55.
  • Context  The 4 2 nicotinic acetylcholine
    receptors (nAChRs) are linked to the reinforcing
    effects of nicotine and maintaining smoking
    behavior. Varenicline, a novel 4 2 nAChR partial
    agonist, may be beneficial for smoking cessation.
  • Objective  To assess efficacy and safety of
    varenicline for smoking cessation compared with
    sustained-release bupropion (bupropion SR) and
    placebo.
  • Design, Setting, and Participants  Randomized,
    double-blind, parallel-group, placebo- and
    active-treatmentcontrolled, phase 3 clinical
    trial conducted at 19 US centers from June 19,
    2003, to April 22, 2005. Participants were 1025
    generally healthy smokers ( 10 cigarettes/d) with
    fewer than 3 months of smoking abstinence in the
    past year, 18 to 75 years old, recruited via
    advertising.
  • Intervention  Participants were randomly
    assigned in a 111 ratio to receive brief
    counseling and varenicline titrated to 1 mg twice
    per day (n  352), bupropion SR titrated to 150
    mg twice per day (n  329), or placebo (n  344)
    orally for 12 weeks, with 40 weeks of nondrug
    follow-up.
  • Main Outcome Measures  Primary outcome was the
    exhaled carbon monoxideconfirmed 4-week rate of
    continuous abstinence from smoking for weeks 9
    through 12. A secondary outcome was the
    continuous abstinence rate for weeks 9 through 24
    and weeks 9 through 52.
  • Results  For weeks 9 through 12, the 4-week
    continuous abstinence rates were 44.0 for
    varenicline vs 17.7 for placebo (odds ratio
    OR, 3.85 95 confidence interval CI,
    2.70-5.50 Plt.001) and vs 29.5 for bupropion SR
    (OR, 1.93 95 CI, 1.40-2.68 Plt.001). Bupropion
    SR was also significantly more efficacious than
    placebo (OR, 2.00 95 CI, 1.38-2.89 Plt.001).
    For weeks 9 through 52, the continuous abstinence
    rates were 21.9 for varenicline vs 8.4 for
    placebo (OR, 3.09 95 CI, 1.95-4.91 Plt.001) and
    vs 16.1 for bupropion SR (OR, 1.46 95 CI,
    0.99-2.17 P  .057). Varenicline reduced craving
    and withdrawal and, for those who smoked while
    receiving study drug, smoking satisfaction. No
    sex differences in efficacy for varenicline were
    observed. Varenicline was safe and generally well
    tolerated, with study drug discontinuation rates
    similar to those for placebo. The most common
    adverse events for participants receiving
    active-drug treatment were nausea (98
    participants receiving varenicline 28.1) and
    insomnia (72 receiving bupropion SR 21.9).
  • Conclusion  Varenicline was significantly more
    efficacious than placebo for smoking cessation at
    all time points and significantly more
    efficacious than bupropion SR at the end of 12
    weeks of drug treatment and at 24 weeks.

For weeks 9 through 52, the continuous abstinence
rates were 21.9 for varenicline vs 8.4 for
placebo (OR, 3.09 95 CI, 1.95-4.91 Plt.001) and
vs 16.1 for bupropion SR (OR, 1.46 95 CI,
0.99-2.17 P  .057).
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SLU Residency Teach Board
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How Many People Have Heard of the ABCD Criteria?
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How Well Do We Distribute New Information?
  • Left to our own devices
  • 1987 Of 28 Landmark trials, only 2 had an
    immediate (1-2 year) effect on clinical practice
    Fineberg HV. Clinical evaluation how does it
    influence medical practice? Bull Cancer
    198774333-46.
  • 1992 Thrombolytic therapy for acute MI 13 years
    after proof of benefit before review articles
    suggest it for routine use
  • Antman EM, et al. A comparison of results of
    meta-analyses of randomized control trials and
    recommendations of clinical experts. Treatments
    for myocardial infarction. JAMA 1992268240-8.

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How Well Do We Distribute New Information?
  • 1996 Little effect of publication of the ISIS-2
    (Aspirin works post-MI) and diltiazem
    post-infarction trial (diltiazem doesnt
    work).---ASA and Diltiazem use---no change after
    trial
  • Col NF, et al. The impact of clinical trials on
    the use of medications for acute myocardial
    infarction. Arch Int Med 1996 156 54 - 60.
  • Majumdar 2003
  • HOPE study ? in ramipril prescribing by 5 per
    month without advertising, 12 ? per month with
    advertising over the next 2 years
  • Majumdar SR, et al. Synergy between publication
    and promotion Comparing adoption of new evidence
    in Canada and the United States. Am J Med
    2003115467-72.

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How Well Do We Distribute New Information?
  • Bottom Line
  • Change occurs quickly
  • When supported by lots of publicity or
    pharmaceutical company marketing (like any
    consumer product)
  • Change is much slower
  • When left up to publications or word of mouth for
    dissemination of information

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Two Tools Needed to Master Information- BMJ 1999
  • 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
  • You dont know that new info. is available
  • You cant 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)

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Hunting and Foraging Tools
  • Foraging
  • InfoPoems---www.infopoems.com
  • Peer View Institute---www.peerview-institute.org/
  • Journal Alerts---www.globalfamilydoctor.com/dailya
    lerts/main.htm
  • Medscape Best Evidence
  • (http//hiru.mcmaster.ca/MORE/HowRatingsAreUsed.h
    tm)
  • MDLinx
  • BMJ Updates (http//bmjupdates.mcmaster.ca)
  • First Watch (www.jwatch.org)
  • Cochrane PEARLS (http//www.cochraneprimarycare.or
    g/ )
  • Hunting
  • First Consultwww.firstconsult.com
  • InfoPoems
  • Up To Date---www.uptodateonline.com
  • DynaMed---www.dynamicmedical.com/
  • Medscape---www.medscape.com
  • Database of Abstracts of Reviews of Effectiveness
    DARE---http//agatha.york.ac.uk/darehp.htm
  • Translating Research Into Practice (TRIP)---
    www.tripdatabase.com

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Information Mastery in a Nutshell
  • Clinically useful information can be defined by
  • Usefulness Relevance x Validity
  • Work
  • Slawson DC, Shaughnessy AF, Bennett JH. Becoming
    a Medical Information MasterFeeling Good About
    Not Knowing Everything. The Journal of Family
    Practice 199438505-13.

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Information Mastery and Computers
  • Slawson DC, Shaughnessy AF, Bennett JH. Becoming
    a Medical Information MasterFeeling Good About
    Not Knowing Everything. The Journal of Family
    Practice 199438505-13.

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  • Effect on Patient-Oriented Outcomes
  • Symptoms
  • Functioning
  • Quality of Life
  • Lifespan

SORT A
SORT B
  • Effect on Disease Markers
  • Diabetes (GFR, albumin, HbA1C, photocoagulation)
  • Arthritis (sed rate, X-ray)
  • Peptic Ulcer (endoscopic ulcers)

SORT C
Relevance of Outcome
  • Effect on Risk Factors for Disease
  • Improvement in markers (blood pressure, glucose,
    cholesterol)
  • Highly Controlled Research
  • Randomized Controlled Trials
  • Systematic Reviews
  • Physiologic Research
  • Preliminary Clinical Research
  • Case reports
  • Observational studies

Uncontrolled Observations Conjecture
Validity of Evidence
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Drilling for the Best Information
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Computers to Drill for the Best Information
Cochrane
Clinical Evidence Clinical Inquiries
POEMs
Reviews/Textbooks
Medline
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A Brief Review
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POEM
  • Patient-Oriented
  • Evidence
  • that Matters
  • matters to the clinician, because if valid, will
    require a change in practice

Shaughnessy AF, Slawson DC, Bennett JH. Becoming
an Information Master A Guidebook to the Medical
Information Jungle. The Journal of Family
Practice 199439(5)489-99.
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Relevance Type of Evidence
  • POE Patient-oriented evidence
  • mortality, morbidity, quality of life
  • Longer, better or both
  • DOE Disease-oriented evidence
  • pathophysiology, pharmacology, etiology

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Validity
  • The hard part of Information Mastery
  • Technique EBM working group
  • Did the researchers find what they think they
    found?
  • Do the results apply to your patients?
  • Self vs delegation- Take responsibility

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Determining Validity
  • Levels of Evidence (LOE)
  • 1a, b, c 2a, b, c etc., 5- expert opinion
  • A, B, C, D
  • SORT Criteria
  • Therapy, diagnosis, prognosis, reviews, etc.
  • A moving target

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Treatment Validity Worksheets
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Diagnosis Validity Worksheets
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Work
  • Not all information sources are created equal
  • Two type of information sources
  • Just-in-case sources high work
  • Just-in-time sources low work

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Minimizing Work Types of Archived Information
Sources
  • Just-in-Case information
  • Libraries, Medline, MDConsult, WebMd, MedSites,
    StatRef, other databases
  • A superstore of information
  • Focus a complete inventory of information
  • Benefit Much information is always in stock to
    meet many needs
  • Detriments Even the simplest needs require time
    to access the information

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Minimizing Work Types of Archived Information
Sources
  • Just-in-Time information
  • Highly filtered information sources with rapid
    access InfoRetriever, Up To Date, Dynamed
  • A Seven-Eleven -- not everything, but quick and
    what you need most of the time
  • Focus the best, most commonly needed information
  • Benefit Rapid access (less than one minute)
    ease of use
  • Detriments Reliance on the filtering
    mechanism---what is the quality of the filtering
    mechanims?

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Clinicians demand just-in-time resources
  • 48 randomly selected generalist physicians in
    ambulatory care
  • Asked 1062 questions but only answered 585 (55)
  • Obstacles
  • Doubt that answer exists (11)
  • Selected source doesnt have answer (26)
  • Requested comprehensive sources that answer
    questions likely to occur in clinical practice
    with emphasis on treatment and bottom-line advice
  • Help locating information quickly with lists,
    bolded sub-headings, algorithms.avoid lengthy
    text

Ely et al J Am Med Inform Assoc. 2005
Mar-Apr12(2)217-24.
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Quality Hunting and Foraging Systems---A New
Definition
  • 1. How is the information filtered?
  • 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?
  • must have levels of evidence labels
  • Beware Trojan Horse!

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Quality Hunting and Foraging Foraging Systems
  • 3. How well is information summarized?
  • 2000 - 3000 words accurately in 200 words
  • 4. Is the information placed into context?
  • Much more than abstracts
  • Translational Validity

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Hunting and Foraging System Risks
  • Spyware May be tracking your usage
  • Trojan Horse whos paying when its free?
  • Abstracts only Journal Watch, Journal Rack, Tips
    from other Journals, Clinical Updates, etc.
  • No relevance/ validity filter
  • You can have information free and you can have
    it uncensored, but you cant have it both ways.
    No Free Lunch!

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Not All Information Tools are Created Equal!
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Quality of Drug Foraging and Hunting Tools
Strayer, SM, Slawson, DC, Shaugnessy, AM,
Disseminating Drug Prescribing Information The
COX-2 Inhibitor Withdrawals. JAMIA 2006.
13396-398.
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A Few Foraging Tools
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Beware of the Trojan Horse
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A Few Hunting Tools
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Rating Hunting and Foraging Tools
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Rating Hunting and Foraging Tools
  • Hunting Tool Evaluation Worksheet
  • Foraging Tool Evaluation Worksheet

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Hunting and Foraging Tools
  • Foraging
  • InfoPoems---www.infopoems.com
  • Peer View Institute---www.peerview-institute.org/
  • Journal Alerts---www.globalfamilydoctor.com/dailya
    lerts/main.htm
  • Medscape Best Evidence
  • (http//hiru.mcmaster.ca/MORE/HowRatingsAreUsed.h
    tm)
  • MDLinx
  • BMJ Updates (http//bmjupdates.mcmaster.ca)
  • First Watch (www.jwatch.org)
  • Cochrane PEARLS
  • Hunting
  • First Consultwww.firstconsult.com
  • InfoPoems
  • Up To Date---www.uptodateonline.com
  • DynaMed---www.dynamicmedical.com/
  • Medscape---www.medscape.com
  • Database of Abstracts of Reviews of Effectiveness
    DARE---http//agatha.york.ac.uk/darehp.htm
  • Translating Research Into Practice (TRIP)---
    www.tripdatabase.com

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Summarize
  • Evidence-based clinical decision making requires
    a coordinated hunting and foraging tool.
  • Use the principles of Information Mastery to
    evaluate your information tools.
  • Not all information tools are created
    alike---evaluate using worksheets.
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