Online information resources for evidence-based clinical care: their evolution and the special role of librarians in their development and dissemination.

1
Online information resources for evidence-based
clinical care their evolution and the special
role of librarians in their development and
dissemination.

• Brian Haynes
• McMaster University

2
Objectives

• Review the evolution of information resources for
  evidence-based clinical decisions
• Review strategies for
• Having evidence find you/your clients (PUSH)
• Finding evidence (PULL)
• Integrating evidence into workflow (PROMPT)
• Apply these strategies to learning about Lantus
  Insulin

3
Clinical case

• 48 year old male with type 1 diabetes mellitus
  for 9 years, collapses on factory loading dock,
  unrousable. Admitted to hospital with severe
  hypoglycemia. No recollection of antecedent
  warning symptoms, but had been engaged in
  increased physical activity just before onset.
• 3 weeks after hospital discharge, wife calls 911
  during nocturnal bout of hypoglycemia no
  warning, unusual activity. (Glucagon on hand but
  not used.)
• Admits that others notice he is not right
  before he recognizes low sugars
• Regimen Humalog with meals Humulin N 25 U am
  and pm
• What about Lantus?
• His doctor asks a librarian for help.

4
The History of Thrombolysis
1975 Trials show life-saving benefits
1985 Most textbooks state benefits few patients are offered thrombolysis
1990 Textbooks uniformly state benefits 40 of patients are offered thrombolytics
Grimes et al, NEJM 1993 Immediate Percutaneous
Coronary Intervention (PCI) is more effective
than thrombolysis for acute MI
Antman, Lau, Kupelnick, Mosteller, and T
Chalmers, JAMA 1992.
5
The Slippery Slope
100
r -0.54 plt0.001
. .. . . .... .
knowledge of current best care
Choudhry, Fletcher and Soumerai, Ann Intern Med
2005142260-73 94 of 62 studies found
decreasing competence for at least some tasks,
with increasing physician age.
...
... ...
50
... ..
.... ....
0
years since graduation
6
How to use Evidence-Based Medicine Resources to
Keep on Top of the Game

• Evidence-based medicine is...
• ...a set of resources to support clinical
  decisions based on current best evidence.

research-enhanced health care
7
Early Realization

• EBHC wont work unless backed up by effective
  information tools and resources

8
Doing EBM Push-Pull-Prompt

• PUSH - having evidence find end-user
• PULL - seeking evidence when needed
• PROMPT evidence-based reminders in clinical
  practice settings and preferably in electronic
  medical records

9
PUSH Resources for Keeping Up-to-Date
10
(No Transcript)
11
(No Transcript)
12
Evidence-Based Journals
Critical Appraisal Filters
2,500 articles/yr meet critical appraisal and
content criteria (95 noise reduction)
50,000 articles/yr from 120 journals
13
Jennifer Holland
Ann McKibbon
Angela Eady
Cindy Walker
14
(No Transcript)
15
McMaster PLUS Project
Clinical Relevancy Filter (MORE)
25 articles/yr for clinicians (99.95 noise
reduction)
2,500 articles/yr meet critical appraisal and
content criteria (95 noise reduction)
5-50 articles/yr for authors of evidence-based
clinical topic reviews
16
Did I mention that its free?
http//bmjupdates.mcmaster.ca
17
PULL Resources for Finding Evidence When You
Need it
18
Examples
Computerized Decision Support System (CDSS)
Evidence-based textbooks
Systems
Evidence-based journals
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
19
Systems Clinical Evidence
http//www.clinicalevidence.com
20
Systems Up-to-Date
21
Systems Physicians Information and Education
Resource
22
EBM Systems vs Traditional Textbook Model

• Traditional textbook
• Author is an authority
• Author selects, reports on own
• One-year production line from manuscript to
  bookstand
• Three-year production schedule

23
Updating in EBM Systems

• Authors are provided with new studies and reviews
  that are
• Assessed for validity
• Rated by clinicians for relevance
• Rated by clinicians for newsworthiness
• Within a month of original publication

24
4S Smorgasbord Ovids EBMR
25
Examples
Computerized Decision Support System (CDSS)
Evidence-based textbooks
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
26
Synopses ACP Journal Club
27
Synopses Evidence-Based Medicine
28
Examples
Computerized Decision Support System (CDSS)
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
29
Syntheses The Cochrane Library
30
Examples
Computerized Decision Support System (CDSS)
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
31
Studies General Resource PubMed
Filters also available on Ovid and Skolar
32
Patients with Type 1 Diabetes and Hypoglycemia
Unawareness

• What about Lantus?

33
Examples
Computerized Decision Support System (CDSS)
Systems
Evidence-based textbook
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
34
(No Transcript)
35
From Up-to-Date
36
Examples
Computerized Decision Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
37
http//bmjupdates.mcmaster.ca
38
(No Transcript)
39
CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal hypoglycaemic
episodes, especially when compared with
once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal
hypoglycaemic episodes, especially when compared
with once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
40
Examples
Computerized Decision Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
41
PubMed Clinical Queries Search for Syntheses
42
(No Transcript)
43
CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal hypoglycaemic
episodes, especially when compared with
once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
CONCLUSIONS The evidence suggests that, compared
with NPH insulin, insulin glargine is effective
in reducing the number of nocturnal
hypoglycaemic episodes, especially when compared
with once-daily NPH. There appears to be no
improvement in long-term glycaemic control and
therefore insulin glargine is unlikely to reduce
the incidence of the long-term microvascular and
cardiovascular complications of diabetes.
44
Examples
Computerized Decision Support System (CDSS)
Evidence-based textbook
Systems
Evidence-based journal abstract
Synopses
Cochrane reviews
Syntheses
Original published articles
Studies
45
PubMed Clinical Queries Search for Studies
46
Patients with Type 1 Diabetes and Hypoglycemia
Unawareness Resolution of Case

• Cut back on total insulin dose
• Evening glargine instead of intermediate (or
  long-acting) insulin
• Close monitoring of glucose
• Scrupulous avoidance of hypoglycemia
• Type 1 class for review and retraining

47
Tomorrow...Prompt

• Computerized decision support systems that
  include
• Instant access to current best evidence
• Reminders for indicated care
• Warnings for contraindicated care

48
Personal digital internet libraries with wireless
PDA access, linked to individual patient records,
with a database of current best evidence, new
evidence alerts, and links to other resources
(patient information product monographs
continuing education with feedback)
Tomorrow...
49
To keep on top

• Push
• Pull
• Prompt..some labs and med orders

systems
synopses
summaries
studies