Download Clinical Decision Ma.. - Faculty Web Sites at the University of Virginia

Clinical Decision Making in
Three Minutes or Less:
Information Mastery at the
Point of Care
Scott M. Strayer, MD, MPH
Assistant Professor
Department of Family Medicine
University of Virginia Health System
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.
SLU Residency Teach Board
How Many People Have
Heard of the “ABCD
Criteria”?
Do We Really Need Help With
Clinical Decision Making?
Clinical Questions
They’re common


Physician recall: 0.1 information needs per encounter
Direct observation: 0.5 information needs per
encounter
They’re important



Only 30% pursued, 75% of those satisfied
Of those not pursued, half were “important”
Journals only used to answer 2 of 1101 questions in
busy practice (J Ely, BMJ 99)
Clinical Questions
Internal Medicine Residents

2 for every 3 patients

29% pursued

textbook (31%); journals (21%); attendings (17%)
Patient expectation, fear of malpractice
associated with seeking answer
Lack of time (60%), forgot (29%).
Am J Med 2000;109:218-33.
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 1987;74:333-46.

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 1992;268:240-8.
How Well Do We Distribute
New Information?
1996: Little effect of publication of the ISIS-2
(Aspirin works post-MI) and diltiazem postinfarction trial (diltiazem doesn’t 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
2003;115:467-72.
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
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 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)
Hunting and Foraging Tools
Foraging

InfoPoems--www.infopoems.com

Peer View Institute--www.peerview-institute.org/

Journal Alerts--www.globalfamilydoctor.co
m/dailyalerts/main.htm

Medscape Daily Update

MDLinx
Hunting




InfoPoems
Up To Date--www.uptodateonline.com
DynaMed--www.dynamicmedical.com/
Medscape--www.medscape.com
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 Master:Feeling Good About Not
Knowing Everything. The Journal of Family Practice
1994;38:505-13.
Information Mastery and
Computers
Not always assessed by software
Usefulness = Relevance x Validity
Work
Can be reduced by
computers
Slawson DC, Shaughnessy AF, Bennett JH. Becoming a Medical Information
Master:Feeling Good About Not Knowing Everything. The Journal of Family
Practice 1994;38:505-13.
Effect on Patient-Oriented
Outcomes
Symptoms
Functioning
Quality of Life
Lifespan
Effect on Disease Markers
Diabetes (GFR, albumin,
HbA1C, photocoagulation)
Arthritis (sed rate, X-ray)
Peptic Ulcer (endoscopic
ulcers)
SORT
B
SORT
A
SORT
C
Effect on Risk Factors for
Disease
Improvement in markers
(blood pressure, glucose,
cholesterol)
Uncontrolled Observations
&
Conjecture
Physiologic Research
Preliminary Clinical
Research
Case reports
Observational studies
Validity of Evidence
Highly Controlled Research
Randomized Controlled
Trials
Systematic Reviews
Drilling for the Best Information
Cochrane Library
EB Practice Guideline
Clinical Evidence
Clinical Inquiries
Specialty-specific
Usefulness
POEMs
Best Evidence
Reviews: Textbooks,
Up-to-Date, 5-Minute
Clinical Consult
Medline
Computers to Drill for the Best Information
Web, InfoRetriever
Cochrane
Clinical Evidence
Clinical Inquiries
Reviews/Textbooks
Medline
Usefulness
POEMs
CogniQ, BMJ, FPIN
InfoRetriever, Journal
Watch, AFP Online
Best Evidence
Unbound, Skyscape
Online Textbooks
CogniQ, Skyscape
PubMed, OVID
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 1994;39(5):489-99.
Relevance: Type of Evidence
POE: Patient-oriented evidence


mortality, morbidity, quality of life
Longer, better or both
DOE: Disease-oriented evidence

pathophysiology, pharmacology, etiology
POEMs:The “Change” Factor
Bextra Causes More Heart Attacks and
Strokes
ALLHAT study---HCTZ is best first agent in
hypertensive patients
3 questions:
A. Is it an outcome patients care about?
B. Is it common to your practice and the
intervention feasible?
C. If valid, would it require you to change your
practice?
Comparing DOES and
POEMs
Example
Antiarrhythmic
Therapy
DiseaseOriented
Evidence
Patient-Oriented
Evidence that
Matters
Drug X  PVCs Drug X increases
on ECG
mortality
Comment
POEM study
contradicts DOE
study
POEM agrees
Antihypertensive Antihypertensive Antihypertensive
therapy  BP
therapy  mortality with DOE
therapy
Prostate
Screening
PSA screening
detects prostate
cancer early
? whether PSA
screening 
mortality
DOE exists, but
the important
POEM is
unknown
Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide
for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60.
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
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”
Treatment Validity Worksheets
Diagnosis Validity Worksheets
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
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
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?
Quality Hunting and Foraging
Systems
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”!
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”
Hunting and Foraging System
Risks
“Spyware”: May be tracking your usage
“Trojan Horse”: who’s paying when it’s 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 can’t have it both
ways. No Free Lunch!
Not All Information Tools
are Created Equal!
Translation of UKPDS into Practice
Shaughnessy AF, Slawson DC. What happened to the valid POEMs? A survey of
review articles on the treatment of type 2 diabetes. BMJ 2003; 327:266-269.
Review Criteria for Study of
Information Tools
What Happened to the Valid
Reviews?
M
D
as
co
n
Ta
r
f
p
Re
om
ug
Dr
cr
at
es
Le
xic
ap
e
eP
o
Lin
x
os
by
's
D
Drug Information Sources
PD
R.
ne
t
PD
I
US
Up
To
Da
Nu
te
rs
in
g
Dr
ug
s
M
icr
oM
ed
ex
M
M
Co
ns
W
ul
eb
t
M
D
He
al
th
FD
A
CD
ER
ed
Sc
Li
pp
in
co
tt's
M
Time (days)
Quality of Drug Foraging and
Hunting Tools
Valdecoxib Withdrawal Notification
120
100
80
60
40
20
0
A Few Foraging Tools…
Beware of the Trojan
Horse
A Few Hunting Tools…
Rating Hunting and
Foraging Tools
Rating Hunting and Foraging Tools
Hunting Tool Evaluation Worksheet
Foraging Tool Evaluation Worksheet
Hunting and Foraging Tools
Foraging

InfoPoems--www.infopoems.com

Peer View Institute--www.peerview-institute.org/

Journal Alerts--www.globalfamilydoctor.co
m/dailyalerts/main.htm

Medscape Daily Update

MDLinx
Hunting




InfoPoems
Up To Date--www.uptodateonline.com
DynaMed--www.dynamicmedical.com/
Medscape--www.medscape.com
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.