Where can you find current best evidence?

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Oswald Walsh
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1 Where can you find current best evidence? Advances in the quest for access to high quality evidence, ready for clinical application. Brian Haynes McMaster University EBCP W/S June 2010

2 By the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up to date clinical information and will reflect the best available evidence. IOM Roundtable on Evidence Based Medicine This can t happen without excellent connections between best evidence and decisions for and by individual patients.

3 The Slippery Slope knowledge of current best care 100% 50% Choudhry, Fletcher and Soumerai, Ann Intern Med 2005;142: % of 62 studies found decreasing 0% years since graduation r = 0.54 p< competence for at least some tasks, with increasing physician age......

.. 94% of 62 studies found decreasing 0% years since graduation r = 0.

4 Typical time to standard implementation of innovations 17 to 20 years

5 E X KT2 = ROI Efficacy Knowledge Translation (type 2) Return Real on Investment Outcomes of Importance

6 E X KT2 = ROI Where: E is typically 0.25 Clinician adherence ~ 50% KT2 is typically 0.25 So: ROI is Patient adherence ~50% typically X.25 =.06

7 Objectives To review the emerging hierarchy of pre appraised best evidence resources Finding To consider current the complementary best evidence roles is of becoming push and pull much evidence easier! services (and prompt ) To illustrate the use of current sources of pre appraised evidence

evidence roles is of becoming push and pull much evidence easier!

8 Who makes regular use of an E B push service? (eg EvidenceUpdates, ACPJC+) an E B pull service? (eg UTD, CE, Dynamed) a federated E B search service? (eg TRIP, SUMSearch)

9 Hierarchy of pre appraised evidence for clinical decisions New Systems School EBHC All of these resources require that clinicians link the Summaries evidence with individual patient problems... Systems are needed to link directly from patient Synopses problems to evidence Examples Computerized decision support Evidence based textbooks Evidence based journal abstracts Olde School EBHC Syntheses Studies Systematic reviews Original journal articles

.. Systems are needed to link directly from patient Synopses problems to evidence Examples Computerized decision

10 The 6S hierarchy of preappraised evidence Examples Computerized decision support Evidence based textbooks (eg, Clinical Evidence, UpToDate) Evidence based journal abstracts (eg, ACP Journal Club) Systematic reviews (eg, in Evidence Updates) Evidence based journal abstracts Original journal articles (eg, in EvidenceUpdates)

journal abstracts (eg, ACP Journal Club) Systematic reviews (eg, in Evidence

11 Evolution of EBM Info Resources PreEBM: Passive diffusion ( publish it and they will come ) Early EBM: Pull diffusion ( teach them to read it and they will come )

12 Evolution of EBM info resources Current EBM info: Push diffusion ( read it for them and send it to them ) Future EBM info: Pull 1 stop search for best evidence Prompt ( read it for them, connect it to their individual patients, prompt them and their patients )

stop search for best evidence Prompt ( read it for them, connect

13 Finding best evidence for healthcare decisions Push, Pull, Prompt of Pre appraised evidence

14 Push:

15 Evidence Based Journals Reliability (kappa) Critical Appraisal Filters >90% beyond chance 50,000 articles/yr from 120 journals ~3,500 articles/yr meet critical appraisal and content criteria (93% noise reduction) Includes all Cochrane Reviews, CADTH Reviews, NHS HTA Reviews, AHRQ Reviews

articles/yr meet critical appraisal and content criteria (93% noise

16 The McMaster PLUS project only a tiny proportion of all research is ready for application only a tiny fraction of the ready research is relevant to the practice of a given clinician only a tiny proportion of the relevant research for a given practitioner is interesting in the sense of being something new, important, and actionable.

of a given clinician only a tiny proportion of the relevant research for a given

17 RELEVANCE McMaster Online Rating of Evidence: >5000 clinicians

18 To become a rater, e mail us at MORE@McMaster.CA (must be in current clinical practice)

19 McMaster PLUS Project Predicts citation counts (p<0.001) Clinical Relevancy Filter (MORE) ~3,500 articles/y meet critical appraisal and content criteria ~20 articles/yr for clinicians (99.96% noise reduction) ~5 50 articles/y for authors of evidencebased guidelines and reviews Health Knowledge Refinery

appraisal and content criteria ~20 articles/yr for clinicians (99.

20 With biomedical research articles 2,000,000/yr, a clinician reading 2 articles/day will be 55 centuries behind each year. Bernier & Yerkey, 1979 The evidence base for clinical effectiveness has become so vast that it is essentially unmanageable for individual providers. Institute of Medicine, 2001

Bernier & Yerkey, 1979 The evidence base for clinical effectiveness has

21 User End Users sign up according to their discipline(s) Users control relevance and flow Users can change disciplines at any time, and can sign up for as many as they wish Searches according to discipline or not Users can access many fulltext articles for free Users can access PubMed Clinical Queries

22 McMaster PLUS Trial Findings: % of participants using evidence based resources by month Baseline (5 mo) Self serve vs Full serve Full Serve Percentage Using PLUS 70.0% % % % % % % 0 RCT begins Relative increase 58.7%, P=0.001 Control cross over begins 0.0% Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Month Self serve Full Serve

23 You can sign up for free at

25 Free at:

26 PULL: Resources for finding evidence when you need it

27 Patient: A 56 year old white woman with type 2 diabetes on metformin with stable A 1c for 5 years asks... Doctor, do I really have to monitor my blood sugars (I can t afford the glucose strips and my fingers hurt)?

28 Current guidelines Canadian Diabetes Association Guidelines 2008 All people with diabetes who are able should be taught how to selfmanage their diabetes, including SMBG [Grade A, Level 1A (5)].

29 Current guidelines American Diabetes Association Guidelines 2010 For patients using noninsulin therapies, or medical nutrition therapy alone, SMBG may be useful as a guide to the success of therapy.(e) Several recent trials have called into question the clinical utility and cost effectiveness of routine SMBG in non insulin treated patients (40 42).

30 What is the best current evidence? Did I miss any important evidence with my search? Is there any way I could have retrieved less junk?

31 Search for Evidence Systems Summaries Synopses Syntheses Studies Systems one under development Summaries Dynamed, UpToDate Synopses ACPJC, DARE Syntheses Cochrane, ACPJC+, EU Studies pre appraised: EvidenceUpdates, ACPJC+, Nursing+ Studies non pre appraised: Clinical Queries; Pubmed

34 Clinical Connect (Hamilton Health Sciences EMR) MacPLUS

35 Search on diabetes and selfmonitoring Results for Summaries Results for Synopses of SRs Results for Syntheses Results for Synopses of Studies Results for Studies

36 Systems Summaries Synopses Syntheses Studies Thus, self monitoring of glucose may not be necessary at all, or only in unusual circumstances, for patients with type 2 diabetes who are treated with oral agents not associated with hypoglycemia. SMBG may be useful for some type 2 diabetic patients who would take action to modify eating patterns or exercise, as well as be willing to intensify pharmacotherapy, based on SMBG results. The ADA recommends that patients with type 2 diabetes who are treated with insulin or oral hypoglycemic drugs monitor blood glucose daily [3,4]. Last literature review version 18.1: January 2010 This topic last updated: October 2, 2009

37 Overview: Systems Summaries Synopses Syntheses Studies inconsistent evidence for effectiveness of glucose monitoring on glycemic control in type 2 diabetes Evidence review

38 Systems Summaries Synopses Syntheses Studies Glycemic control was not affected by self monitoring of blood glucose in type 2 diabetes O Kane MJ, Bunting B, Copeland M, Coates VE. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008;336: Self monitoring of blood glucose was not cost effective in non insulin treated type 2 diabetes Simon J, Gray A, Clarke P, et al. Cost effectiveness of self monitoring of blood glucose in patients with noninsulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ. 2008;336: Conclusion: Intensive self monitoring of blood glucose was associated with higher cost and lower quality of life than usual care in non insulin treated type 2 diabetes.

39 CONCLUSIONS: SMBG is of limited clinical effectiveness in improving glycemic control in people with T2DM on oral agents, or diet alone, and is therefore unlikely to be cost effective. Systems Summaries Synopses Syntheses Studies

40 Systems Summaries Synopses Syntheses Studies For type 2 DM on metformin, is glucose self monitoring worth it? Systems: not yet (so far as I know) Summaries: in UTD, Dynamed Synopses: ACPJC Syntheses: EvidenceUpdates (via MacPLUS) Studies: in UTD, Dynamed, ACPJC, EvidenceUpdates (and more, unappraised studies in Clinical Queries)

41 To keep up with evidence Pull Systems Summaries Synopses Syntheses Studies Push Prompt some labs and EMRs with a credible evidence based pedigree

43 (PickOne) Free at

44 FREE AT

Finding current best evidence for clinical decisions and having best evidence find you and your patients. Brian Haynes McMaster University

Finding current best evidence for clinical decisions and having best evidence find you and your patients Brian Haynes McMaster University Conflict Disclosures My research team, the Health Information Research