Revealing the Revealing the Mysteries of Mysteries of Information Information

MasteryMasterySteven R. Brown, MDSteven R. Brown, MD

Banner Good Samaritan Family Banner Good Samaritan Family Medicine ResidencyMedicine Residency

December 2010December 2010

“It’s not how much you know, it’s how fast you can find the answer.”®

Shaughnessy and Slawson

How helpful is the answer? How helpful is the answer? The usefulness equationThe usefulness equation

Relevance x ValidityWork

Usefulness =

How will you find How will you find information?information?

How will it find How will it find you?you?

The information jungleThe information jungle

MEDLINE: 9 Million articles adding MEDLINE: 9 Million articles adding 300,000/year300,000/year

In primary care to keep up to date, In primary care to keep up to date, we would need to read 17 articles a we would need to read 17 articles a day, 365 days a yearday, 365 days a year

But… Less than 15% of articles But… Less than 15% of articles published on a topic are usefulpublished on a topic are useful

Clinical trials are of varying qualityClinical trials are of varying quality

““Information anxiety”Information anxiety”

““The frustration that occurs when The frustration that occurs when

there is a great deal of information, there is a great deal of information,

but it doesn’t tell us what we want but it doesn’t tell us what we want

or need to know.”or need to know.” Richard Wurman.Richard Wurman.

What’s the problem?What’s the problem?

We generate questionsWe generate questions About 5 times for every About 5 times for every

in-patient case and twice in-patient case and twice for every 3 clinic patients.for every 3 clinic patients.

Thus for each day of 25 Thus for each day of 25 patients seen, we patients seen, we generate ~15 questions.generate ~15 questions.

We get answers for less We get answers for less than a third (33%) of than a third (33%) of them.them.

Covell DG, UmanGC, Manning PR. Information needs in office practice: are they being met?Ann Intern Med 1985;103:596-9

How do we find How do we find answers?answers?

Clinical questionsClinical questions

BackgroundBackground General knowledge about a condition or General knowledge about a condition or

thingthing ForegroundForeground

Specific knowledge to inform clinical Specific knowledge to inform clinical decisions or actionsdecisions or actions

““PICO”PICO”

Questions change as experience Questions change as experience increasesincreases

P atient/Population

I ntervention

C omparison

O utcome

In post-menopausal In post-menopausal women, what are the women, what are the

effects of HRT on bone effects of HRT on bone density/fractures?density/fractures?

patientpatient intervention intervention outcome(s)outcome(s)

post-menopausal

woman

hormone replacement therapy

osteoporosis

bone mineral density

fracture

The “O” in PICOThe “O” in PICO

Applicability to PracticeApplicability to PracticeApplicability to PracticeApplicability to Practice DOE DOE (disease oriented (disease oriented

evidence)evidence) Until recently, only Until recently, only

information availableinformation available Aimed at increasing Aimed at increasing

our understanding of our understanding of diseasedisease

Crucial to medicine, Crucial to medicine, how a “disease works”how a “disease works”

DOE vs. POEMDOE vs. POEM

““Assuming”Assuming”

POEM POEM (patient oriented (patient oriented evidence that matters)evidence that matters) Aimed at evidence Aimed at evidence

that patients care that patients care about & clinicians about & clinicians care about their care about their patientspatients

HCTZ in HTN HCTZ in HTN reduces morbidity reduces morbidity and mortalityand mortality

““Knowing”Knowing”

POEM:POEM:Patient-Oriented Evidence that Patient-Oriented Evidence that

MattersMattersWhat matters to patients and their What matters to patients and their

doctors?doctors?

Morbidity (fractures, heart attacks)Morbidity (fractures, heart attacks) MortalityMortality CostCost

Example: HCTZ lowers risk of stroke, Example: HCTZ lowers risk of stroke, myocardial infarctionmyocardial infarction

What doesn’t matter to What doesn’t matter to patients?patients?

Lab values (HDL, LDL)Lab values (HDL, LDL) Clinical measures (blood pressure)Clinical measures (blood pressure) Disease markers (bone density)Disease markers (bone density)

Disease Oriented Evidence (DOE)Disease Oriented Evidence (DOE)

Important for understanding the disease Important for understanding the disease process, but not ready for “prime time”process, but not ready for “prime time”

Comparing DOEs and Comparing DOEs and POEMsPOEMs

Example

Disease-Oriented Evidence

Patient-Oriented Evidence that

Matters

Comment Antiarrhythmic Therapy

Drug X PVCs on ECG

Drug X increases mortality

POEM study contradicts DOE study

Antihypertensive therapy

HCTZ Antihypertensive therapy BP

HCTZ Antihypertensive therapy mortality

POEM agrees with DOE

Prostate Screening

PSA screening detects prostate cancer early

? whether PSA screening mortality

DOE exists, but the important POEM is unknown

Shaughnessy and Slawson

The usefulness equation The usefulness equation revisitedrevisited

Relevance x ValidityWork

Usefulness =

The worksheet

Highly Controlled ResearchRandomized Controlled TrialsSystematic Reviews

Physiologic ResearchPreliminary Clinical ResearchCase reportsObservational studies

Uncontrolled Observations&

Conjecture

Effect on Patient-Oriented OutcomesSymptomsFunctioningQuality of LifeLifespan

Effect on Disease Markers A1c in diabetes MICs in infection BMD in osteoporosis

Effect on Risk Factors for DiseaseImprovement in markers (blood pressure, cholesterol)

Valid Patient-OrientedEvidence

Validity of Evidence

Re

lev

an

ce o

f O

utc

om

e

Highly Controlled ResearchRandomized Controlled TrialsSystematic Reviews

Physiologic ResearchPreliminary Clinical ResearchCase reportsObservational studies

Uncontrolled Observations&

Conjecture

Effect on Patient-Oriented OutcomesSymptomsFunctioningQuality of LifeLifespan

Effect on Disease MarkersDiabetesArthritisPeptic Ulcer

Effect on Risk Factors for DiseaseImprovement in markers (blood pressure, cholesterol)

SORTA

Validity of Evidence

Relevance

of O

utco

me

SORTB

SORTC

Strength of Recommendation Taxonomy

Assessing validityAssessing validityThe 5 “A”s of Evidence-The 5 “A”s of Evidence-

based Medicinebased Medicine

AskAsk AcquireAcquire AppraiseAppraise ApplyApply AssessAssess

Secondary Secondary sources of sources of literatureliterature

Let someone else do the hard Let someone else do the hard work!work!

DOE vs. POEMDOE vs. POEMsome practicesome practice

Finding the answerFinding the answer

Ask a good questionAsk a good question Use efficient methods and sourcesUse efficient methods and sources Question includes relevance screenQuestion includes relevance screen Use abstract to briefly assess Use abstract to briefly assess

validityvalidity

Have relevant, Have relevant, valid information valid information

find you!find you!

Evidence-based Evidence-based ResourcesResources

American Family PhysicianAmerican Family Physician Dynamed www.dynamicmedical.comDynamed www.dynamicmedical.com Essential Evidence Plus Essential Evidence Plus

www.essentialevidenceplus.comwww.essentialevidenceplus.com PubMedPubMed ACP PierACP Pier Primary Care Medical Abstracts Primary Care Medical Abstracts

http://ccme.org/pcma/http://ccme.org/pcma/ 2011 AzAFP Clinical Education Conference 2011 AzAFP Clinical Education Conference

March 4-5, 2011, Phoenix, AZ. March 4-5, 2011, Phoenix, AZ. www.azafp.orgwww.azafp.org. Course director, Mark . Course director, Mark Ebell, MD.Ebell, MD.

Information mastery Information mastery proficiencyproficiency

Level 0:Level 0: Decisions based on 3 Decisions based on 3 influences: Patient request, local influences: Patient request, local experts, pharm. repsexperts, pharm. reps

Level 1:Level 1: Use the highest quality Use the highest quality information to guide clinical information to guide clinical decisions (100%)decisions (100%)

Level 2:Level 2: Search, evaluate, and make Search, evaluate, and make available specialty specific Level 1 available specialty specific Level 1 information (<1%)information (<1%)

Level 3:Level 3: Create original research Create original research (primary) or systematic reviews (primary) or systematic reviews (secondary)(secondary)

So, does duct tape work So, does duct tape work for warts?for warts?

One answer:One answer: Duct tape vs. Duct tape vs. cryotherapy in the treatment cryotherapy in the treatment

of the common wartof the common wartArch Ped Adol MedArch Ped Adol Med 2002;156 2002;156

““A supply of standard duct tape was provided.”A supply of standard duct tape was provided.” ““Cut the tape as close to the size of the wart as Cut the tape as close to the size of the wart as

possible.”possible.” ““Leave the tape in place for 6 days.”Leave the tape in place for 6 days.” ““If the tape falls off…reapply a new piece of If the tape falls off…reapply a new piece of

tape.”tape.” After 6 days, remove the tape, debride, and After 6 days, remove the tape, debride, and

apply again the next morning.apply again the next morning. Cryotherapy causes “fear and discomfort for Cryotherapy causes “fear and discomfort for

many children.”many children.”

Duct tape vs. cryotherapy in Duct tape vs. cryotherapy in the treatment of the the treatment of the

common wartcommon wartArch Ped Adol Med 2002;156Arch Ped Adol Med 2002;156

85% resolution with duct tape vs. 85% resolution with duct tape vs. 60% resolution with cryotherapy at 2 60% resolution with cryotherapy at 2 monthsmonths

ARR = 25%ARR = 25% NNT = 4NNT = 4