Where can you find current best evidence?

(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

uptodate clinical information and will reflect the best available evidence.

IOM Roundtable on EvidenceBased Medicine This can’t happen without excellent

connections between best evidence and

decisions for and by individual patients.

(3)

The Slippery Slope

years since graduation

r = 0.54 p<0.001

...

. ..

. . .... .

....

...

..

knowledge ...

of current best care

100%

0%

50%

Choudhry, Fletcher and Soumerai, Ann Intern Med 2005;142:260‐73 94% of 62 studies found decreasing

competence for at least some tasks, with

increasing physician age.

(4)

Typical time to “standard”

implementation of innovations

17 to 20 years

(5)

E X KT2 = ROI

Efficacy ^Knowledge

Translation (type 2)

Return on Investment Real

Outcomes of

Importance

(6)

E X KT2 = ROI

Where:

E is typically ≤ 0.25

KT2 is typically ≤ 0.25

Clinician adherence

~ 50%

Patient adherence

~50%

.25 X .25 = .06

So:

ROI is

typically...

(7)

Objectives

¨

To review the emerging hierarchy of preappraised “best evidence”

resources

¨

To consider the complementary roles of “push” and “pull” evidence

services (and “prompt”)

¨

To illustrate the use of current

sources of “preappraised” evidence

Finding current best evidence

is becoming much easier!

(8)

Who makes regular use of…

¨

an EB “push” service? (eg EvidenceUpdates, ACPJC+)

¨

an EB “pull” service? (eg UTD, CE, Dynamed)

¨

a “federated” EB search service?

(eg TRIP, SUMSearch)

(9)

Systems

Summaries

Synopses

Syntheses

Studies

Examples

Computerized decision support

Evidencebased textbooks

Evidencebased journal abstracts

Systematic reviews

Original journal articles

Olde School EBHC

New School

EBHC

Hierarchy of preappraised evidence for clinical decisions

All of these resources require that clinicians link the evidence with individual patient problems...

Systems are needed to link directly from patient

problems to evidence

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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)

The 6S hierarchy of preappraised evidence

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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”)

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Evolution of EBM info resources

¨

Current EBM info: Push diffusion (“read it for them and send it to them”)

¨

Future EBM info:

¤

Pull – 1stop search for best evidence

¤

Prompt (“read it for them, connect it to

their individual patients, prompt them

and their patients”)

(13)

Finding best evidence for healthcare decisions

¨

Push, Pull, Prompt

¤ of Preappraised

evidence

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Push:

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50,000 articles/yr from 120 journals

~3,500 articles/yr

meet critical appraisal and content criteria (93% ‘noise’ reduction)

Evidence‐Based Journals

Critical Appraisal Filters Reliability (kappa)

>90% beyond chance

Includes all Cochrane Reviews,

CADTH Reviews, NHS HTA Reviews, AHRQ Reviews

(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.

(17)

McMaster Online Rating of Evidence: >5000 clinicians RELEVANCE

(18)

To become a rater, email us at MORE@McMaster.CA

(must be in current clinical practice)

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~3,500 articles/y meet critical appraisal and content criteria

McMaster PLUS Project

Clinical Relevancy Filter (MORE⁾

~20 articles/yr for clinicians (99.96%

noise reduction)

~550 articles/y for authors of evidence

based guidelines and reviews

Health Knowledge Refinery

Predicts citation counts (p<0.001)

(20)

With biomedical research articles

published @ 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

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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 evidencebased resources by month

Percentage Using PLUS

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 03 03 04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05

Month 70

60 50 40 30 20 10

0

Baseline (5 mo) Selfserve vs Fullserve FullServe

Selfserve FullServe

Relative increase 58.7%, P=0.001

RCT begins Control crossover begins

(23)

You can sign up for free at

http://plus.mcmaster.ca/EvidenceUpdates

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Free at: http://plus.mcmaster.ca/np/

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PULL: Resources for finding

evidence when you need it

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…Doctor, do I really have to monitor my blood sugars (I can’t afford the glucose strips and my fingers hurt)?

Patient: A 56 year old white woman

with type 2 diabetes on metformin

with stable A

_1c

for 5 years asks...

(28)

Current guidelines

Canadian Diabetes Association Guidelines 2008

“All people with diabetes who are able should be taught how to self

manage 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 costeffectiveness of routine SMBG in non–insulintreated patients (40–42).”

(30)

Did I miss any important

evidence with my search?

Is there any way I could have

retrieved less

“junk”?

What is the best current evidence?

(31)

Systems Summaries

Synopses Syntheses

Studies

Search for Evidence

¨

Systems – one under development

¨

Summaries – Dynamed, UpToDate

¨

Synopses – ACPJC, DARE

¨

Syntheses – Cochrane, ACPJC+, EU

¨

Studies – preappraised:

EvidenceUpdates, ACPJC+, Nursing+

¨

Studies – nonpreappraised: Clinical

Queries; Pubmed

(32)

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http://medportal.ca

(34)

Clinical Connect

(Hamilton Health Sciences EMR)

MacPLUS

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Search on “diabetes and self- monitoring”

Results for

“Summaries”

Results for

“Synopses of SRs”

Results for

“Syntheses”

Results for

“Studies”

Results for “Synopses of Studies”

http://plus.mcmaster.ca/macplusfs/Who.aspx

(36)

Last literature review version 18.1: January 2010 | This topic last updated:

October 2, 2009

Thus, selfmonitoring 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].

Studies

(37)

Overview:

¨

inconsistent evidence for effectiveness of glucose

monitoring on glycemic control in type 2 diabetes

Studies

Evidence review

(38)

Conclusion: Intensive selfmonitoring of blood glucose was associated with higher cost and lower quality of life than usual care in non–insulintreated type 2 diabetes.

Studies

Glycemic control was not affected by selfmonitoring 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;336:11747.

Selfmonitoring of blood glucose was not costeffective in non–

insulintreated type 2 diabetes

Simon J, Gray A, Clarke P, et al. Cost effectiveness of self monitoring of blood glucose in patients with non

insulin treated type 2 diabetes:

economic evaluation of data from the DiGEM trial. BMJ. 2008;336:117780.

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Studies

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 costeffective.

(40)

Studies

For type 2 DM on metformin, is

glucose selfmonitoring “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)

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To keep up with evidence

¨ Pull

¨ Push

¨ Prompt…some labs and EMRs with a credible evidencebased pedigree

Systems

Summaries

Synopses

Syntheses

Studies

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Free at www.tripdatabase.com

(Pick One)

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Where can you find current best evidence?

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