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
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.
The Slippery Slope
years since graduation
r = 0.54 p<0.001
. . .... .
of current best care
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.
Typical time to “standard”
implementation of innovations
17 to 20 years
E X KT2 = ROI
Translation (type 2)
Return on Investment Real
E X KT2 = ROI
E is typically ≤ 0.25
KT2 is typically ≤ 0.25
.25 X .25 = .06
To review the emerging hierarchy of preappraised “best evidence”
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!
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)
Computerized decision support
Evidencebased journal abstracts
Original journal articles
Olde 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
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
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”)
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”)
Finding best evidence for healthcare decisions
Push, Pull, Prompt
¤ of Preappraised
50,000 articles/yr from 120 journals
meet critical appraisal and content criteria (93% ‘noise’ reduction)
Critical Appraisal Filters Reliability (kappa)
>90% beyond chance
Includes all Cochrane Reviews,
CADTH Reviews, NHS HTA Reviews, AHRQ Reviews
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
¨ only a tiny proportion of the “relevant”
research for a given practitioner is
“interesting” in the sense of being
something new, important, and actionable.
McMaster Online Rating of Evidence: >5000 clinicians RELEVANCE
To become a rater, email us at MORE@McMaster.CA
(must be in current clinical practice)
~3,500 articles/y meet critical appraisal and content criteria
McMaster PLUS Project
Clinical Relevancy Filter (MORE)
~20 articles/yr for clinicians (99.96%
~550 articles/y for authors of evidence
based guidelines and reviews
Health Knowledge Refinery
Predicts citation counts (p<0.001)
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
Institute of Medicine, 2001
¨ 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
McMaster PLUS Trial Findings: % of
participants using evidencebased resources by month
Percentage Using PLUS
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
60 50 40 30 20 10
Baseline (5 mo) Selfserve vs Fullserve FullServe
Relative increase 58.7%, P=0.001
RCT begins Control crossover begins
You can sign up for free at
Free at: http://plus.mcmaster.ca/np/
PULL: Resources for finding
evidence when you need it
…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 A1c
for 5 years asks...
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)].”
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).”
Did I miss any important
evidence with my search?
Is there any way I could have
What is the best current evidence?
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
(Hamilton Health Sciences EMR)
Search on “diabetes and self- monitoring”
“Synopses of SRs”
Results for “Synopses of Studies”
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].
inconsistent evidence for effectiveness of glucose
monitoring on glycemic control in type 2 diabetes
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.
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.
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.
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.
For type 2 DM on metformin, is
glucose selfmonitoring “worth it”?
Systems: not yet (so far as I know) Summaries: in UTD, Dynamed
Syntheses: EvidenceUpdates (via MacPLUS) Studies: in UTD, Dynamed, ACPJC,
EvidenceUpdates (and more, unappraised studies in Clinical Queries)
To keep up with evidence
¨ Prompt…some labs and EMRs with a credible evidencebased pedigree
Free at www.tripdatabase.com