Evaluating Foraging Tools for Keeping Up with New, Relevant and Valid Information. A Bigger Problem?. “It’s not what you don’t know that hurts you (your patients), it’s what you think you know that’s not so” Important to answer practice-based questions with best source
“It’s not what you don’t know that hurts you (your patients), it’s what you think you know that’s not so”
Important to answer practice-based questions with best source
Equally important to make sure the necessary questions are being asked
Usefulness = Relevance x Validity
of any source Work
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.
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)
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)
Coordinated hunting and foraging tools
Specific and reproducible criteria for relevance and validity
Available at the point-of-care
All backed up by levels of evidence
Two patients in first week with mild COPD, minimal symptoms, history of CAD/MI, secondary prevention.
Currently on Spiriva- should I stop it?
Doc not seeing study would never ask question!!! (no known link)
Bottom line: and Valid Information Adults with chronic obstructive pulmonary disease (COPD) treated with inhaled anticholinergics, including ipratropium (Atrovent) and tiotropium (Spiriva), are at an increased risk of adverse major cardiovascular events including myocardial infarction (MI) and cardiovascular death. However, anticholinergics do improve the important patient oriented outcome of quality of life while not increasing the risk of all-cause mortality. Clinicians should assess the individual risk and benefit of treatment for each patient (e.g. withhold anticholinergics from patients with mild to moderate symptoms of COPD at high risk of CVD and strongly consider treating patients with life-altering symptoms from COPD at medium or low risk of CVD). (Common POEM)
Bottom lineThis study finds some support for the safety of tiotropium (Spiriva) in patients with chronic obstructive pulmonary disease (COPD). However, an important limitation of the study was that the authors only looked at studies sponsored by the manufacturer, and the results were heavily weighted by a single large, long study that excluded patients with recent evidence of heart disease. Studies of ipratropium have found different results (Chest 2010;137(1):13-19), and it is unclear why there would be an important difference in risk given the similarity of these drugs.
Singh S, Loke YK, Enright PL, et al. and Valid InformationMortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. BMJ 2011 Jun 14;342:d3215.
RESULTS: Five randomised controlled trials were eligible for inclusion. Tiotropium mist inhaler was associated with a significantly increased risk of mortality (90/3686 v 47/2836; relative risk 1.52, 95% confidence interval, 1.06 to 2.16; P=0.02; I(2)=0%). Both 10 microg (2.15, 1.03 to 4.51; P=0.04; I(2)=9%) and 5 microg (1.46, 1.01 to 2.10; P=0.04; I(2)=0%) doses of tiotropium mist inhaler were associated with an increased risk of mortality. The overall estimates were not substantially changed by sensitivity analysis of the fixed effect analysis of the five trials combined using the random effects model (1.45, 1.02 to 2.07; P=0.04), limiting the analysis to three trials of one year`s duration each (1.50, 1.05 to 2.15), or the inclusion of additional data on tiotropium mist inhaler from another investigational drug programme (1.42, 1.01 to 2.00). The number needed to treat for a year with the 5 microg dose to see one additional death was estimated to be 124 (95% confidence interval 52 to 5682) based on the average control event rate from the long term trials.
CONCLUSIONS: This meta-analysis explains safety concerns by regulatory agencies and indicates a 52% increased risk of mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease.
Specialty specific, POC (work)
Disease vs Patient Oriented (relevance)
LOE rating, best if SORT (validity)
Coordinated with HQ hunting tool
1. How is the information filtered?
2. Is the information valid?
3. How well is information summarized?
4. Is the information placed into context?
Black box warning on Avandia (rosiglitazone) NEJM, then JAMA
Blood sugar still too high, what about Actos (pioglitazone) ?
Should I still be recommending Actos? (did my foraging tool keep me UTD?)
www.google.com and Valid Information
www.bmjupdates.com (user ID: dcs6e; password: marnie
www.medscape.com (user: slawson44; pass: andrew
Twenty-two trials which randomised approximately 6200 people to pioglitazone treatment were identified. Longest duration of therapy was 34.5 months. Published studies of at least 24 weeks pioglitazone treatment in people with type 2 diabetes mellitus did not provide convincing evidence that patient-oriented outcomes like mortality, morbidity, adverse effects, costs and health-related quality of life are positively influenced by this compound. Metabolic control measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint did not demonstrate clinically relevant differences to other oral antidiabetic drugs. Occurrence of oedema was significantly raised. The results of the single trial with relevant clinical endpoints (Prospective Pioglitazone Clinical Trial In Macrovascular Events - PROactive study) have to be regarded as hypothesis-generating and need confirmation.
Stacy Hom MD, Scott Strayer MD MPH,
and David Slawson MD
alerts sent out at least monthly in frequency
automatic push service (user did not have to take additional steps to receive email updates)
Measured Translational Accuracy (MTA): Time to Diffusion and Quality of Assessment.
Emails were collected continuously from September 2008 to September 2010
We using the search terms “Tiotropium” and “Spiriva”
Search results were reviewed and only those related to Tiotropium’s impact on cardiovascular health were included
This was confirmed by checking online archives of email updates sent
We limited our search to a six month period from the date of article publication
1. BMJ Evidence Updates
2. Doctor’s Guide
4. Essential Evidence POEMs
5. Global Family Doctor
6. Peerview Institute
7. Physician’s First Watch
8. Cochrane Pearls
1. Doctor’s Guide
3. Peerview Institute
4. Cochrane Pearls
5. Essential Evidence POEMs: 6 months later
• 6 out of 8 email services looked at were missing
updates on one or both articles.
• Physician’s First Watch & Wonca Global Family
Doctor alerted clinicians on both articles.
• Average time to update was 12 days for the 2008
study, and 37 days for the 2010 study
• Essential Evidence was the only email service to
make the distinction that the 2010 study largely
excluded patients with recent heart disease.
Time to Diffusion
Quality of Assessment
Just like getting to Fenway Park for Game 7 World Series