Information Mastery TM

1. Information MasteryTM Module 1 • EBM – success or failure? • Implementation approaches – do they work? • How are clinical decisions made? • How is knowledge found -and used - in consultations? • What would something better look like? Module 2 • Information Mastery • Finding summarised evidence • Understanding it (Sums) Module 3 • The Consultation • Risk communication • Shared decision making

2. “Eternity is the time it takes to know everything”.

3. A method to combat ‘information overload’ and improve the quality of care for patients and the quality of life for clinicians It allows integrationof the expertise of the practitioner, the wishes of the patient together with the best available evidence What is ‘Information Mastery’?

4. Evidence based healthcare Judicious use of the the best available evidence, moderated by patient circumstances and preferences, to guide our practice to improve the quality of clinical judgements and facilitate effective healthcare.

5. Information Mastery • Information Mastery requires two different approaches to managing information: • Foraging - a method of being alerted to new information when it is published • Hunting - a method of finding information when it is needed • Without both: • clinicians won’t know when new important information becomes available • clinicians won’t be able to find it easily, even when they remember reading it

6. Finding the ‘best answer’, first time Cochrane Library NICE, (NSFs) Clinical Evidence InfoPOEMs, Prodigy BestTreatments NPC ref sheets EBM DTB MeReC Bandolier “Ivy League” journals Usefulness Medline, Google scholar InfoRetriever, DrCompanion, self-assembly Textbooks

7. Locate the best answer, rather than ‘an’ answer by using a hunting (search for evidence when needed) and foraging (rapid alerts of appraised and relevant evidence) approach

8. 3 steps to NSAID HeavenTM • Don’t use them unless you have to. • Paracetamol works for many • Employ non-drug interventions routinely. • Rubefacients or even tNSAIDs (if you have to) are preferable to step 2. • Glucosamine and chondroitin are worth considering. • If you have to use them, use them wisely. • Safest drug (ibuprofen, then diclofenac / naproxen) in lowest effective dose for shortest period. • NSAID users should be a high priority for medication reviews • Think about heart failure, hypertension and renal issues routinely. • Consider gastroprotection in those at high risk (NICE definition). • Options are misoprostol, PPIs, double dose H2RAs, and COX-2s. • COX-2s are not a panacea and the evidence for their gastroprotective effect (and their CV safety) is now questioned by licensing organisations internationally. All of this particularly applies to those aged over 65

9. Reading and critical appraisal MUST (largely) be replaced by reading pre-digested sources of evidence from trusted sources

10. Technology can help • Computer systems can store vast amounts of information (and never forget it). • Clinicians must learn to use computers as their ultimate source of knowledge and use their own brains to manipulate this vast store of knowledge in any individual circumstance to produce the optimal outcome for their patients.

12. Clinicians are valuable for how they think, and how they consult, but not for what they know

13. Skills required to sift the good evidence from the not so good • How do we locate the best evidence? • What are the reliable sources? • How do we decide? • How do we interpret the important bits? • What if someone gives you some ‘new’ evidence?

14. How can we quickly spot what is NOT important to us? • Not RELEVANT • Upstream to clinical decisions being made, e.g. animal or in vitro studies • Study populations and / or settings do not reflect question type, practice population and settings. • Not VALID • Poor study design • Bias and confounding • Measurement validity • Insufficient power

15. Usefulness = Relevance x ValidityWork What are the criteria used when looking for the best answer or important evidence? Slawson DC and Shaughnessy AF. J Am Board Fam Pract 1999; 12: 444-449

16. When we read ANYTHING related to work – we MUST first assess for RELEVANCE THINK…… F O C C

17. Relevance • Feasible (intervention) • Outcomes (patient-orientated) – more later • Common (condition) • Change in practice required If there’s a negative answer to any of these, you say the best seven words EVER!!!!!!!!!

18. I don’t know, and I don’t care!!!!!!!

19. After checking it is relevant, is the answer likely to be valid? • How to quickly spot the fatal flaws: • Is it a high level of evidence? • Is it statistically significant? • Is it clinically significant?: • Do you understand what the the numbers tell you? • Absolute vs. relative risk vs. NNT • Was there enough people in the study for long enough? • Was the allocation concealed? If there is a fatal flaw, say them with me………..

20. I don’t know, and I don’t care!!!!!!!

21. POEMs vs PROSE • POEMS • Patient-Oriented Evidence that Matters • matters to you, the practitioner, because if valid, will require you to change your practice • PROSE • Prescribing Recommendation(s) based On Substandard Evidence

22. So, filtering for relevance • Feasible (intervention) • Outcomes (patient-orientated) • Common (condition) • Change in practice required

23. What you measure matters – POOs and DOOs Patient Oriented Outcomes: • Reduces heart attacks and strokes • Reduces diabetic foot ulcers • Reduces night time awakenings Disease Oriented Outcomes: • Reduces Blood pressure • Improves HBA1c • Improves PEF

24. DOOs can mislead and don’t always relate to POOsEbell M, et al. Am Fam Physician 2004; 69: 548–556

26. Filtering for relevance • Group work • 9 papers • Look at the conclusions quickly • Ask yourselves: • Is the intervention feasible • Are the outcomes patient-orientated • Is it something I see commonly in my practice • If the information is true, will it require me to change my practice

27. Assessing the validity of the results

28. Usefulness = Relevance x ValidityWork What are the criteria used when selecting information to solve a clinical question ? Slawson DC and Shaughnessy AF. J Am Board Fam Pract 1999; 12: 444-449

29. N Engl J Med 2001; 345: 494-502

30. How many of you have had teaching / read articles on critical appraisal? Warning Warning Warning!

31. How do you feel about your ability to appraise the evidence? Level 1: • Use the highest quality information to guide clinical decisions (100%) Level 2: • Search, evaluate, and make available specialty specific Level 1 information (<1%) Level 3: • Create original research (primary) or systematic reviews (secondary) • Many healthcare professionals may be at level 0

32. Large scale critical appraisal hasn’t worked…..and is unlikely to

33. Reading and critical appraisal MUST (largely) be replaced by reading pre-digested sources of evidence from trusted sources

34. Where does the information on effectiveness come from? • Where does the information on safety come from?

35. A hierarchy of evidence • (MA of several, similar, large well designed randomised controlled trials (RCTs)) • Large well designed RCT • Meta analysis of smaller RCTs • Case control and cohort studies • (Case reports and case series) • Consensus from expert panels • I think

36. Randomised controlled trials General population Our sample Experimental intervention Improved Not improved Time Improved Comparison intervention Not improved

37. Meta analysis of RCTs(First do a systematic review, then decide which studies are RCTs, which ones compare what we are interested in, which ones have measured acceptable and the same outcomes, and then….. )

38. Controls General population Cases Case control studies Exposure to Risk Factor STUDY Yes No Yes No TIME

39. General population Our sample Cohort studies Yes Exposed No Population Time Yes Not exposed No

40. You admit a young man with severe Crohn’s disease of recent onset. When admitting him you are struck by the fact that his diet has, for the last four years, consisted largely of three bowls of breakfast cereal a day. Over the next three months you admit four more cases of Crohn’s disease and two of them have a similar dietary history • Does this mean breakfast cereals cause Crohn’s disease? • What could you do?

41. 1. Write up a case series

42. Controls General population Cases 2. Do a case control study Exposure to Risk Factor STUDY Yes No Yes No TIME

43. General population Our sample 3. Access a cohort and do a cohort study Yes Exposed No Population Time Yes Not exposed No

44. 4. Do a randomised controlled trial General population Our sample Experimental intervention Improved Not improved Time Improved Comparison intervention Not improved

45. A hierarchy of evidence • (MA of several, similar, large well designed randomised controlled trials (RCTs)) • Large well designed RCT • Meta analysis of smaller RCTs • Case control and cohort studies • (Case reports and case series) • Consensus from expert panels • I think

46. Why are RCTs the “gold standard”? • Remember the hierarchy of evidence? • Large well designed RCTs • Meta analysis of smaller RCTs • Case control and cohort studies • (Case reports and case series) • Consensus from expert panels • I think • Why is this????

47. Why are RCTs the “gold standard”?Egger M, et al. BMJ 1998; 316: 140-144 Does beta-carotene reduce CV mortality?

48. Another exampleChalmers TC, et al. N Engl J Med 1983; 309: 1358-61 • 145 trials of treatment of acute MI • 57 were RCTs where allocation was concealed • 45 were RCTs where allocation may not have been concealed • 43 were non-randomised trials • Results by type of study: • Control Group • Case Fatality Rate RRR • Non-randomised trials 32.1% 33% • RCTs 22.7% 23% • RCTS with concealed allocation 15.6% 3%

49. Why don’t we always use an RCT then? Ethics Cost Feasibility Practicality How much does it cost to do an RCT with around 4000 people?