Post on 19-Feb-2016
description
transcript
Where can you find “current best evidence”? Advances in the quest for access to high
quality evidence, ready for clinical application.
Brian HaynesMcMaster University
Objectives
! To review the emerging hierarchy of pre-appraised “best evidence”resources
! To consider the complementary roles of “push” and “pull” evidence services (and “prompt”)
! To illunstrate the use of current sources of “pre-appraised” evidence
Systems
Summaries
Synopses
Syntheses
Studies
Examples
Computerized decision support
Evidence-based textbooks
Evidence-based journal abstracts
Systematic reviews
Original journal articles
Olde School EBHC
New School EBHC
The evolution of information resources for evidence-based 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
Evolution of EBM Info
! 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
! Current EBM: Push diffusion (“read it for them and send it to them”)
! Future EBM: Prompt diffusion (“read it for them, connect it to their individual patients, prompt them and their patients”)
Push:
70,000 articles/yrfrom 160 journals
~4,500 articles/yrmeet critical appraisaland content criteria(94% ‘noise’ reduction)
Evidence!Based"Journals
Critical Appraisal FiltersReliability (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 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.
~4,500 articles/y meet critical appraisal and content criteria
McMaster PLUS Project
Clinical Relevancy Filter (MORE)
~20 articles/yr for clinicians (99.96%noise reduction)
~5-50 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 individual providers.
Institute of Medicine, 2001
User End
! Users sign up according to discipline! Users control relevance and flow! Users can change disciplines at any time,
and can sign up for as many as they wish! Users can search 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 evidence-based resources by month
Perc
enta
ge U
sing
PLU
S
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 05Month
70
60
50
40
30
20
10
0
Baseline (5 mo) Self-serve vs Full-serve Full-Serve
Self-serve Full-Serve
Relative increase 58.7%, P=0.001
RCT begins Control cross-over begins
…is there an alternative to insulin?
Patient: A 36 year old white woman with gestational diabetes and elevated bloods sugars despite exercise and dietary measures asks...
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?
SystemsSummariesSynopsesSyntheses
Studies
Search for Evidence
! Systems – none that I know of! Summaries – Clinical Evidence,
UpToDate, ! Traditional texts – MD Consult,
ACP Medicine! Pull resources: EvidenceUpdates,
ACPJC+, Nursing PLUS
MEDICAL THERAPY — If normoglycemia cannot be maintained by medical nutritional therapy, then anti-hyperglycemic agents should be initiated [43]. There are two options in pregnant patients who require medical therapy aimed at controlling blood glucose: insulin (and some insulin analogs), which is the only recommended approach in the United States [11]; and oral anti-hyperglycemic agents, which are used in some other countries.
Currently, the ADA and the American College of Obstetricians and Gynecologists do not endorse the use of oral anti-hyperglycemic agents during pregnancy and such therapy has not been approved by the Unites States Food and Drug Administration for treatment of GDM [5,11]. [references are from 2001 and 2004]
RATIONALE FOR TREATMENT — Identifying women with GDM is important because appropriate therapy can decrease fetal and maternal morbidity, particularly macrosomia [1,2]. An effective treatment regimen consists of dietary therapy, self blood glucose monitoring, and the administration of insulin if target blood glucose values are not met with diet alone.
CONCLUSIONS!
There!is!little!evidence!available!on!the!benefits!and!harmsof!screening!for!gestational!diabetes.!Limited!evidence!suggests
that!treatment!!of!gestational!
diabetes!after!24!weeks!of!gestation
may!improve!!maternal!and!neonatal!
outcomes.
SystemsSummariesSynopsesSyntheses
Studies
CONCLUSION:!No!substantial!maternal!or!neonatal!outcome!
differences!were!found!with!the!use!of!glyburide!or!metformin!
compared!with!use!of!insulin!in!women!with!GDM.
SystemsSummariesSynopsesSyntheses
Studies
SystemsSummariesSynopsesSyntheses
Studies
For gestational diabetes, what is the best current management?
Systems: no Computerized Decision SupportSummaries: in UTD, not CESynopses: EBM, EBN, ACPJCSyntheses: EvidenceUpdates Studies: in UTD, CE, EvidenceUpdates; more
in Clinical Queries
To keep up with evidence! Pull
! Push
! Prompt…some labs and EMRs with a credible evidence-based pedigree
Systems
Summaries
Synopses
Syntheses
Studies
Finding evidence-based guidelines
UK National Institute of Clinical Effectiveness (no guideline on GDM)
US National Guideline Clearinghouse(no guideline on GDM)
http://www.evidence.nhs.uk
DARE Synopsis of Nicholson et al. Evidence Report/Technology Assessment; 162. 2008Practice: the authors stated that clinicians should be aware that there was insufficient evidence to determine the effectiveness of alternatives to insulin for either birth weights or maternal glucose control, but use of such alternatives was unlikely to result in maternal or foetal adverse events.
http://www.guideline.gov
NGC Search ResultsYour search criteria: Keyword: gestational diabetes and oral hypoglycemic Guideline Categories: Assessment of Therapeutic Effectiveness Age Range: Adult (19 to 44 years) Gender: Female Sort Order: Relevance
No guidelines were found that matched your query.