Searching with Point of Care ToolsClerkship - Meds 2012Sept 21, 2010

Robin Featherstone, MLISClinical Medicine Librarianrfeathe@uwo.ca

Presentation available at: http://www.slideshare.net/featherr

Objectives

1. Recognize where Point-of-Care tools fit within the evidence-based hierarchy of information resources

2. Gain familiarity using a variety of Point-of-Care tools to answer clinical questions

Agenda

• Sources of medical evidence • Case studies and searching exercises

Lots of questions...

Study conducted of 64 residents in 2 hospitals• 401 consultations• 280 questions (2 questions for every 3 patients seen)• Answers were sought for 80 (29%) of the questions

References:

Green ML, Ciampi MA and Ellis PJ (2000). Residents’ medical information needs in clinical: are they being met? AmericanJournal of Medicine 109:218-233.

Lots of barriers...Focus groups with 34 residents• Barriers to answering clinical questions were reported as:

– Access to electronic information resources– Skills in searching information resources– Clinical question tracking– Time– Clinical question priority– Personal initiative– Team dynamics– Institutional culture

Reference:

Green ML, and Ruff TR (2005). Why do residents fail to answer their clinical questions? A qualitative study of barriers topracticing evidence-based medicine. Academic Medicine, 80(2): 176-182.

Evidence to answer clinical questions1,2

Type of Question Type of Evidence

Aetiology •Randomized controlled trials•Case-control or cohort studies•Case series

Diagnosis •Diagnostic validation studies•Prospective studies / blind comparison to a gold standard

Prognosis •Inception cohort studies•Case control studies•Case series

Therapy •Randomized controlled trials•Systematic reviews / meta-analyses

Prevention •Randomizes controlled trials•Cohort studies, case control studies•Systematic reviews / meta-analyses

Cost-effectiveness •Economic analyses

Quality of life •Qualitative studies1 Heneghan, Carl, and Douglas Badenoch. Evidence-Based Medicine Toolkit. 2nd ed. Malden, Mass.: BMJ Books/Blackwell Pub., 2006.2 Glover, Jan, and Lei Wang. Find it Fast: The Clinical Question : www.med.yale.edu/library/education/guides/screencasts/finditfast/finditfast_2/

Level of Evidence Pyramid

Qualitative Studies

Trip searches both

Systems, Synopses & Summaries

Systems Synopses SummariesFew exist Number in the thousands Fewer than 50,000

Textbook-like; integrate clinical evidence with other types of info; directed at clinical practice decisions

Summaries of studies and systematic reviews; includes guides or advice from expert clinicians

Systematic reviews of articles and guidelines; you assess and make decisions

Very easy to use Easy to use May require searching

Criteria for Selecting a Resource

1. Soundness of evidence-based approach2. Comprehensiveness and specificity3. Ease of use4. Availability

Studies

• Number in the millions• No processing of evidence – must individually

assess• Require searching large databases

Qualitative Studies

Available from Western Libraries (or for free)Systems Synopses Syntheses Studies

• ACP PIER

• DynaMed

• Natural Standard

• UpToDate

• Micromedex

• E-CPS

• ACP Journal Club

• InfoPOEMS (Essential Evidence Plus)

• DARE (Database of Reviews of Effects)

Centre for Reviews and Dissemination

• Cochrane Database of Systematic Reviews

Cochrane Library

• US National Guidelines Clearinghouse

• MEDLINE PubMed Ovid Medline Pubget

• EMBASE• SCOPUS• Cochrane Controlled Trials Registry (CCTR)

Cochrane Library

• CINAHL• PsycINFO• Web of Science

•TRIP Database

Find at: www.lib.uwo.ca/programs/undergraduatemedicaleducation/

Accessing Point-of-Care Tools (AKA Systems): www.lib.uwo.ca/programs/undergraduatemedicaleducation

SEARCHING EXERCISESDIAGNOSIS QUESTIONPROGNOSIS QUESTIONTREATMENT QUESTIONSCREENING QUESTIONDRUG INFORMATION – DOSINGDRUG INFORMATION – INTERACTION

Diagnosis Question

Search the following to answer the question: What tests should be ordered to diagnose Lyme Disease?

1. ACP Pier2. UpToDate3. DynaMed

Diagnosis Question - Results

Source Contains

ACP Pier - Diagnosis Summary- Evidence grading- Differential diagnosis- Test information- References

UpToDate - Diagnosis topic page- Test information- References

DynaMed - Diagnosis (Dx) summary- Differential diagnosis- Test information- References

Prognosis Question

Search the following to answer the question: What is the prognosis for a patient with Bell’s Palsy?

1. ACP Pier2. UpToDate3. DynaMed

Prognosis Question - Results

Source Contains

ACP Pier - Follow-up summary- Case studies- References

UpToDate - Prognosis and Treatment information together- Information tables- Rick factors for recurrence- References

DynaMed - Prognosis (Pr) summary- Evidence grading- Risk factors for recurrence- References

Treatment Question

• Search the following sources to answer the question: What is an appropriate second-line topical treatment for atopic dermatitis?

1. ACP Pier2. UpToDate3. DynaMed4. Natural Standard

Treatment Question - ResultsSource Contains

ACP Pier •Evidence rating •Evidence summary•Recommendations

•Link to drug monograph from AHFS DI Essentials (US)

UpToDate •Some evidence ratings•Evidence summary•Recommendations

•Link to detailed drug monograph from Lexi-Comp (US)

DynaMed •Evidence rating•Evidence summary•Links to guidelines

•Link to detailed drug monograph from AHFS DI Essentials (US)

Natural Standard

• Evidence ratings• Includes integrative therapies

• No links to drug information

• Search the following tools to answer the question: Should a 53 year old, postmenopausal woman who smokes one pack of cigarettes a day and reports low calcium intake be screened for osteoporosis?

1. ACP Pier2. UpToDate3. DynaMed4. TRIP Database

Screening Question

Screening Question - ResultsSource Contains

ACP Pier •Evidence rating •Evidence summary•Links to assessment tools

UpToDate •Detailed screening topic•Screening recommendations•List of risk factors

DynaMed •Prevention and Screening Information together•Evidence rating•Evidence summary

TRIP Database •Filter by Evidence level•Links to guidelines (including Canada)•Links to websites that include assessment tools

SEARCHING EXERCISE – DRUG INFORMATION

Drug Information - Dosing

Search the following information tools to answer the question: What is the proper dosage of Digoxin for a 2 year old?

1. UpToDate (Lexi-Comp)2. DynaMed (AHFS)3. MICROMEDEX4. E-CPS

Drug Dosing - Results

Source Results

UpToDate (Lexi-Comp) •Pediatric drug information•Detailed dosing chart

DynaMed •Pediatric dosing guide (under “Special Populations”)

MICROMEDEX •Pediatric Dosing Summary•Canadian

E-CPS •Dosing information for Infants and Children•Canadian

Drug Information - Interactions

You consider prescribing Tacrolimus to a patient who is taking Fluconazole, Gabapentin and Aspirin. Search the following tools to identify any potential interactions:

1. Lexi-Interact (UpToDate)2. MICROMEDEX3. E-CPS

Drug Interactions - Results

Source Results

Lexi-Interact •Interaction analysis tool•Risk ratings•Patient Management recommendations

MICROMEDEX •Interaction analysis tool•Risk ratings•Includes other interactions (ex. Drug-Food)•Canadian

E-CPS •Detailed drug monographs•Drug Interactions

Summary

• Point-of-Care tools can be found...• Point-of-Care tools are also known as...• An example of a free Point-of-Care tool is...• For alternative medicine information, try...• For Canadian drug information, try...• UpToDate’s drug information comes from...

QUESTIONS

Robin Featherstone, MLISClinical Medicine Librarianrfeathe@uwo.ca

Presentation available at: http://www.slideshare.net/featherr