r.m. balen pharmd 2004 1 - vhpharmsci.com · use internet-based strategies for keeping up with...

R.M. Balen PharmD 2004 1

Tips For Evaluating & Keeping Up With The Healthcare Literature

Robert M. Balen BSc(Pharm), PharmDInformatics Coordinator CSU Pharmaceutical SciencesVancouver General HospitalEmail: [email protected]

Background

� Information explosion� Technology → more information for less effort� Rapidly available information affects decision making� > 50% time spent gathering sharing analyzing seeking info� Excess information can be a barrier to finding what you need� Published health information growing beyond manageable level

Ref: Young KM. Informatics for Healthcare Professionals. Philadelphia, PA: F.A. Davis Co; 2000

Goals

� Awareness of most common published study types � Familiarity with process for literature evaluation

� Meta-analysis� Randomized controlled trials

� Access the “right amount” of information� Minimize your NNR (Number Needed To Read)*� Use Internet-based strategies for keeping up with literature

* Ref: Identifying Diagnostic Studies in MEDLINE: Reducing the Number Needed to Read

Lucas M. Bachmann, Reto Coray, Pius Estermann, and Gerben ter Riet J Am Med Inform Assoc 2002; 9: 653-658.

Objectives

� Adopt a literature evaluation approach for� Meta-analysis� Randomized controlled trials

� Use the available technology to help you� Subscribe to an eTOC of a professional journal � Identify 2 Internet-based strategies for staying current:

� new literature from publications that do not offer eTOC � with new literature from a “Therapeutic Topic” perspective

Case of the Very Busy Pharmacist

� Pharmacist � Very very busy� Good clinical skills � Good knowledge base� No personal professional journal subscriptions� Department subscriptions to some pharmacy literature

� Problem: How to keep up with healthcare literature? Hundreds of Hits!


•You can’t read everything

•growing stacks of unread material can be debilitating,depressing, & paralyzing

•Develop strategies to prioritize what youbrowse/read … or risk burial

•Aspire for "appropriate balance" …

•Avoid getting overwhelmed •Be a browser•Concentrate on spotting the one or two items you need to know

Tips Borrowed From The Web•Use your e-mail client to get organized

•Time is the resource we must trade off to keep up and there is no certain payoff, if done cautiously, wisely, and with a clear strategy, there is no limit to what might be gained. http://www.ala.org/acrl/keepup.html

The Keeping Up Philosophy

Know The 5 “Rights” Of Information

1. Right information2. Right person3. Right time4. Right place5. Right amount

� “Technology promises more information for less effort”� “Excess information … a barrier to finding what you need”

TIP: Admit You Could Use Some Help

Information Management Overview

“Pharmacist as Information Manager”

Dr. P. Loewenhttp://www.vhpharmsci.com/PresentationIndex.htm

Challenges

� MEDLINE 10,000 citations added weekly� PubMed, EMBASE, IPA� Government agencies� Medical societies� Popular press

� Increasing use of internet by general public� Increasingly informed healthcare consumer� Competing demands on time� Evidence-Based Practice

Major Study Types

� Case-control studies� Cohort studies� Randomized clinical trials� Meta-analysis

Reigelman RK. Studying a study and testing A test. How to read the medical evidenceLippincott Williams & Wilkins Publishers; 4th edition (January 15, 2000)


Case Control Studies

� Cases� Individuals who developed disease

� Controls� Individuals who have not developed disease

� Begin after development or failure of disease development� Back in time to determine characteristics

� E.g. association between birth control pill (bcp) and stroke


Case Control Studies Example

Assignments� Study group (cases) - Females who had stroke� Controls – similar subjects with no strokeAssessment� Each woman's exposure to bcpAnalysis� Odds of stroke in each groupInterpretation� Draw conclusions about meaning of bcp use in these womenExtrapolation� Conclusions about other women taking bcp e.g. lower doses


Cohort Studies

� Cohort = group who share a common experience� Identify subjects before disease development� Identify cohort that possesses study characteristic� Identify cohort not possessing study characteristic� Compare frequency of disease in both groups� Eg. Relationship between bcp and stroke

Cohort Study Example

Assignments� Select group of women using bcp� Select similar group of women not using bcpAssessment� Observe both groups for stroke developmentAnalysis� Odds of stroke in women using vs not using bcpInterpretation� Draw conclusions about meaning of bcp use in these womenExtrapolation� Conclusions about other women taking bcp e.g. lower doses



Randomized Clinical Trial

� Randomization� Method of assigning to groups

� Equal chance of assignment to study or control group

� Blinding� Single or double blind

� E.g. Effect of bcp use on stroke

Randomized Clinical Trial ExampleAssignments� Randomized blinded assignment

� Study group - using bcp� Control group – no bcp

Assessment� Observe both groups for stroke developmentAnalysis� Probability of developing stroke in study groupInterpretation� Draw conclusions about meaning of bcp use in these womenExtrapolation� Conclusions about other women taking bcp e.g. lower doses



Meta-analyses

� Review of all relevant studies on specific topic� Predetermined review methods

� Systematic:� Identification� Appraisal� Synthesis� Statistical aggregation

Cook DJ et al. Improving the quality of reports of meta-analyses of randomizedControlled trials: the QUOROM statement. Lancet 1999; 354: 1896 - 900

Study Types: Strengths

� Case-control� Rare conditions� Few subjects needed

� Cohort� Greater evidence of characteristic preceding disease

� Randomized clinical trial� Helps ensure study characteristic produces result

� Meta-analyses � Aggregation of results from smaller trials Levels of Evidence

http://www.cebm.net/levels_of_evidence.asp#levels

Evaluating The Healthcare Literature: Interventional Studies

� Why� Clear purpose?

� How� Study design

� Randomized / blinded?

� Who� Study population� Group differences� Inclusion exclusion criteria

http://www.familypractice.ubc.ca/residency/educritap.htm

Evaluating The Healthcare Literature: Interventional Studies cont.

� What� Compliance� Outcome measures� Interventions clearly defined � Subject withdrawal and follow-up

� How many� Statistical tests� Statistical significance

� So what� Clinical significance

http://www.familypractice.ubc.ca/residency/educritap.htm


Evaluating The Healthcare Literature: Meta-analysis

http://www.consort-statement.org/QUOROM.pdf

Yikes! How do I keep up with all this stuff

TIP: Invest in “Informatics”

� Skills� Information management� Computer competency

� Software� Searching� Storage

� Resources� Hardware� Software� Enabling tools

� Time

What to Read TIP:Distinguish “Need vs. Nice” to Know Info

� Need to Know� Literature that may affect practice� You prioritize

� Nice to Know� Everything else

� Interesting “peripheral” articles� Popular press� Regulatory news

� Easy to find with current search technology� Google / PubMed / Ovid / Medscape / MD Consult

TIP: Select Your “CORE” Sources

� High circulation journals� High return on time investment� Priority list for your area of practice� Ditch the “throw aways”

“Regular perusal of a small set of well-chosen journals is probably the mosteffective way for a scientist to maintain a reasonable level of current awareness in a rapidly proliferating field of research.”

Ref: http://www.mds.qmul.ac.uk/lib/bmedsci/keepup/journals.htm


TIP: Scan Your Core Sources Regularly

� Develop a literature scanning habit� Select relevant articles to read

� Triage� Abstract

� Would valid results affect your practice� Original articles� Review articles

� familiarity with new topics

� Critical appraisal

TIP: Push and Pull

� Push � Automatic delivery of information

� Electronic Table of Contents (eTOC)� Amedeo

� Pull� Active retrieval of information

� PubMed Cubby� Focused searching

“Pushing takes less effort”

Electronic Table of Contents (eTOC)

Subscribe eTOC

http://www.theannals.com/

eTOCAnnals of Pharmacotherapy

www.amedeo.com

Amedeo:Journal Options – Critical Care


Amedeo (www.amedeo.com): Specific Content from Various Journals

Personal Web Page

www.pharmacistsletter.com/

Warning:Maintain Control of Your Inbox

FoldersFiltersRules

PubMed Cubby

� Cubby to store and rerun searches� Journal search in PubMed� Store & rerun searches

� Rerun periodically for new citations

� Very useful for:� Journals without eTOC service� Clinical topic searches

� Registration required� Free


Cubby Link

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed Activate a Cubby Account

Stored Journal Search

Re-run for updates

Tip: Minimize Your NNR

� Invest time in scanning� Triage

� Original articles� Valid and clinically applicable� Scan of abstract and methods section� Review articles - familiarity with new topics

Pick an “Impact” Article to Read

NEJMVolume 347:1549-1556 November 14, 2002 Number 20 Dexamethasone in Adults with Bacterial Meningitis

“prospective, randomized, double-blind”

Conclusions: Early treatment with dexamethasoneimproves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding.

Case: Critical Care Pharmacist

eTOC� Annals Pharmacotherapy� NEJM� JAMA� CHEST� Am J Resp Crit Care Med� Critical Care Med

PubMed Cubby � AJHP� Pharmacotherapy� Lancet

Scanning

EBP – Focused Clinical Question & Search


Other Options:

Allied Journal Club: http://www.alliedjournalclub.com/

Medscape: http://www.medscape.com/

Ingenta: http://www.ingenta.com/

Highwire: http://highwire.stanford.edu/

Theheart.org http://www.theheart.org/index.cfm

MDConsult: http://www.mdconsult.com/

Summary

� Select sources� Use technology � Spend time scanning� Form a literature scanning habit� Access right amount of information� Separate need to know from nice to know� Read the “impact” articles� Critical evaluation

Tips For Evaluating & Keeping Up With The Healthcare Literature

Robert M. Balen BSc(Pharm), PharmDInformatics Coordinator CSU Pharmaceutical SciencesVancouver General HospitalEmail: [email protected]

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