Keeping up with the Medical Literature


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Rachel Chapman, MD - Presentation from Pediatric Grand Rounds and Mott Children's Hospital, University of Michigan, Ann Arbor
January 26th, 2011

Published in: Health & Medicine
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Keeping up with the Medical Literature

  1. 1. Keeping Up With the Medical Literature in the 21 st Century Rachel Chapman, M.D. Clinical Assoc. Professor of Pediatrics University of Michigan School of Medicine Photo from Fraser and Dunstan “On the Impossibility Of being expert,” BMJ 2010
  2. 2. The Situation <ul><li>In the year 2010: </li></ul><ul><ul><li>60,493 publications including Infant, Child, or Adolescent as Subject Headings (English language) </li></ul></ul><ul><ul><ul><li>5,964 Clinical Trials </li></ul></ul></ul><ul><ul><ul><ul><li>3,221 Randomized Controlled Trials </li></ul></ul></ul></ul><ul><ul><ul><li>113 Clinical Practice Guidelines </li></ul></ul></ul><ul><ul><ul><li>65 EBM Reviews </li></ul></ul></ul>
  3. 3. So, we should read more… <ul><li>What? </li></ul><ul><li>When? </li></ul><ul><li>Where? </li></ul><ul><li>How? </li></ul>
  4. 4. Possible Strategies <ul><li>BMJ Editorial 12/18/2010 </li></ul><ul><li>“ Strategies for coping with information overload: you need a machine to help you” </li></ul>Richard Smith, M.D., Chair, Patients Know Best, Cambridge BMJ2010;341:c7126 Photo from Richard Smith, M.D., Chair, Patients Know Best, Cambridge BMJ2010;341:c7126
  5. 5. Learning Objectives <ul><li>Identify strategies for rapid identification of current literature that may impact patient care </li></ul><ul><li>Develop strategies for staying up to date emphasizing “best evidence” literature </li></ul><ul><li>Identify potential approaches for efficient “just in time” literature searches with emphasis on evidence-based summaries to answer clinical questions in real time </li></ul>
  6. 6. <ul><li>Part I: Keeping Current </li></ul><ul><li>Part II: Efficient Approaches for Answering Clinical Questions at the Point of Care </li></ul>
  7. 7. Possible Plans of Attack <ul><li>Peruse the Health Section of the daily paper/evening news/NPR </li></ul><ul><li>Subscribe to and read regularly as many journals as possible </li></ul><ul><li>Scan electronic tables of contents for select journals and read select articles of interest </li></ul><ul><li>Read “Summary” journals or journal sections, summarizing articles published in the broader literature </li></ul><ul><li>Read “Review” Journals </li></ul>
  8. 12. Scanning Journals
  9. 13. In Which Journals Will Pediatricians Find the Best Evidence for Clinical Practice? Birken CS, Parkin, PC. Pediatrics 1999 <ul><li>Reviewed journal citations from 3 sources </li></ul><ul><ul><li>AAP Policy Statements 1994-96 </li></ul></ul><ul><ul><li>Cochrane Database of Systematic Reviews 1997 </li></ul></ul><ul><ul><li>Canadian Paediatric Society Statements: 1990-97 </li></ul></ul>
  10. 14. In Which Journals Will Pediatricians Find the Best Evidence for Clinical Practice? Birken CS, Parkin, PC. Pediatrics 1999 <ul><li>7 journals were among the 10 most cited journals using all 3 sources </li></ul><ul><ul><li>Archives of Diseases in Childhood </li></ul></ul><ul><ul><li>British Medical Journal </li></ul></ul><ul><ul><li>JAMA </li></ul></ul><ul><ul><li>Journal of Pediatrics </li></ul></ul><ul><ul><li>Lancet </li></ul></ul><ul><ul><li>New England Journal of Medicine </li></ul></ul><ul><ul><li>Pediatrics </li></ul></ul>
  11. 15. “ Scanning” Journals for Articles Relevant to your Practice: Options <ul><li>Scanning a high-yield subset of paper journals </li></ul><ul><li>Subscribing to Electronic TOC Alerts from a single journal or group of journals </li></ul><ul><li>Subscribing to electronic “Topic Alerts” from high impact multi-specialty journals </li></ul><ul><li>Setting up saved searches with automatic e-mail alerts when new papers are published </li></ul>
  12. 16. E-mail Alerts: Tables of Contents <ul><li>Available through the journal website for many journals </li></ul><ul><li>Multiple journal TOC alerts are available through PubMed, and other services </li></ul><ul><li>Many can also be set up as RSS Feeds </li></ul><ul><li>Almost always free for TOC and abstracts </li></ul><ul><ul><li>Full text available with subscription or through UMHS connection (Taubman) </li></ul></ul>
  13. 21. E-mail Alerts: Topic Searches <ul><li>Many journals with a broad topic base (i.e. NEJM, JAMA and Archives, BMJ), offer topic alert e-mails and/or RSS feeds </li></ul>
  14. 25. Saved Searched with Auto Alerts <ul><li>In the personal version of both PubMed and Ovid there is an option to save a “Search” </li></ul><ul><li>Similar service offered through Pub Crawler TM </li></ul><ul><ul><li>Runs multiple searches weekly and send a single e-mail with new results </li></ul></ul><ul><li>Any saved search can then be selected to be run on a weekly bases with updated search results e-mailed (or sent as RSS feed) indefinitely </li></ul>
  15. 30. “ Foraging Tools” <ul><li>Topic searches can also be set up through evidence-based review services to provide “pre-digested” information </li></ul><ul><ul><li>Deliver the most recent systematic reviews, clinical practice guidelines, and critically appraised primary articles relevant to your topics of interest </li></ul></ul>
  16. 31. Information Alerting Services Updating or “Push” Tools <ul><li>What are they? </li></ul><ul><ul><li>Alerts the clinician to new evidence that may change clinical practice </li></ul></ul><ul><li>Where are they? </li></ul><ul><ul><li>Most are linked to a Clinical Reference Tool </li></ul></ul><ul><li>What do they cost? </li></ul>
  17. 32. How good are they???
  18. 33. <ul><li>Reviewed 18 currently available information alerting tools (most with emphasis on internal medicine/family medicine) </li></ul><ul><li>Average quality was poor (2.7 on 0-7 scale) </li></ul><ul><li>Best performer was Essential Evidence Plus </li></ul><ul><ul><li>Requires individual subscription </li></ul></ul><ul><ul><li>Limited Pediatric content </li></ul></ul><ul><li>Among those with pediatric content, Dynamed Weekly Updates and BMJ Updates performed well </li></ul>
  19. 37. Other Pediatric Resources for EBM Summaries of High Impact Articles <ul><li>Current Best Evidence </li></ul><ul><ul><li>Critical appraisal of recent papers EBM experts </li></ul></ul><ul><ul><li>Published 6-8 times a year in J Pediatrics </li></ul></ul><ul><li>AAP Grand Rounds </li></ul><ul><ul><li>Evidence eMended (Free RSS feed summaries of article reviews) </li></ul></ul><ul><li>Pediatric Care On-Line (AAP) </li></ul><ul><ul><li>Offers alert service for new AAP Policy Statements and Clinical Practice Guidelines </li></ul></ul><ul><li>Journal Watch Pediatrics </li></ul><ul><ul><li>Alert service for article reviews </li></ul></ul>
  20. 43. Review Journals <ul><li>Standard review journals are most useful for solidifying background information </li></ul><ul><li>Evidence base and currency is variable </li></ul><ul><li>Choice of information often directed by a single or small group of authors </li></ul><ul><li>Most helpful early in training to solidify background knowledge, although some are targeted more toward CME audience </li></ul>
  21. 44. <ul><li>Part I: Keeping Current </li></ul><ul><li>Part II: Efficient Approaches for Answering Clinical Questions at the Point of Care </li></ul>
  22. 45. Five Steps of EBM <ul><li>Ask answerable clinical questions </li></ul><ul><li>Search relevant literature efficiently </li></ul><ul><li>Appraise found data critically </li></ul><ul><li>Apply valid evidence into clinical decision-making </li></ul><ul><li>Evaluate and improve the process for future use </li></ul><ul><li>(Onady & Raclich, Pediatrics in Review September 2002) </li></ul>
  23. 46. PICO Question Patient or Problem Intervention Comparison intervention Outcomes Tips for Building Describe a group of patients similar to your own What intervention are you considering What is the main alternative to the intervention What do you hope to accomplish with the intervention Example “ In patients with anemia of prematurity… … does treatment with erythropoietin… … when compared with standard therapy alone… … lead to a decrease in the number of needed transfusions?”
  24. 47. Oxford Centre for EBM Levels of Evidence for Therapy Questions Level Type of Evidence 1 Systematic Review of RCTs with homogeneity Individual RCT with narrow confidence interval 2 Systematic Review of cohort studies with homogeneity Individual Cohort study or low quality RCT Outcomes Research; Ecological studies 3 Systematic Review of case-control studies with homogeneity Individual Case-Control Study 4 Case series and poor quality cohort and case-control studies 5 Expert opinion without critical appraisal, or based solely on physiology or bench research
  25. 48. “ Just in Time” Information Tools <ul><li>Clinical questions arise almost daily </li></ul><ul><li>EBM 5 step process is effective, not always efficient and practical for “on the job” decision making </li></ul><ul><li>Tools are available that are focused on identifying high level evidence intended for USERS of evidence-based medicine </li></ul><ul><ul><li>Ideally pre-digested and easily accessible and applicable at the point of care </li></ul></ul>
  26. 49. Systematic Reviews <ul><li>Identify a focused research question </li></ul><ul><li>Identify inclusion and exclusion criteria for studies to be included </li></ul><ul><li>Include a full description of the search strategy </li></ul><ul><li>Assess validity of each primary trial </li></ul><ul><li>Outcome data are extracted and tabulated for each included trial </li></ul><ul><li>A “typical effect” weighted average for each outcome is then calculated </li></ul>
  27. 50. Resources for Systematic Reviews for Pediatricians <ul><li>Cochrane Collaboration </li></ul><ul><li>DARE (Database of Abstracts of Reviews of Effectiveness) </li></ul><ul><li>ACP Journal Club </li></ul><ul><li>Journal of Pediatrics </li></ul><ul><li>Archives of Pediatrics and Adolescent Medicine </li></ul><ul><li>Pediatrics </li></ul>
  28. 51. The Cochrane Library <ul><li>Easiest way to access is through OVID (search Cochrane Database or EBM Reviews) or PubMed (Clinical Queries: Systematic Review) </li></ul>
  29. 53. “ Just in Time” Search Strategies <ul><li>Select your most likely source </li></ul><ul><ul><li>Emphasis on Systematic Reviews, Clinical Practice Guidelines </li></ul></ul><ul><ul><li>Can always go on to a standard Medline search if no luck </li></ul></ul><ul><li>Both Ovid and Pubmed allow you to select filters to maximize your chances of obtaining helpful results </li></ul><ul><li>Consider use of Proprietary “Clinical Information-Retrieval Technology” tools </li></ul>
  30. 54. What databases are available? <ul><li>Medline </li></ul><ul><ul><li>Most comprehensive </li></ul></ul><ul><ul><li>Can be hard to find what you are looking for </li></ul></ul><ul><ul><li>Available through Ovid Technologies and PubMed </li></ul></ul><ul><ul><li>Strategies for identifying Systematic Reviews are available </li></ul></ul><ul><li>Cochrane Library </li></ul><ul><ul><li>Compendium of systematic reviews, available through OVID or PubMed, or by subscription </li></ul></ul><ul><li>EBM Reviews </li></ul><ul><ul><li>Cochrane Library plus several other EBM databases (Best Evidence, DARE, ACP Journal Club) </li></ul></ul><ul><ul><li>Available through OVID </li></ul></ul>
  31. 59. OVID: EBM Search Strategies
  32. 61. Proprietary CIRT Tools <ul><li>Clinical Information Retrieval Technology (CIRT or CRT) </li></ul><ul><ul><li>“ Databases that merge or link digital libraries, computerized clinical practice guidelines or computerized synopses, electronic journals or textbooks, and medical websites” </li></ul></ul><ul><li>Examples Including Pediatric Content </li></ul><ul><ul><ul><li>DynaMed </li></ul></ul></ul><ul><ul><ul><li>Up to Date </li></ul></ul></ul><ul><ul><ul><li>Clinical Evidence </li></ul></ul></ul>Strayer SM, et al. Int J Med Informat 2010
  33. 64. Clinical Practice Guidelines <ul><li>Increasingly evidence-based, with levels of evidence included in recommendations </li></ul><ul><li>Searchable through PubMed or Ovid (Publication Type) </li></ul><ul><li>Other Sources for Guidelines: </li></ul><ul><ul><li>National Guideline Clearinghouse </li></ul></ul><ul><ul><li>MD Consult </li></ul></ul><ul><ul><li>Pediatric Care On-Line (AAP)/ AAP website </li></ul></ul>
  34. 67.
  35. 68.
  36. 69. Summary <ul><li>There is a tremendous number of pediatric publications coming to press each year </li></ul><ul><li>Keeping up with the literature can be an overwhelming and time-consuming endeavor </li></ul><ul><li>There are strategies that can maximize exposure to important clinical studies in a timely manner </li></ul><ul><li>There are strategies that can help to expedite and focus searches of the literature to answer clinical questions as they arise </li></ul>