In the previous post I reviewed a paper from Rita Banzi and colleagues from the Italian Cochrane Centre . They analyzed 18 POCs with respect to their “volume”, content development and editorial policy. There were large differences among POCs, especially with regard to evidence-based methodology scores, but no product appeared the best according to the criteria used.
In this post I will review another paper by Banzi et al, published in the BMJ a few weeks ago .
This article examined the speed with which EBP-point of care summaries were updated using a prospective cohort design.
First the authors selected all the systematic reviews signaled by the American College of Physicians (ACP) Journal Club and Evidence-Based Medicine Primary Care and Internal Medicine from April to December 2009. In the same period the authors selected all the Cochrane systematic reviews labelled as “conclusion changed” in the Cochrane Library. In total 128 systematic reviews were retrieved, 68 from the literature surveillance journals (53%) and 60 (47%) from the Cochrane Library. Two months after the collection started (June 2009) the authors did a monthly screen for a year to look for potential citation of the identified 128 systematic reviews in the POCs.
Only those 5 POCs were studied that were ranked in the top quarter for at least 2 (out of 3) desirable dimensions, namely: Clinical Evidence, Dynamed, EBM Guidelines, UpToDate and eMedicine. Surprisingly eMedicine was among the selected POCs, having a rating of “1” on a scale of 1 to 15 for EBM methodology. One would think that Evidence-based-ness is a fundamental prerequisite for EBM-POCs…..?!
Results were represented as a (rather odd, but clear) “survival analysis” ( “death” = a citation in a summary).
Fig.1 : Updating curves for relevant evidence by POCs (from )
I will be brief about the results.
Dynamed clearly beated all the other products in its updating speed.
Expressed in figures, the updating speed of Dynamed was 78% and 97% greater than those of EBM Guidelines and Clinical Evidence, respectively. Dynamed had a median citation rate of around two months and EBM Guidelines around 10 months, quite close to the limit of the follow-up, but the citation rate of the other three point of care summaries (UpToDate, eMedicine, Clinical Evidence) were so slow that they exceeded the follow-up period and the authors could not compute the median.
Dynamed outperformed the other POC’s in updating of systematic reviews independent of the route. EBM Guidelines and UpToDate had similar overall updating rates, but Cochrane systematic reviews were more likely to be cited by EBM Guidelines than by UpToDate (odds ratio 0.02, P<0.001). Perhaps not surprising, as EBM Guidelines has a formal agreement with the Cochrane Collaboration to use Cochrane contents and label its summaries as “Cochrane inside.” On the other hand, UpToDate was faster than EBM Guidelines in updating systematic reviews signaled by literature surveillance journals.
Dynamed‘s higher updating ability was not due to a difference in identifying important new evidence, but to the speed with which this new information was incorporated in their summaries. Possibly the central updating of Dynamed by the editorial team might account for the more prompt inclusion of evidence.
As the authors rightly point out, “slowness in updating could mean that new relevant information is ignored and could thus affect the validity of point of care information services”.
A slower updating rate may be considered more important for POCs that “promise” to “continuously update their evidence summaries” (EBM-Guidelines) or to “perform a continuous comprehensive review and to revise chapters whenever important new information is published, not according to any specific time schedule” (UpToDate). (see table with description of updating mechanisms )
In contrast, Emedicine doesn’t provide any detailed information on updating policy, another reason that it doesn’t belong to this list of best POCs.
Clinical Evidence, however, clearly states, “We aim to update Clinical Evidence reviews annually. In addition to this cycle, details of clinically important studies are added to the relevant reviews throughout the year using the BMJ Updates service.” But BMJ Updates is not considered in the current analysis. Furthermore, patience is rewarded with excellent and complete summaries of evidence (in my opinion).
Indeed a major limitation of the current (and the previous) study by Banzi et al [1,2] is that they have looked at quantitative aspects and items that are relatively “easy to score”, like “volume” and “editorial quality”, not at the real quality of the evidence (previous post).
Although the findings were new to me, others have recently published similar results (studies were performed in the same time-span):
Shurtz and Foster  of the Texas A&M University Medical Sciences Library (MSL) also sought to establish a rubric for evaluating evidence-based medicine (EBM) point-of-care tools in a health sciences library.
They, too, looked at editorial quality and speed of updating plus reviewing content, search options, quality control, and grading.
Their main conclusion is that “differences between EBM tools’ options, content coverage, and usability were minimal, but that the products’ methods for locating and grading evidence varied widely in transparency and process”.
Thus this is in line with what Banzi et al reported in their first paper. They also share Banzi’s conclusion about differences in speed of updating
“DynaMed had the most up-to-date summaries (updated on average within 19 days), while First Consult had the least up to date (updated on average within 449 days). Six tools claimed to update summaries within 6 months or less. For the 10 topics searched, however, only DynaMed met this claim.”
Table 3 from Shurtz and Foster 
Ketchum et al  also conclude that DynaMed the largest proportion of current (2007-2009) references (170/1131, 15%). In addition they found that Dynamed had the largest total number of references (1131/2330, 48.5%).
Yes, and you might have guessed it. The paper of Andrea Ketchum is the 3rd paper I’m going to review.
I also recommend to read the paper of the librarians Shurtz and Foster , which I found along the way. It has too much overlap with the Banzi papers to devote a separate post to it. Still it provides better background information then the Banzi papers, it focuses on POCs that claim to be EBM and doesn’t try to weigh one element over another.
- Banzi, R., Liberati, A., Moschetti, I., Tagliabue, L., & Moja, L. (2010). A Review of Online Evidence-based Practice Point-of-Care Information Summary Providers Journal of Medical Internet Research, 12 (3) DOI: 10.2196/jmir.1288
- Banzi, R., Cinquini, M., Liberati, A., Moschetti, I., Pecoraro, V., Tagliabue, L., & Moja, L. (2011). Speed of updating online evidence based point of care summaries: prospective cohort analysis BMJ, 343 (sep22 2) DOI: 10.1136/bmj.d5856
- Shurtz, S., & Foster, M. (2011). Developing and using a rubric for evaluating evidence-based medicine point-of-care tools Journal of the Medical Library Association : JMLA, 99 (3), 247-254 DOI: 10.3163/1536-5050.99.3.012
- Ketchum, A., Saleh, A., & Jeong, K. (2011). Type of Evidence Behind Point-of-Care Clinical Information Products: A Bibliometric Analysis Journal of Medical Internet Research, 13 (1) DOI: 10.2196/jmir.1539
- Evidence Based Point of Care Summaries  No “Best” Among the Bests? (laikaspoetnik.wordpress.com)
- How will we ever keep up with 75 Trials and 11 Systematic Reviews a Day? (laikaspoetnik.wordpress.com
- UpToDate or Dynamed? (Shamsha Damani at laikaspoetnik.wordpress.com)
- How Evidence Based is UpToDate really? (laikaspoetnik.wordpress.com)
Related articles (automatically generated)
- New Study of Top Five Point-of-Care Tools Finds DynaMed™ is the Most Current (prweb.com)
- UpToDate Now Available on iPhone (medgadget.com)
- FUTON Bias. Or Why Limiting to Free Full Text Might not Always be a Good Idea. (laikaspoetnik.wordpress.com)
- How Evidence-Based Management Pays Off – NYTimes.com (nytimes.com)
- McMaster University and DynaMed™ Partner to Identify Practice-Changing Evidence Across Medical Disciplines (prweb.com)