Complementary Medicine & Pharmacists

30 11 2009

I don’t know if the situation is the same in other countries, but in the Netherlands we can only get prescribed medications in pharmacies. Drugstores are only allowed to sell over-the counter (OTC) medicines.

Most Pharmacies have a small shop of 5 square meters (besides a large storage room). What surprises me is that the counter is not only full with non-allergic creams, and the shelves are not only filled with liquorice and plasters, but the counter and shelves predominantly display naturopathic and herbal “medicines”. In this flu-season there are even leaflets how to prevent flu with all kinds of naturopathic medicine. Dr Vogel’s Echinaforce “helps to augment your natural resistance, lowers the risk of flu and shortens the duration or decreases the severity of symptoms once you have the flu” (..”vermindert u de kans op griep en herstelt u sneller als u toch ziek wordt“). Apparently A Vogel.nl (via Biohorma) started a campaign in the Netherlands. At their website there is even an advertisement for an offer by an insurance company -OHRA- because it generously refunds homeopathic medicine. Biohorma also made a You-Tube video.
In contrast, in the US there is a disclaimer at the Echinaforce site:” These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure or prevent any disease.”

There is no evidence that Echinacea prevents flu (see Cochrane Review and de Volkskrant [Dutch newspaper referring to clinical trials]), although it is not excluded that it helps for the early treatment of colds in adults.

Isn’t such a promotion of ineffective stuff a bad advice considering we have  a real flu-epidemic, and given the inverse relationship between pediatric vaccination and CAM usage (see Respectful Insolence)?

It is quite confusing, however, because Echinacea is advertised as an homeopathic medicine, whereas it seems a herbal medicine (not diluted ad infinitum). To date there is no evidence that homeopathy ‘works’. All 6 published Cochrane systematic reviews with ‘homeopathy’ or ‘homeopathic’ in the title conclude that there is little or no evidence that it works beyond the placebo-effect.

During the recent The House of Commons Science and Technology Committee meeting calling in homeopaths and scientists to discuss evidence for the alternative therapy Prof. Dr Ernst (with experience as a homeopath) said: “I have supplied a list of systematic reviews of homeopathy. There are two dozen. None in that list were positive.” (see this excellent summary of the meeting by Ian Sample). For the entire memorandum of Dr Ernst see here.

Besides that the clinical trials are ineffective, the whole theory is incompatible with the laws of physics and chemistry.

Nevertheless:

  • There is a lot of homeopathic research going on, i.e. funded by the NHS (National Health Sevice) in the UK and the NCCAM (National Center for Complementary and Alternative Medicin, NIH) in the US.
  • In the UK homeopathic medicine is endorsed by the MHRA (Medicines and Healthcare products Regulatory Agency)
  • CAM is booming business (£1.5bn industry in the UK)
  • CAM is covered by insurance companies.
  • CAM is sold and sometimes advocated by pharmacists.

Thus all over the world people are buying these ineffective homeopathic medicines while believing they ‘work’, or at least cause no harm. However, while homeopathic medicines may not harm themselves, they may cause harm if they are used in place of proven treatment for any life-threatening illness.” Indeed the WHO has warned people with conditions such as HIV, TB and malaria not to rely on homeopathic treatments (BBC NEWS 20 August 2009 ) 

For me it is incomprehensible, that pharmacists who are trained in pharmacology and chemistry (at the University Level), just sell those ineffective costly water-dilutions and advocate them directly or indirectly by putting them on the shelves, providing ample leaflets and brochures and giving positive “advise”. What could be the reason for doing that other than ignorance or MONEY?


Recommended Reading:

Photo Credits

  1. Pharmacists mortar and pestle http://commons.wikimedia.org/wiki/File:PharmacistsMortar.svg
  2. Homeopathic Medicine on the shelves http://www.flickr.com/photos/caseywest/ / CC BY-SA 2.0
    (this photo has nothing to do with the subject)
, but all kind of complementary medicine (CAM).
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Categories : Evidence Based Medicine, Medical/Clinical stuff, Reflections, quack

Adding Methodological Filters to MyNCBI

26 11 2009

Idea: Arnold Leenders
Text: “Laika”

Methodological Search Filters can help to narrow down a search by enriching for studies with a certain study design or methodology. PubMed has build-in methodological filters, the so called Clinical Queries for domains (like therapy and diagnosis) and for evidence based papers (like the“Systematic Review subset” in Pubmed). These searches are often useful to quickly find evidence on a topic or to perform a CAT (Critical Appraised Topic). More exhaustive searches require broader  filters not incorporated in PubMed. (See Search Filters. 1. An Introduction.).

The Redesign of PubMed has made it more difficult to apply Clinical Queries after a search has been optimized. You can still go directly to the clinical queries (on the front page) and fill in some terms, but we rather advise to build the strategy first, check the terms and combine your search with filters afterwards.

Suppose you would like to find out whether spironolactone effectively reduces hirsutism in a female with PCOS (see 10+ 1 Pubmed Tips for Residents and their Instructors, Tip 9). You first check that the main concepts hirsutism and spironactone are o.k. (i.e. they map automatically with the correct MeSH). Applying the clinical queries at this stage would require you to scroll down the page each time you use them.

Instead you can use filters in My NCBI for that purpose. My NCBI is your (free) personal space for saving searches, results, PubMed preferences, for creating automatic email alerts and for creating Search Filters.
The My NCBI-option is at the upper right of the PubMed page. You first have to create a free account.

To activate or create filters, go to [1] My NCBI and click on [2] Search Filters.

Since our purpose is to make filters for PubMed, choose [3] PubMed from the list of NCBI-databases.

Under Frequently Requested Filters you find the most popular Limit options. You can choose any of the optional filters for future use. This works faster than searching for the appropriate limit each time. You can for instance use the filter for humans to exclude animals studies.

The Filters we are going to use are under “Browse Filters”, Subcategory Properties….

….. under Clinical Queries (Domains, i.e. therapy) and Subsets (Systematic Review Filters)

You can choose any filter you like. I choose the Systematic Review Filter (under Subsets) and the Therapy/Narrow Filter under  Clinical Queries.

In addition you can add custom filters. For instance you might want to add a sensitive Cochrane RCT filter, if you perform broad searches. Click Custom Filters, give the filter a name and copy/paste the search string you want to use as filter.

Control via “Run Filter” if the Filter works (the number of hits are shown) and SAVE the filter.

Next you have to activate the filters you want to use. Note there is a limit of five filters (including custom filters) that can be selected and listed in My Filters.

Under  My Filters you now see the Filters you have chosen or created.

From now on I can use these filters to limit my search. So lets go to my original search in “Advanced Search”. Unfiltered, search #3 (hirsutism  AND spironolactone) has 197 hits.

When you click on the number of hits you arrive at the results page.
At the right are the filters with the number of results of your search combined with these filters (between brackets).

When you click at the Systematic Reviews link you see the 11 results, most of them very relevant. Filters (except the Custom Filters) can be appended to the search (and thus saved) by clicking the yellow + button.

Each time you do a search (and you’re logged in into My NCBI)  the filtered results are automatically shown at the right.

—

Clinical Queries zijn vaak handig als je evidence zoekt of een CAT (Critical Appraised Topic) maakt. In de nieuwe versie van PubMed zijn de Clinical Queries echter moeilijker te vinden. Daarom is het handig om bepaalde ‘Clinical Queries’ op te nemen in ‘My NCBI’. Deze queries bevinden zich onder Browse Filters (mogelijkheid onder Search Filters)

Het is ook mogelijk speciale zoekfilters te creëeren, zoals b.v. het Cochrane highly sensitive filter voor RCT’s. Dit kan onder Custom Filters.

Controleer wel via ‘Run Filter” of het filter werkt en sla het daarna op.

Daarna moet je het filter nog activeren door het hokje aan te vinken. Dus je zou alle filters van de ‘Clinical study category’ kunnen opnemen en deze afhankelijk van het domein van de vraag kunnen activeren.

Zo heb je altijd alle filters bij de hand. De resultaten worden automatisch getoond (aan de rechterkant.

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Categories : Evidence Based Searching, PubMed/MEDLINE, Search Filters, Tips and Tricks

Presentation at the #NVB09: “Help, the doctor is drowning”

16 11 2009

15-11-2009 23-24-33 nvb congressenLast week I was invited to speak at the NVB-congress, the Dutch society for librarians and information specialists. I replaced Josje Calff in the session “the professional”, chaired by Bram Donkers of the magazine InformatieProfessional. Other sessions were: “the client”, “the technique” and “the connection”. (see program)

It was a very successful meeting, with Andrew Keen and Bas Haring in the plenary session. I understand from tweets and blogposts that @eppovannispen en @lykle who were in parallel sessions were especially interesting.
Some of the (Dutch) blogposts (Not about my presentation….pfew) are:

I promised to upload my presentation to Slideshare. And here it is.

Some slides are different from the original. First, Slideshare doesn’t allow animation, (so slides have to be added to get a similar effect), second I realized later that the article and search I showed in Ede were not yet published, so I put “top secret” in front of it.

The title refers to a Dutch book and film: “Help de dokter verzuipt” (“Help the doctor is drowning”).

Slides 2-4: NVB-tracks; why I couldn’t discuss “the professional” without explaining the changes with which the medical profession is confronted.

Slides 5-8: Clients of a medical librarian (dependent on where he/she works).

Slides 9-38: Changes to the medical profession (less time, opinion-based medicine gradually replaced by evidence based medicine, information overload, many sources, information literacy)

Slides 39-66: How medical librarians can help (‘electronic’ collection accessible from home, study landscape for medical students, less emphasis on books, up to date with alerts (email, RSS, netvibes), portals (i.e. for evidence based searching), education (i.e. courses, computer workshops, e-learning), active participation in curriculum, helping with searches or performing them).

Slides 67-68: Summary (Potential)

Slide 69: Barriers/Risks: Money, support (management, contact persons at the departments/in the curriculum), doctors like to do it theirselves (it looks easy), you have to find a way to reach them, training medical information specialists.

Slides 70-73 Summary & Credits

Here are some tweets related to this presentation.

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Categories : Conference/Meeting, Evidence Based Searching, Medical Librarian, Presentation

Role of Consumer Networks in Evidence Based Health Information

11 11 2009

Guest author: Janet Wale
member of the Cochrane Consumer Network

People are still struggling with evidence or modern medicine – clinicians, patients, health consumers, carers and the public alike. Part of this is because we always thought medicine was based on quality research, or evidence. It is not only that. For evidence to be used most effectively in healthcare systems researchers, clinicians and ‘the existing or potential patients and carers’ have to communicate and resonate with each other – to share knowledge and responsibilities both in developing the evidence and in individual decision making. On the broader population level, this may include consultation but is best achieved by developing partnerships.

The Cochrane Collaboration develops a large number of the published systematic reviews of best evidence on healthcare interventions, available electronically on The Cochrane Library. Systematic reviews are integral to the collation of evidence to inform clinical practice guidelines. They are also an integral part of health technology assessments, where the cost-effectiveness of healthcare interventions is determined for a particular health system.

With the availability of the Internet we are able to readily share information. We are also acutely aware of disadvantage for many of the World’s populations. What this has meant is pooled efforts. Now we have not only the World Health Organization but also The Cochrane Collaboration, Guidelines International Network, and Health Technology Assessment International. What is common among these organizations? They involve the users of health care, including patients, consumers and carers. The latter three organizations have a formal consumer/patient and citizen group that informs their work. In this way we work to make the evidence relevant, accessible and being used. We all have to be discerning whatever knowledge we are given and apply it to ourselves.

This is  a short post on request.
It also appeared as a comment at: http://e-patients.net/archives/2009/11/tell-the-fda-the-whole-story-please.html

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#Cochrane Colloquium 2009: Better Working Relationship between Cochrane and Guideline Developers

19 10 2009

singapore CCLast week I attended the annual Cochrane Colloquium in Singapore. I will summarize some of the meetings.

Here is a summary of an interesting (parallel) special session: Creating a closer working relationship between Cochrane and Guideline Developers. This session was brought together as a partnership between the Guidelines International Network (G-I-N) and The Cochrane Collaboration to look at the current experience of guideline developers and their use of Cochrane reviews (see abstract).

Emma Tavender of the EPOC Australian Satellite, Australia reported on the survey carried out by the UK Cochrane Centre to identify the use of Cochrane reviews in guidelines produced in the UK ) (not attended this presentation) .

Pwee Keng Ho, Ministry of Health, Singapore, is leading the Health Technology Assessment (HTA) and guideline development program of the Singapore Ministry of Health. He spoke about the issues faced as a guideline developer using Cochrane reviews or -in his own words- his task was: “to summarize whether guideline developers like Cochrane Systematic reviews or not” .

Keng Ho presented the results of 3 surveys of different guideline developers. Most surveys had very few respondents: 12-29 if I remember it well.

Each survey had approximately the same questions, but in a different order. On the face of it, the 3 surveys gave the same picture.

Main points:

  • some guideline developers are not familiar with Cochrane Systematic Reviews
  • others have no access to it.
  • of those who are familiar with the Cochrane Reviews and do have access to it, most found the Cochrane reviews useful and reliable. (in one survey half of the respondents were neutral)
  • most importantly they actually did use the Cochrane reviews for most of their guidelines.
  • these guideline developers also used the Cochrane methodology to make their guidelines (whereas most physicians are not inclined to use the exhaustive search strategies and systematic approach of the Cochrane Collaboration)
  • An often heard critique of Guideline developers concerned the non-comprehensive coverage of topics by Cochrane Reviews. However, unlike in Western countries, the Singapore minister of Health mentioned acupuncture and herbs as missing topics (for certain diseases).

This incomplete coverage caused by a not-demand driven choice of subjects was a recurrent topic at this meeting and a main issue recognized by the entire Cochrane Community. Therefore priority setting of Cochrane Systematic reviews is one of the main topics addressed at this Colloquium and in the Cochrane Strategic review.

Kay Dickersin of the US Cochrane Center, USA, reported on the issues raised at the stakeholders meeting held in June 2009 in the US (see here for agenda) on whether systematic reviews can effectively inform guideline development, with a particular focus on areas of controversy and debate.

The Stakeholder summit concentrated on using quality SR’s for guidelines. This is different from effectiveness research, for which the Institute of Medicine (IOM) sets the standards: local and specialist guidelines require a different expertise and approach.

All kinds of people are involved in the development of guidelines, i.e. nurses, consumers, physicians.
Important issues to address, point by point:

  • Some may not understand the need to be systematic
  • How to get physicians on board: they are not very comfortable with extensive searching and systematic work
  • Ongoing education, like how-to workshops, is essential
  • What to do if there is no evidence?
  • More transparency; handling conflicts of interest
  • Guidelines differ, including the rating of the evidence. Almost everyone in the Stakeholders meeting used GRADE to grade the evidence, but not as it was originally described. There were numerous variations on the same theme. One question is whether there should be one system or not.
  • Another -recurrent- issue was that Guidelines should be made actionable.

Here are podcasts covering the meeting

Gordon Guyatt, McMaster University, Canada, gave  an outline of the GRADE approach and the purpose of ‘Summary of Findings’ tables, and how both are perceived by Cochrane review authors and guideline developers.

Gordon Guyatt, whose magnificent book ” Users’ Guide to the Medical Literature”  (JAMA-Evidence) lies at my desk, was clearly in favor of adherence to the original Grade-guidelines. Forty organizations have adopted these Grade Guidelines.

Grade stands for “Grading of Recommendations Assessment, Development and Evaluation”  system. It is used for grading evidence when submitting a clinical guidelines article. Six articles in the BMJ are specifically devoted to GRADE (see here for one (full text); and 2 (PubMed)). GRADE not only takes the rigor of the methods  into account, but also the balance between the benefits and the risks, burdens, and costs.

Suppose  a guideline would recommend  to use thrombolysis to treat disease X, because a good quality small RCTs show thrombolysis to be slightly but significantly more effective than heparin in this disease. However by relying on only direct evidence from the RCT’s it isn’t taken into account that observational studies have long shown that thrombolysis enhances the risk of massive bleeding in diseases Y and Z. Clearly the risk of harm is the same in disease X: both benefits and harms should be weighted.
Guyatt gave several other examples illustrating the importance of grading the evidence and the understandable overview presented in the Summary of Findings Table.

Another issue is that guideline makers are distressingly ready to embrace surrogate endpoints instead of outcomes that are more relevant to the patient. For instance it is not very meaningful if angiographic outcomes are improved, but mortality or the recurrence of cardiovascular disease are not.
GRADE takes into account if indirect evidence is used: It downgrades the evidence rating.  Downgrading also occurs in case of low quality RCT’s or the non-trade off of benefits versus harms.

Guyatt pleaded for uniform use of GRADE, and advised everybody to get comfortable with it.

Although I must say that it can feel somewhat uncomfortable to give absolute rates to non-absolute differences. These are really man-made formulas, people agreed upon. On the other hand it is a good thing that it is not only the outcome of the RCT’s with respect to benefits (of sometimes surrogate markers) that count.

A final remark of Guyatt: ” Everybody makes the claim they are following evidence based approach, but you have to learn them what that really means.”
Indeed, many people talk about their findings and/or recommendations being evidence based, because “EBM sells well”, but upon closer examination many reports are hardly worth the name.

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Cochrane 2.0 Workshop at the Cochrane Colloquium #CC2009

12 10 2009

Today Chris Mavergames and I held a workshop at the Cochrane Colloquium, entitled:  Web 2.0 for Cochrane (see previous post and abstract of the workshop)

First I gave an introduction into Medicine 2.0 and (thus) Web 2.0. Chris, Web Operations Manager and Information Architect of the Cochrane Collaboration, talked more about which Web 2.0 tools were already used by the Cochrane Collaboration and which Web 2.0 might be useful as such.

We had half an hour for discussion which was easily filled. There was no doubt about the usefulness of Web 2.0 for the Cochrane in this group. Therefore, there was ample room for discussing technical aspects, like:

  • Can you load your RSS feed of a PubMed search in Reference Manager? (According to Chris you can)
  • How can you deal with this lot of information (by following a specific subject, or not too much people – not many updates on a daily basis; you don’t have to follow it all, just pick up the headlines, when you can)
  • Are you involved in a Wiki that is successful? (it appears very difficult to involve people)
  • What happens if people comment or upload picture on facebook (of the Cochrane collaboration) in an appropriate way (Chris: didn’t happen, but you have to check and remove them)
  • How do you follow tweets (we showed Tweetdeck,  hashtags # and #followfridays)
  • What is the worst thing that happened to you (regarding web 2.0)? Chris and I thought a long time. Chris: that I revealed something that wasn’t officially public yet (though appeared to be o.k.). Me: spam (but I remove it/don’t approve it).
    Later I remembered two better (worse) examples, like the “Clinical Reader” social misbehaviour, a good example of how “branding” should not be done, and sites that publish top 50 and 100 list of bloggers just to get more traffic to their spam websites

Below is my presentation on Slideshare.

The (awful) green blackgound color indicates I went “live” on the web. As a reminder of what I did, I included some screendumps.

The current workshop was just meant to introduce and discuss Medicine 2.0 and Cochrane 2.0.

I hope we have a vivid discussion Wednesday when the plenary lectures deal with Cochrane 2.0.

The answers to my question on Twitter

  1. Why Web 2.0 is useful? (or not)
  2. Why we need Cochrane 2.0? (or not)

can be found on Visibletweets (temporary) and saved as: Quoteurl.com/sggq0 (permanent selection).

I think it would be good when these points are taken into account during the Cochrane 2.0 plenary discussions.

* possible WIKI (+ links) might appear at http://medicine20.wetpaint.com/page/Cochrane+2.0

<!–[if !mso]> Dia 52

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Categories : Cochrane Collaboration, Education, General, Web 2.0

This week I will blog from…..

10 10 2009

35167809 singapore colloquiumPicture taken by Chris Mavergames http://twitpic.com/kxrnl

Chris and I will facilitate a web 2.0 workshop for the Cochrane (see here, for all workshops see here).
The entire program can be viewed at the Cochrane Colloquium site.

Chris Mavergames, Web Operations Manager and Information Architect of the Cochrane Collaboration will also give a plenary presentation entitled:
“Cochrane for the Twitter generation:
inserting ourselves into the ‘conversation‘”.

The session has the promising title: The Cochrane Library – brave new world?

Here is the introductory text of the session:

The Cochrane Collaboration is not unique in facing a considerable challenge to the way it packages and disseminates healthcare information. The proliferation of communication platforms and social networking sites provides opportunities to reach new audiences, but how far can or should the Collaboration go in embracing these new media? In this session we hear from speakers who are at the heart of the discussions about The Cochrane Library’s future direction, including the Library’s Editor in Chief. We finish the session with reflections on the week’s discussions with respect to the Strategic Review (…)

Request (for the workshop, not the plenary session):
If you ‘re on Twitter, could you please tell the participants of the (small) web 2.0 workshop  your opinion on the following, using the hashtag #CC20.*

  1. Why Web 2.0 is useful? (or not)
  2. Why we need Cochrane 2.0? (or not)

An example of such an answer (from @Berci):

#CC20 Web 2.0 opens up the world and eases communication. Cochrane 2.0 is needed bc such an important database should have a modern platform

If you don’t have Twitter you can add your comment here and I will post it for you (if you leave a name).

Thanks for all who have contributed so far.

—–

*this is only for our small-scaled workshop, I propose to use #CC2009 for the conference itself.

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Grey Literature: Time to make it systematic

6 09 2009

Guest author: Shamsha Damani (@shamsha)

Grey literature is a term I first encountered in library school; I remember dubbing it “the-wild-goose-chase search” because it is time consuming, totally un-systematic, and a huge pain altogether. Things haven’t changed much in the grey literature arena, as I found out last week, when my boss asked me to help with the grey literature part of a systematic review.

Let me back up a bit and offer the official definition for grey literature by the experts of the Grey Literature International Steering Committee: “Information produced on all levels of government, academics, business and industry in electronic and print formats not controlled by commercial publishing i.e. where publishing is not the primary activity of the producing body.” Grey literature can include things such as policy documents, government reports, academic papers, theses, dissertations, bibliographies, conference abstracts/proceedings/papers, newsletters, PowerPoint presentations, standards/best practice documents, technical specifications, working papers and more! (Benzies et al 2006). So what is so time consuming about all this? There is no one magic database that will search all these at once. Translation: you have to search a gazillion places separately, which means you have to learn how to search each of these gazillion websites/databases separately. Now if doing searches for systematic reviews is your bread-and-butter, then you are probably scoffing already. But for a newbie like me, I was drowning big time.

After spending what seemed like an eternity to finish my search, I went back to the literature to see why inclusion of grey literature was so important. I know that grey literature adds to the evidence base and results in a comprehensive search, but it is often not peer-reviewed, and the quality of some of the documents is often questionable. So what I dug up was a bit surprising. The first was a Cochrane Review from 2007 titled “Grey literature in meta-analyses of randomized trials of health care interventions (review).” The authors concluded that not including grey literature in meta-analyses produced inflated results when looking at treatment effects. So the reason for inclusion of grey literature made sense: to reduce publication bias. Another paper published in the Bulletin of the World Health Organization concluded that grey literature tends to be more current, provides global coverage, and may have an impact on cost-effectiveness of various treatment strategies. This definitely got my attention because of the new buzzword in Washington: Comparative Effectiveness Research (CER). A lot of the grey literature is comprised of policy documents so it definitely has a big role to play in systematic reviews as well. However, the authors also pointed out that there is no systematic way to search the grey literature and undertaking such a search can be very expensive and time consuming. This validated my frustrations, but gave no solutions.

When I was struggling to get through my search, I was delighted to find a wonderful resource from the Canadian Agency for Drugs and Technologies in Health. They have created a document called “Grey Matters: A Practical Search Tool for Evidence-Based Medicine”, which is a 34-page checklist of many of the popular websites for searching grey literature, including a built-in documentation system. It was still tedious work because I had to search a ton of places, many resulting in no hits. But at least I had a start and a transparent way of documenting my work.

However, I’m still at a loss for why there are no official guidelines for librarians to search for grey literature. There are clear guidelines for authors of grey literature. Benzies and colleagues give compelling reasons for inclusion of grey literature in a systematic review, complete with a checklist for authors! Why not have guidelines for searching too? I know that every search would require different tools; but I think that a master list can be created, sort of like a must-search-these-first type of a list. It surely would help a newbie like me. I know that many libraries have such lists but they tend to be 10 pages long, with bibliographies for bibliographies! Based on my experience, I would start with the following resources the next time I encounter a grey literature search:

  1. National Guideline Clearinghouse
  2. Centre for Reviews and Dissemination
  3. Agency for Healthcare Research and Quality (AHRQ)
  4. Health Technology Assessment International (HTAI)
  5. Turning Research Into Practice (TRIP)

Some databases like Mednar, Deep Dyve, RePORTer, OAIster, and Google Scholar also deserve a mention but I have not had much luck with them. This is obviously not meant to be an exhaustive list. For that, I present my delicious page: http://delicious.com/shamsha/greylit, which is also ever-growing.

Finally, a request for the experts out there: if you have any tips on how to make this process less painful, please share it here. The newbies of the world will appreciate it.

Shamsha Damani

Clinical Librarian

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UpToDate or Dynamed?

5 07 2009

Guest author: Shamsha Damani (@shamsha) ;
Submission for the July Medlib’s Round

Doctors and other healthcare providers are busy folks. They often don’t have time to go through all the primary literature, find the best evidence, critique it and apply it to their patients in real-time. This is where point-of-care resources shine and make life a bit easier. There are several such tools out there, but the two that I use on a regular basis are UpToDate and DynaMed. There are others like InfoPoems, ACP’s PIER, MD Consult and BMJ’s Point of Care. I often get asked which ones are the best to use and why. The librarian answer to this question: depends on what you are looking for! Not a fair answer I admit, so I wanted to highlight some pros and cons of UpToDate and DynaMed to help you better determine what route to take the next time you find yourself in need of a quick answer to a clinical question.

UpToDate

Pros:

  • Comprehensive coverage
  • Easy-to-read writing style
  • The introduction of grading the evidence is certainly very welcome!

Cons:

  • Expensive
  • Conflict of interest policy a bit perplexing
  • Search feature could use a makeover
  • Remote access at a high premium
  • Not accessible via smart phones
  • They didn’t come to MLA’09 this year and medical librarians felt snubbed (ok, that is not a con, just an observation!)

DynaMed

Pros:

  • Bulleted format is easy to read
  • Remote access part of subscription
  • No conflict of interest with authors
  • A lot of the evidence is graded
  • Accessible on PDAs (iPhones and Blackberries included!)

Cons:

  • The user interface is a bit 1990s and could use a makeover
  • The coverage is not as extensive yet, though they keep adding more topics

A lot has been written about UpToDate and DynaMed, both in PubMed as well as on various blogs. Jacqueline also did a fabulous post of the evidence-based-ness of UpToDate not too long ago. I used to think that I should pick one and stick to it, but have recently found myself re-thinking this attitude. I think that we need to keep in mind that these are point-of-care tools and should not be utilized as one’s only source of information. Use the tool to get an idea about current evidence and combine it with your own clinical judgment when needed at point-of-care. If suspicious, look up the primary literature the good old way by using MEDLINE or other such databases. A point-of-care database will get you started; however, it is not meant to be a one-stop-shop.

I can almost hear people saying: so which one do you prefer anyways? That’s like asking me if I prefer Coke or Pepsi. My honest answer: both! (databases as well as beverages!). So what is a busy clinician to do? If you have access to both (or more), spend some time playing with them and see which one you like. Everyone has a different searching and learning style and it is sometimes a matter of preference. DynaMed’s concise structure may be appealing to newbies, whereas seasoned clinicians may prefer UpToDate’s narrative approach. Based on my very unscientific observation of Twitter conversations, it appears that clinicians in general prefer UpToDate whereas librarians prefer DynaMed. Could this be because UpToDate markets heavily to clinicians and snubs librarians? Or could it be the price? Or could it be the age-old debate on what is evidence? I don’t know the answer, partly because I find it all a bit too political. I’ve seen healthcare providers often use Google or Wikipedia for medical answers, which is quite sad. If you are using either UpToDate or DynaMed (or another similar product), you have already graduated to the big leagues and are a true EBM player! So relax and don’t feel like you have to pick a side. I find myself using both on a regular basis; the degree of success I have with each can be gauged by my daily Twitter feed!

Shamsha Damani


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#CECEM Bridging the Gap between Evidence Based Practice and Practice Based Evidence

15 06 2009

cochrane-symbol A very interesting presentation at the CECEM was given by the organizer of this continental Cochrane meeting, Rob de Bie. De Bie is Professor of Physiotherapy Research and director of Education of the Faculty of Health within the dept. of Epidemiology of the Maastricht University. He is both a certified physiotherapist and an epidemiologist. Luckily he kept the epidemiologic theory to a minimum. In fact he is a very engaging speaker who keeps your attention to the end.

Guidelines

While guidelines were already present in the Middle Ages in the form of formalized treatment of daily practice, more recently clinical guidelines have emerged. These are systematically developed statements which assists clinicians and patients in making decisions about appropriate treatement for specific conditions.

Currently, there are 3 kinds of guidelines, each with its own shortcomings.

  • Consensus based. Consensus may be largely influenced by group dynamics
    Consensus = non-sensus and Consensus guidelines are guidelies.
  • Expert based. Might be even worse than consensus. It can have all kind of biases, like expert and opinion bias or external financing.
  • Evidence based. Guideline recommendations are based on best available evidence, deals with specific interventions for specific populations and are based on a systematic approach.

The quality of Evidence Based Guidelines depends on whether the evidence is good enough, transparent, credible, available, applied and not ‘muddled’ by health care insurers.
It is good to realize that some trials are never done, for instance because of ethical considerations. It is also true that only part of what you read (in the conclusions) has actually be done and some trials are republished several times, each time with a better outcome…

Systematic reviews and qualitatively good trials that don’t give answers.

Next Rob showed us the results of a study ( Jadad and McQuay in J. Clin. Epidemiol. ,1996) with efficacy as stated in the review plotted on the X-axis and the Quality score on the Y-axis. Surprisingly meta-analysis of high quality were less likely to produce positive results. Similar results were also obtained by Suttorp et al in 2006. (see Figure below)

12066264 rob de bie CECEM

Photo made by Chris Mavergames

There may be several reasons why good trials not always give good answers. Well known reasons are  the lack of randomization or blinding. However Rob focused on a less obvious reason. Despite its high level of evidence, a Randomized Controlled Trial (RCT) may not always be suitable to provide good answers applicable to all patients, because RCT’s often fail to reflect the true clinical practice. Often, the inclusion of patients in RCT’s is selective: middle-aged men with exclusion of co-morbidity. Whereas co-morbidity occurs in > 20% of the people of 60 years and older and in >40% of the people of 80 years and older (André Knottnerus in his speech).

Usefulness of a Nested Trial Cohort Study coupled to an EHR to study interventions.

Next, Rob showed that a nested Trial cohort study can be useful to study the effectiveness of  interventions. He used this in conjunction with an EHR (electronic health record), which could be accessed by practitioner and patient.

One of the diseases studied in this way, was Intermittent Claudication. Most commonly Intermittent Claudication is a manifestation of  peripheral arterial disease in the legs, causing pain and cramps in the legs while walking (hence the name). The mortality is high: the 5 year mortality rates are in between those of colorectal cancer and Non-Hodgkin Lymphoma. This is related to the underlying atherosclerosis.

There are several risk factors, some of which cannot be modified, like hereditary factors, age and gender. Other factors, like smoking, diet, physical inactivity and obesity can be tackled. These factors are interrelated.

Rob showed that, whereas there may be an overall null effect of exercise in the whole population, the effect may differ per subgroup.

15-6-2009 3-06-19 CI 1

  • Patients with mild disease and no co-morbidity may directly benefit from exercise-therapy (blue area).
  • Exercise has no effect on smokers, probably because smoking is the main causative factor.
  • People with unstable diabetes first show an improvement, which stabilized after a few weeks due to hypo- or hyperglycaemia induced by the exercise,
  • A similar effect is seen in COPD patients, the exercise becoming less effective because the patients become short of breath.

It is important to first regulate diabetes or COPD before continuing the exercise therapy. By individually optimizing the intervention(s) a far greater overall effect is achieved: 191% improval in the maximal (pain-free) walking distance compared to for instance <35% according to a Cochrane Systematic Review (2007).

Another striking effect: exercise therapy affects some of the prognostic factors: whereas there is no effect on BMI (this stays an important risk factor), age and diabetes become less important risk factors.

15-6-2009 3-35-10 shift in prognostic factors

Because guidelines are quickly outdated, the findings are directly implemented in the existing guidelines.

Another astonishing fact: the physiotherapists pay for the system, not the patient nor the government.

More information can be found on https://www.cebp.nl/. Although the presentation is not (yet?) available on the net, I found a comparable presentation here.

** (2009-06-15) Good news: the program and all presentations can now be viewed at: https://www.cebp.nl/?NODE=239


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#CECEM David Tovey -the Cochrane Library’s First Editor in Chief

13 06 2009

cochrane-symbolThis week I was attending another congress, the Continental European Cochrane Entities Meeting (CECEM).

This annual meeting is meant for staff from Cochrane Entities, thus Centre Staff, RGC’s (Review Group Coordinators), TSC’s (Trial Search Coordinators) and other staff members of the Cochrane Collaboration based in Continental Europe.

CECEM 2009 was held in Maastricht, the beautiful old Roman city in the South of the Netherlands. The city where my father was born and where I spend many holidays.

One interesting presentation was by Cochranes’ 1st Editor in chief, David Tovey, previously GP in an urban practice in London for 14 years and  Editorial Director of the BMJ Group’s ‘Knowledge’ division (responsible for BMJ Clinical Evidence and its sister product Best Treatments, see announcement in Medical News Today)

David began with saying that the end user is really the key person and that the impact of the Cochrane Reviews is most important.

“How is it that a Senior health manager in the UK may shrug his shoulders when you ask him if he has ever heard of Cochrane?”

“How do we make sure that our work had impact? Should we make use of user generated content?”

Quality is central, but quality depends on four pillars. Cochrane reviews should be reliable, timely, relevant and accessible.

Cochrane Tovey wit

How quality is perceived is dependent on the end users. There are several kinds of end users, each with his own priorities.

  1. doctor: wants comprehensive and up-to-date info, wants to understand and get answers quickly.
  2. patient: trustworthiness, up-to-date, wants to be able to make sense of it.
  3. scientist: wants to see how the conclusions are derived.
  4. policy and guideline-makers.

Reliable: Several articles have shown Cochrane Systematic Reviews to be more reliable then other systematic reviews  (Moher, PLOS BMJ)*

Timely: First it takes time to submit a title of a Cochrane Review and then it takes at least 2 years before a protocol becomes a review. Some reviews take even longer than 2 years. So there is room for improvement.

Patients are also very important as end user. Strikingly, the systematic review about the use of cranberry to prevent recurrent urinary tract infection is the most frequently viewed article,- and this is not because the doctors are most interested in this particular treatment….

Doctors: Doctors often rely on their colleagues for a quick and trustworthy answer. Challenge: “can we make consulting the Cochrane Library as easy as asking a colleague: thus timely and easy?”

Solutions?

  • making plain language summaries more understandable
  • Summary of Findings
  • podcasts of systematic reviews (very successful till now), .e. see an earlier post.
  • Web 2.0 innovations

Key challenges:

  • ensure and develop consistent quality
  • (timely) updating
  • putting the customer first: applicability & prioritization
  • web delivery
  • resources (not every group has the same resources)
  • make clear what an update means and how important this update is: are there new studies found? are these likely to change conclusions or not? When was the last amendment to the search?

I found the presentation very interesting. What I also liked is that David stayed with us for two days -also during the social program- and was easy approachable. I support the idea of a user-centric approach very much. However, I had expected the emphasis to be less on the timeliness (of updates for instance), but more on how users (patients, doctors) can get more involved and how we review the subjects that are most urgently needed. Indeed, when I twittered that Tovey suggested that we “make consulting the Cochrane Library as easy as asking a colleague”, Jon Brassey of TRIP answered that a lot has to be done to fulfill this, as the Cochrane only answers 2 out of 350+ questions asked by GPs in the UK, a statement that appeared to be based on his own experience (Jon is founder of the TRIP-database).

But in principle I think that Jon is correct. Right now too few questions (in the field of interventions) are directly answered by Cochrane Systematic Reviews and too little is done to reach and involve the Cochrane Library users.

13-6-2009 15-43-17 twitter CECEM discussion

click to enlarge

During the CECEM other speakers addressed some of these issues in more detail. André Knottnerus, Chair of the Dutch Health Council, discussed “the impact of Cochrane Reviews”, and Rob the Bie of the Rehabilitation & Related Therapies field discussed “Bridging the  gap between evidenced based practice and practice based evidence”, while Dave Brooker launched ideas about how to implement Web 2.0 tools. I hope to summarize these (and other) presentations in a blogpost later on.

*have to look this up

NOTE (2009-11-10).

I had forgotten about this blank “citation” till this post was cited quite in another context (see comment: http://e-patients.net/archives/2009/11/tell-the-fda-the-whole-story-please.html) and someone commented that the asterisk to the “the amazing statement” had still to be looked up,  indirectly arguing that this statement thus was not reliable- and continuing by giving an example of a typically flawed Cochrane Review that hit the headlines 4 years ago, a typical exception to the rule that “Cochrane systematic reviews are more reliable than other systematic reviews”. Of course when it is said that A is more trustworthy than B it is meant on average. I’m a searcher, and on average the Cochrane searchers are excellent, but when I do my best I surely can find some that are not good at all. Without doubt that also pertains to other parts of Cochrane Systematic Reviews.
In addition -and that was the topic of the presentation- there is room for improvement.

Now about the asterisk, which according to Susannah should have been (YIKES!) 100 times bigger. This was a post based on a live presentation and I couldn’t pick up all the references on the slides while making notes. I had hoped that David Tovey would have made his ppt public, so I could have checked the references he gave. But he didn’t and so I forgot about it. Now I’ve looked some references up, and, although they might not be identical to the references that David mentioned, they are in line with what he said:

  1. Moher D, Tetzlaff J, Tricco AC, Sampson M, Altman DG, 2007. Epidemiology and Reporting Characteristics of Systematic Reviews. PLoS Med 4(3): e78. doi:10.1371/journal.pmed.0040078 (free full text)
  2. The PLoS Medicine Editors 2007 Many Reviews Are Systematic but Some Are More Transparent and Completely Reported than Others. PLoS Med 4(3): e147. doi:10.1371/journal.pmed.0040147 (free full text; editorial coment on [1]
  3. Tricco AC, Tetzlaff J, Pham B, Brehaut J, Moher D, 2009. Non-Cochrane vs. Cochrane reviews were twice as likely to have positive conclusion statements: cross-sectional study. J Clin Epidemiol. Apr;62(4):380-386.e1. Epub 2009 Jan 6. [PubMed -citation]
  4. Anders W Jørgensen, Jørgen Hilden, Peter C Gøtzsche, 2006. Cochrane reviews compared with industry supported meta-analyses and other meta-analyses of the same drugs: systematic review BMJ  2006;333:782, doi: 10.1136/bmj.38973.444699.0B (free full text)
  5. Alejandro R Jadad, Michael Moher, George P Browman, Lynda Booker, Christopher Sigouin, Mario Fuentes, Robert Stevens (2000) Systematic reviews and meta-analyses on treatment of asthma: critical evaluation BMJ 2000;320:537-540, doi: 10.1136/bmj.320.7234.537 (free full text)

In previous posts I regularly discussed that (Merck’s Ghostwriters, Haunted Papers and Fake Elsevier Journals and One Third of the Clinical Cancer Studies Report Conflict of Interest) that pharma-sponsored trials rarely produce results that are unfavorable to the companies’ products [e.g. see here for an overview, and many papers of Lisa Bero].

Also pertinent to the abovementioned discussion at E-patient-Net is my earlier post: The Trouble with Wikipedia as a Source for Medical Information. (references still not in the correct order. Yikes!)

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MedLib’s Round 1.3

8 04 2009

The 3rd Medlib’s Round, a blog carnival of medical-library related blogposts, is up at First Person Narrative. Anne Welsh did a great job pulling together an interesting collection of posts.

From Anne’s introduction

This month’s theme was “evidence” – not just in the terms of “Evidence Based Medicine” but in the widest possible sense. Evidence is a hot topic in the UK at the moment – indeed, the National Library for Health (NLH) is to be relaunched at the end of this month as NHS Evidence, “a web-based service that will help people find, access and use high-quality clinical and non-clinical evidence and best practice.”

Please have a look at the First Person Narrative and enjoy reading.

Want to stay informed? You can take a RSS subscription to the Medlib’s Round. An aggregated feed of credible, rotating health and medicine blog carnivals is also available (thanks Walter Jessen)

**************************************************************

The Next MedLib’s Round will be hosted by Nicole S. Dettmar at Eagle Dawg Blog. Nikki is a medical librarian at the National Network of Libraries of Medicine (NN/LM). The main theme will be PubMed or 3rd party PubMed tools. Post addressing this subject will get extra emphasis.

You can submit the permalink (url) of the post (you have already written on your blog) at the Blog Carnival submission form (you have to login, scroll down (!), submit links to selected posts and give an optional description). Don’t forget to submit before Saturday May 2, 2009 round midnight (EST)

Perhaps you would like to host a future edition as well. If so, please inform me which edition (June, July or August) you would like to host.

Further Reading:


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How Evidence Based is UpToDate really?

5 04 2009

logo-uptodate-2KevinMD or Kevin Pho is one of the top physician bloggers. He writes many posts per day, often provocatively commenting on breaking medical news or other blogposts.

A few weeks ago Kevin wrote a post on comparative effectiveness research [5] (tweet below), which is “(funded) research to evaluate and compare clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments or services that address a particular medical condition” (definition from DB Medical Rants).

utd1-uptodate-kevin

Kevin stated that doctors certainly need an authoritative, unbiased, source to base their decisions on and that that kind of information is already there in the form of UpToDate®. According to Kevin:

For those who don’t know, UpToDate is a peer-reviewed, evidence-based, medical encyclopedia [1] available via DVD or online that’s revised every 3 months. It does not carry advertisements, and is funded entirely via paid subscriptions [3]. I am a big proponent, and like many other doctors, could not practice medicine effectively without it by my side.” [2]

Kevin Pho also refers to a recent study showing that hospitals who used UpToDate scored better on patient safety and complication measures, as well as length of stay, when compared to institutions who did not use the resource.[4]

Kevin’s post actually summarized a post of yet another well known blogger, Val Jones MD (dr Val) of Better Health. In her blog post Dr Val wonders whether we should incentivize hospitals and providers to use UpToDate more regularly. Incentives can range from pay for performance bonuses to malpractice immunity for physicians who adhere to UpToDate’s, evidence-based, unbiased, clinical recommendations. According to Dr. Val, this might be an effective and easy way to target the problem of inconsistent practice styles on a national level, since many physicians know and respect UpToDate.[5]

The tweet of KevinMD elicited many responses on Twitter. To read most of the discussion on twitter follow this link.

Below I shall discuss the points addressed in the blogpost of KevinMD and DrVal. When relevant I will show/discuss the tweets as well.***

[1] Is UpToDate Evidence based?
The main discussion point on twitter was to which extent UpToDate is evidence based. As you can see below (the oldest tweet is at the bottom, the newest at the top) the opinions differ as to the level of UpToDate’s “evidence-basedness”. It varies from the one extreme of UpToDate doing systematic reviews and being entirely evidence based (drval) to ‘a slant of EBM*’ (@kevinmd) and UpToDate being an online book with narrative reviews.

utd2-tot2-uptodate

UpToDate used to be entirely an online book with (excellent) narrative reviews written by experts in the field. From 2006 onwards UpToDate began grading recommendations for treatment and screening using a modification of the GRADE system. Nowadays UpToDate calls its database an evidence based, peer reviewed information resource. According UpToDate the evidence is compiled from:

  • Hand-searching of over 400 peer-reviewed journals
  • Electronic searching of databases including MEDLINE, The Cochrane Database, Clinical Evidence, and ACP Journal Club
  • Guidelines that adhere to principles of evidence evaluation
  • Published information regarding clinical trials such as reports from the FDA and NIH
  • Proceedings of major national meetings
  • The clinical experience and observations of our authors, editors, and peer reviewers

Although it is an impressive list of EBM-sources, this does not mean that UpToDate itself is evidence based. A selection of journals to be ‘handsearched’ will undoubtedly lead to positive publication bias (most positive results will reach the major journals). The electronic searches -if done- are not displayed and therefore the quality of any search performed cannot be checked. It is also unclear on which basis articles are in- or excluded. And although UpToDate may summarize evidence from Systematic Reviews, including Cochrane Systematic Reviews it does not perform Systematic Reviews itself. At the most it gives a synthesis of the evidence, which is (still) gathered in a rather nontransparent way. Thus the definition of @kevinmd comes closest: “it gives an evidence based slant”. After all, Evidence-based medicine is a set of procedures, pre-appraised resources and information tools to assist practitioners to apply evidence from research in the care of individual patients” (McKibbon, K.A., see defintions at  the scharr webpage). Merely summarizing and /or referring to evidence is not enough to be evidence based.
It is also not clear what peer reviewed implies, i.e.can articles (chapters) be rejected by peer reviewers?

As a consequence the chapters differ in quality. Regularly I don’t find the available evidence in UpToDate. That is also true for students and docs preparing a Critically Appraised Topic (CAT). In my experience, UpToDate is hardly ever useful for finding recent evidence on a not too common question. @Allergynotes tweeted a specific example on chronic urticaria and H. pylori, where the available evidence could not be found in UpToDate.
In an older post (2007)*** @Allergynotes (Ves Dimov) commented on an interesting post by Dr. RW: “Are you UpToDate dependent?” by citing an old proverb: “beware the man of a single book (homo unius libri), which describes people with limited knowledge. The current version of the Internet has billions of scientific journal pages and the answer to your questions must be somewhere out there.” Ves:

“I don’t think anybody should be dependent on a single source. If one cannot practice medicine without UpToDate, may be one should not practice at all.”

Likewise, an anonymous commenter on Kevin’ posts stated:

“Don’t overlook the fact that there is a lot of good research outside of UpToDate. This is a great source, but if it’s your only source you’re closing off a tremendous amount of the literature. The articles are also written by people, and are subject to the biases of individuals.”

In another comment Dr. Matthew Mintz of the excellent blog with the same name puts forward that many of the authors have substantial ties to the pharmaceutical industry, meaning that UptoDate (although not financed) is not completely unbiased.

utd1-uptodate-allergynotes-laikas-evidence-not-always-found-3[2] Usefulness
@Allergynotes rightly states that usability/perceived usefulness my be more important to physicians (than real usefulness) and that we should look at what make UpToDate so useful rather than just say “it’s not EBM”. In one of his posts Ves Dimov (@allergynotes) refers to a (Dutch) paper showing that answers to questions posed during daily patient care are more likely to be answered by UpToDate than PubMed.** At my hospital some doctors (especially intern med docs) consider UpToDate as their Bible. It is without doubt that UpToDate is a very useful source both for clinicians, patients and even librarians. It is ideal for background questions (How can disease X be treated, what is the differential diagnosis?, what might be the cause of this disease?), to look up things and as a starting point. And it has a broad coverage. However the point here was not whether UpToDate is a useful source for clinicians – but whether it is a sufficiently unbiased evidence based source to incentive docs to follow its recommendations and its recommendations alone. Or as Shamsha says it: “I don’t like putting all my eggs in UpToDate’s basket.

utd-ebm-eggs-shamsha[3] Disadvantages/Alternatives
As highlighted by the twitter discussions (read from down up), the major disadvantages of UpToDate are its high pricing, its ridigity, monopolistic tendencies and strict denial of remote access. I don’t know if you have seen the recent post of David Rothman on a very unpolite, aggressive vendor trying to push a trial. Most of David readers guess the vendor was from UpToDate (2nd: MD consult). Is it reasonable to positively discriminate in favor of UpToDate, while not everyone may be able to afford this costly database or may prefer another source? Incentives will only enhance UpToDate’s monopolistic position.
The most ideal situation would be an open source UTD, as suggested by @nursedan. Allergynotes thinks that this should be possible. A role for Web 2.0 in EBM?

It should be noted that (besides the databases mentioned in the tweets) there are also other freely available evidence based sources, like

utd1-uptodate-price-disadv

[4] Hospitals using UptoDate score better?
Kevin and Dr Val also refer to a study in International Journal of Medical Informatics showing hospitals that used UptoDate scored better than hospitals that didn’t (even in a dose-response way). This study is shown prominently at the UpToDate’s site.

Now let’s just “score” the Evidence.

First one can wonder how representative this article is. A quick and dirty Google search gives many hits on the very same subject not (directly) linking to UpToDate. For instance, a paper published in the January issue of Ann Intern Med tells us the results from a large-scale study of more than 40 hospitals and 160,000 patients showing that when health information technologies replace paper forms and handwritten notes, both hospitals and patients benefit strongly (fewer complications, lower mortality rates, and lower costs). Etcetera. One would like to know how the evidence in the “UpToDate paper” would relate to other studies or even better one would like to see a head to head comparison of UpToDate with any other (specific) evidence based source.

The Impact Factor of INT J MED INFORM is 1.579. This says nothing about its value, but such a paper wouldn’t likely appear in UpToDate’s handsearch list.

More important 2 of the 4 authors are from UpToDate. This is an important bias.

Furthermore the study is a retrospective and observational study, comparing hospitals with online access to UpToDate with other acute care hospitals. According to the GRADE system this would automatically yield a Grade C: low-quality evidence from observational evidence. Most important, as admitted by the authors, the study could not fully account for additional features at the included hospitals that may also have been associated with better health outcomes. It is easy to imagine, for instance that a hospital being able to subscribe to UpToDate has a medical staff that was already predisposed to delivering higher quality care or might have a greater budget ;) . And although the average, severity-adjusted lenght of stay was significantly shorter in UpToDate® hospitals than in other hospitals with a P value of less than 0.0001, the mean difference was only 0.167 days with a not very impressive 95% confidence interval of 0.081–0.252 days.

[5] Incentives?
Based on the above arguments I don’t think it would be reasonable, effective or fair to incentive those hospitals or doctors that consult (and can afford) UpToDate or to indirectly punish those that don’t (because they don’t have the money or they have a good alternative).

Furthermore such a positive discrimination would not solve the problem of lack of head to head comparison, what was what it was all about. Dr Mintz explains this very clearly in his comment to Kevin.

“… the authors of UptoDate are providing their own summary of already published data, which most is funded by industry. This is similarly true of other so-called unbiased sources.(..)
The problem goes even deeper than the potential bias of industry funded research, which has been consistently shown to be favorable to the sponsor. The fact that most research, and virtually all therapeutic research is funded by the industry allows the industry to dictate what scientific knowledge is available, and by default clinical practice.(…)
There are hundreds of important studies that are never done because the industry only takes a “safe” bet.
We need comparative effectiveness not just to see whether the more expensive treatment is worth the cost, but we also need it to answer scientifically important questions that the industry will unlikely fund.”

*EBM = evidence based medicine
** It should be noted though that an other interface of PubMed is used in this hospital, to allow recording of the queries.The study participants were doctors in internal medicine.
*** I’ve added this sentence because people thought I merely summarized the tweets. In addition I added some new references.

References:

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Evidence Based Medicine: The Facebook of Medicine?

4 04 2009

Guest author: Shamsha Damani (@shamsha) ;
Submission for the April Medlib’s Round

Let’s face it: Facebook is pretty popular these days. Everyone and their grandmother (literally!) is on Facebook. In fact, if you don’t have a Facebook account, you are considered a social pariah. As I pondered over my next guest blog post on Jacqueline’s blog (thanks Jacqueline!), I started thinking that evidence based medicine (EBM) has a lot in common with Facebook. EBM, like Facebook, is very popular, everyone “claims” to be using it, and god help you if you shun it.

However, in my day-to-day work as a Clinical Librarian, I find that many healthcare providers really don’t know how to practice EBM. EBM surely gets a lot of press but many healthcare providers fail to explore it in depth. This can be due to lack of time, lack of resources, or not really knowing where to start. And you know what, it is okay to feel overwhelmed because EBM can be overwhelming. But looking at the big picture helps. Consider Facebook for a moment again: many people get overwhelmed by the applications, the groups, the wall, and forget the big picture: Facebook is about connecting with your friends and family. Similarly, think about the big picture of EBM: it is about using good evidence to treat your patient (defining good evidence however, can be a blog post of its own!).

Keep the basic principles of EBM in mind: Ask a focused question, find the evidence, critique the studies found, and then make a decision. Some people get overwhelmed by the evidence and allow it to usurp their own clinical judgment. Yes, EBM is about evidence, but it is also about using that evidence in conjunction with your clinical judgment. Don’t let the evidence hijack your clinical expertise. And lastly, don’t forget your patient. You can have the best evidence in hand with sound clinical judgment; but if your patient’s wishes differ from your evidence, then you have to respect them and let go of the evidence.

triad

Many people think that EBM, like Facebook, is a fad and will be replaced by something else. They may be right. However, until something better comes along, I think that healthcare professionals should get back to the basics of EBM, see the big picture, and put in the extra time it takes to practice EBM correctly. An appointment with your medical librarian wouldn’t hurt either! Evidence keeps changing (kind of like Facebook!) and it takes hard work to keep up; but the results are totally worth it!

Shamsha Damani


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