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Where can you find “current best evidence�? Advances in the quest for access to high quality evidence, ready for clinical application. Brian Haynes McMaster University

Objectives To review the emerging hierarchy of pre-appraised “best evidence” resources ! To consider the complementary roles of “push” and “pull” evidence services (and “prompt”) ! To illunstrate the use of current sources of “pre-appraised” evidence !

The evolution of information resources for evidence-based decisions Examples New Systems Computerized decision School support All of these resources require that EBHC clinicians link Summaries the evidence with individual patient problems... Systems are needed to link directly from patient Synopses problems to evidence

Olde School EBHC


Evidence-based textbooks Evidence-based journal abstracts

Systematic reviews

Studies Original journal articles

Evolution of EBM Info !


PreEBM: Passive diffusion (“publish it and they will come”) Early EBM: Pull diffusion (“teach them to read it and they will come”)

Evolution of EBM Info !


Current EBM: Push diffusion (“read it for them and send it to them”) Future EBM: Prompt diffusion (“read it for them, connect it to their individual patients, prompt them and their patients”)

Finding best evidence for healthcare decisions

Push, Pull, Prompt ! of Pre-appraised evidence



Evidence!Based"Journals Reliability (kappa) Critical Appraisal Filters >90% beyond chance

70,000 articles/yr from 160 journals

Includes all Cochrane Reviews, CADTH Reviews, NHS HTA Reviews, AHRQ Reviews

~4,500 articles/yr meet critical appraisal and content criteria (94% ‘noise’ reduction)

The McMaster PLUS project !



only a tiny proportion of all research is “ready for application” only a tiny fraction of the “ready” research is “relevant” to the practice of a given clinician only a tiny proportion of the “relevant” research for a given practitioner is “interesting” in the sense of being something new, important, and actionable.

RELEVANCE McMaster Online Rating of Evidence: >5000 clinicians

To become a rater, e-mail us at MORE@McMaster.CA (must be in current clinical practice)

McMaster PLUS Project Predicts citation counts (p<0.001) Clinical Relevancy Filter (MORE)

~4,500 articles/y meet critical appraisal and content criteria

~20 articles/yr for clinicians (99.96% noise reduction) ~5-50 articles/y for authors of evidencebased guidelines and reviews

Health Knowledge Refinery

With biomedical research articles published @ 2,000,000/yr, a clinician reading 2 articles/day will be 55 centuries behind each year. Bernier & Yerkey, 1979 The evidence base for clinical effectiveness has become so vast that it is essentially unmanageable for individual providers. Institute of Medicine, 2001

User End ! ! !




Users sign up according to discipline Users control relevance and flow Users can change disciplines at any time, and can sign up for as many as they wish Users can search according to discipline â&#x20AC;&#x201C; or not Users can access many fulltext articles for free Users can access PubMed Clinical Queries

McMaster PLUS Trial Findings: % of participants using evidence-based resources by month

Percentage Using PLUS

Baseline (5 mo)

Self-serve vs Full-serve


70 60 50 40

Relative increase 58.7%, P=0.001

30 20 10 0

RCT begins

Control cross-over begins

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 03


04 04 04 04

04 04 04 04 04 04 04 04



05 05 05 05 05



You can sign up for free at



PULL: Resources for finding evidence when you need it

Patient: A 36 year old white woman with gestational diabetes and elevated bloods sugars despite exercise and dietary measures asks... â&#x20AC;Śis there an alternative to insulin?

What is the best current evidence? Did I miss any important evidence with my search?

Is there any way I could have retrieved less â&#x20AC;&#x153;junkâ&#x20AC;??

Search for Evidence

Systems Summaries Synopses Syntheses Studies

Systems – none that I know of ! Summaries – Clinical Evidence, UpToDate, ! Traditional texts – MD Consult, ACP Medicine ! Pull resources: EvidenceUpdates, ACPJC+, Nursing PLUS !

MEDICAL THERAPY â&#x20AC;&#x201D; If normoglycemia cannot be maintained by medical nutritional therapy, then anti-hyperglycemic agents should be initiated [43]. There are two options in pregnant patients who require medical therapy aimed at controlling blood glucose: insulin (and some insulin analogs), which is the only recommended approach in the United States [11]; and oral anti-hyperglycemic agents, which are used in some other countries.

Currently, the ADA and the American College of Obstetricians and Gynecologists do not endorse the use of oral anti-hyperglycemic agents during pregnancy and such therapy has not been approved by the Unites States Food and Drug Administration for treatment of GDM [5,11]. [references are from 2001 and 2004]

RATIONALE FOR TREATMENT â&#x20AC;&#x201D; Identifying women with GDM is important because appropriate therapy can decrease fetal and maternal morbidity, particularly macrosomia [1,2]. An effective treatment regimen consists of dietary therapy, self blood glucose monitoring, and the administration of insulin if target blood glucose values are not met with diet alone.

Systems Summaries Synopses Syntheses Studies

CONCLUSIONS! There!is!little!evidence!available!on!the!benefits!and!harms of!screening!for! gestational!diabetes.!Limited!evidence!suggests that!treatment!!of!gestational! diabetes!after!24!weeks!of!gestation may!improve!!maternal!and!neonatal! outcomes.

Systems Summaries Synopses Syntheses Studies

CONCLUSION:!No!substantial!maternal!or!neonatal!outcome! differences!were!found!with!the!use!of!glyburide!or!metformin! compared!with!use!of!insulin!in!women!with!GDM.

For gestational diabetes, what is the Systems best current management? Summaries Synopses Syntheses Studies

Systems: no Computerized Decision Support Summaries: in UTD, not CE Synopses: EBM, EBN, ACPJC Syntheses: EvidenceUpdates Studies: in UTD, CE, EvidenceUpdates; more in Clinical Queries

To keep up with evidence !









Push Prompt…some labs and EMRs with a credible evidence-based pedigree

Finding evidence-based guidelines UK National Institute of Clinical Effectiveness (no guideline on GDM) US National Guideline Clearinghouse (no guideline on GDM)

DARE Synopsis of Nicholson et al. Evidence Report/Technology Assessment; 162. 2008

Practice: the authors stated that clinicians should be aware that there was insufficient evidence to determine the effectiveness of alternatives to insulin for either birth weights or maternal glucose control, but use of such alternatives was unlikely to result in maternal or foetal adverse events.

NGC Search Results Your search criteria: Keyword: gestational diabetes and oral hypoglycemic Guideline Categories: Assessment of Therapeutic Effectiveness Age Range: Adult (19 to 44 years) Gender: Female Sort Order: Relevance

No guidelines were found that matched your query.

(PickO ne)

Free at


Current Best Evidence Sources  

Presented by Brian Haynes at McMaster Workshop 2009

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