Models of Information Summary, Synthesis, and Dissemination In Clinical Medicine

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Models of Information Summary, Synthesis, and
Dissemination In Clinical Medicine

• Sources and Organization of Evidence-based
  Knowledge

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Evolution of Medical Models of Information
Dissemination

• Information explosion
• Increase in expectations of EBM practice
• Improved access to electronic info

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Evolution of Medical Models of Information
Dissemination

• Market forces are driving rapid development of
  many new online resources to support clinical
  medical practice
• Limited public and foundation funds support
  public health resources

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Comparing Info Needs in Clinical Medicine and PH
Comm. Dis.
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Clinical Medical Information Models

• Research Reports
• Collections
• Summaries
• Critiques
• Commentaries
• Reviews, meta-analyses, guidelines
• Comprehensive knowledge sources

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Research Reports
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Accessing Collections of Research Reports
Search Tools and Alerts

• Searching MEDLINE (PubMed)
• Simple search
• Prepared Filters
• Alerts
• Tables of contents
• Individualized content alerts

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PubMed Search on Drug Resistant Salmonella

• united statesmh AND (salmonella
  infectionsmajr OR salmonellamajr) AND drug
  resistancemajr AND (prevention and
  controlsubheading OR prevention OR public
  health OR disease outbreaks OR population
  surveillance OR risk factors OR prospective
  studies OR case-control studies OR follow-up
  studies OR comparative study OR pilot projects OR
  retrospective studies OR longitudinal studies OR
  infection control) AND englishlang AND
  humanmh

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Research Reports

• Alerts on Recently Published Literatures

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Research ReportsSummaries, Critiques, and
Commentaries

• Summary Structured, reorganization of data and
  conclusions just the key points
• Critique Criticism of methods, interpretation of
  findings, conclusions
• Commentary Puts findings into context of current
  knowledge and practice

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Research ReportsSummaries, Critiques, and
Commentaries

• Medical Examples
• Journal Watch
• ACP Journal Club
• Annals of Internal Medicine
• Public health examples
• Journal Watch Infectious Diseases
• Evidence-based Health Care

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Evidence-based Healthcare covers the following
types of studies Evaluations of financing
and organization of healthcare Evidence-based
patient and public choice Health economics
Health technology assessment Managing
healthcare Promotion of evidence-based
clinical practice Public health policy
Purchasing
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Systematic Reviews, Meta-Analyses and
Evidence-Based Guidelines
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Systematic Reviews, Meta-Analyses and
Evidence-Based Guidelines

• Medical examples
• Cochrane Database of Systematic Reviews
• National Guideline Clearinghouse
• Guide to Clinical Preventive Services
• Guidelines authored by medical specialty societies

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Systematic Reviews, Meta-Analyses and
Evidence-Based Guidelines

• Public health examples
• Cochrane Public Health topic reviews
• National Guideline Clearinghouse
• Guide to Community Preventive Services
• CDC Prevention Guidelines System

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• Systematic Review
• Thorough literature review
• Explicit criteria for selecting studies
• Tables, narrative to summarize findings
• Conclusions acknowledge strengths, weaknesses of
  evidence

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Cochrane Database of Systematic Reviews

• Separate Public Health Group
• Standardized approach to systematic reviews
• Individual or institutional subscription required
  for access to full text
• About 50 reviews and many more planned

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Cochrane Review Index (Ovid)
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Main results 11 trials were included with a
total of 8,130 randomized participants.
Preventive therapy (any anti-TB drug) versus
placebo was associated with a lower incidence of
active tuberculosis (RR 0.64, 95 CI 0.51 to
0.81). This benefit was more pronounced in
individuals with a positive tuberculin skin test
(RR 0.38, 95 CI 0.25 to 0.57) than in those who
had a negative test (RR 0.83, 95 CI 0.58 to
1.18.). Limited data suggest that the initial
protective effect against tuberculosis may
decline over the short to medium term. Efficacy
was similar for all regimens (regardless of drug
type, frequency or duration of treatment).
However, compared to INH monotherapy, short
-course multi-drug regimens were much more likely
to require discontinuation of treatment due to
adverse effects. Overall, there was no evidence
that preventive therapy versus placebo reduced
all-cause mortality (RR 0.95, 95 CI 0.85 to
1.06), although a favourable trend was found in
people with a positive tuberculin test (RR 0.80,
95 CI 0.63 to 1.02).
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• Conclusions
• Treatment of latent tuberculosis infection (LTBI)
  reduces the risk of active tuberculosis in HIV
  positive individuals with a positive tuberculin
  skin test.
• The choice of regimen will depend on factors such
  as cost, adverse effects, adherence and drug
  resistance. Future studies should assess these
  aspects.
• In addition, trials evaluating the long-term
  effects of anti-tuberculosis chemoprophylaxis and
  the influence of level of immunocompromise on
  effectiveness are needed.

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Meta-analysis

• Similar to systematic review
• Statistically assesses aggregated data from two
  or more studies to increase sample size

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Guideline

• Ideally based on a systemic review
• Focuses on practice implications of the existing
  evidence
• Informed by expert opinion when evidence is
  limited
• Usually consensus of multiple experts
• Usually vetted by an organization

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• The Guide to Community Preventive Services
• Evaluating and making recommendations on
  population-based and public health interventions 
  
• Reviews
• Evidence on effectiveness
• Applicability of findings to diverse populations
• Intervention's other effects
• Economic impact
• Barriers to implementation of interventions

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• The Guide to Community Preventive Services
• The steps for generating recommendations
• Searching for and retrieving evidence on
  effectiveness
• Assessing the quality of and summarizing the
  body of evidence
• Translating the evidence into recommendations
• Considering information on evidence other than
  effectiveness
• Identifying and summarizing research gaps.

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• CDC Recommends The Prevention Guidelines System
• Over 400 documents
• Up-to-date guidance on many public health issues
• Full text or links
• Most published in MMWR
• Sophisticated search engine
• Limited indexing within documents

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Comprehensive Knowledge Bases

• Full coverage of important and useful knowledge
  in one or more domains
• May focus on one or more types of knowledge
  within a domain (e.g. , pathophysiology,
  diagnosis, treatment)
• Fills in gaps in evidence with expert opinion
• Key strength Provides answers to most/all
  questions asked of it by users

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Comprehensive Knowledge Bases

• Formats
• Hardcopies of Textbooks
• Electronic Books (Web or CDROM)
• Direct translation of hardcopy
• Original electronic texts
• Collections with searching across many items
• Databases
• Full text journals
• Textbooks
• Other content

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Comprehensive Knowledge Bases

• Electronic Books
• Direct Translation of Hardcopy

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Comprehensive Knowledge Bases

• Collections With Searching Across Many Items

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Comprehensive Knowledge Bases

• Original Electronic Textbooks
• Original content prepared and organized to
  facilitate rapid finds of specific information
• May include other databases or texts
• Sophisticated indexing displays and search
  engines
• Cross-referenced links within/between chapters
• External links to article abstracts of
  references, etc.
• Online, CDROM, PDA
• ACP Pier Online, eMedicine, Harrison's Online,
  Praxis MD, Sci. Am. Med., UpToDate

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UpToDate Comp. Knowledge Base Example

• Topics
• Adult Primary Care, Cardiology, Drug
  Information Endocrinology, Family Practice,
  Gastroenterology, Gynecology, Hematology,
  Hepatology, Infectious Diseases, Nephrology,
  Obstetrics, Oncology, Pulmonology, Rheumatology,
  Women's Health
• In Development
• Allergy/Immunology, Neurology, Pediatrics

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UpToDate Comp. Knowledge Base Example

• Initial cards created by consulting staff of
  gt7000
• content experts
• In some cases review by practitioners
• Extensive editing for consistency by in-house
  staff of
• physicians and editors
• Monthly review of 300 key journals by in-house
  staff
• Content experts receive any important new
  studies and
• must update their card/s
• Authors/editors encouraged to use evidence-based
• methodologies and cite high quality references
  but
• no specific evidence criteria

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UpToDate
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Bulletins, News Reports, Program Reports

• Information often hot off the presses
• Disseminated by Email as individual or collected
  items
• Often Selected, organized and edited
• May be collected on websites

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Bulletins, News Reports, Program Reports
Examples

• TB-related News and Journal Items Weekly Update
• CDC HIV/STD/TB Prevention News Update
• Epi-X reports of outbreaks
• Pro-Med Mail reports of outbreaks

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Bulletins, News Reports, Program Reports
Strengths and Weaknesses

• Timely information, rapidly disseminated
• Multiple sources
• Limited structure, organization, and indexing
• May be provided in large amounts with limited or
  no means to locate relevant information (User
  must browse)

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Bulletins, News Reports, Program Reports Options

• Service to filter, sort, organize and index
  content in emails and on websites to improve
  efficiency of access to relevant information

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