Answering Clinical Questions at the Point of Patient Care

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You may request permission from the Department of Family Medicine, East Tennessee State University, Division of Research, fax 1+ (423) 439-5795 or email tate@etsu.edu. Marcus Welby Meets Perry Mason: Translating Evidence into Practice Generating Evidence from Practice East Tennessee State University May 28, 2003 Bernard Ewigman, MD MSPH Professor & Chairman Department of Family Medicine University of Chicago Revised 5/28/03 Ewigman, Bernard. ―Marcus Welby Meets Perry Mason: Translating Evidence into Practice Generating Evidence from Practice.‖ [Online] 30 May 2003. Experience Meets Evidence: Key Problems  Experience is essential but not sufficient in modern medical practice  The best available evidence is frequently not used for clinical decision making in primary care practice  Much of the available evidence is either not relevant to patients presenting to the primary care clinician, lacks validity or is lacking altogether In My Experience….. ♦ ♦ Does lithium cause edema? – No (correct) Is penicillin the antibiotic of choice for a tooth abscess? – Yes (not correct) Irritable bowel syndrome--What instructions should I give? – What should I say...- (is what I say effective? useful? correct?) ♦ Experience is great, but…..  Some doctors make the same mistake for twenty years and call it experience.  Experience is what you rely on when you can’t find the evidence at the time you need it Using Evidence in Practice: Translation of Research into Practice Research knowledge Clinical practice How Well Do We Translate Research into Practice? ♦ Medical texts were still failing to recommend thrombolytic therapy for MI six years following the first meta-analysis showing effectiveness. (Antman, et.al., JAMA, 1992) Publication to Implementation Antman EM, Lau J, Kupelnick B, Mosteller F, and Chalmers TC. JAMA, 268:240-8, 1992 ―Errors‖ My Family Doctor Made  Ephedrine in shock  Corticosteroids for ambulatory pneumonia  Routine tonsillectomy  Routine episiotomy  General anesthesia for vaginal delivery  Recommended bottle feeding ―Errors‖ I Was Taught in Medical School  Routine episiotomy  Once a c-section, always a c-section  50% of lympadenopathy = cancer  Vaginal breech delivery is safe  Patching for corneal abrasion  Flecainide for ventricular ectopy Evidence and the academic approach is great, but…..  Instructors can take a point and explain it  Assistant professors can take a point and turn it into a lecture  Associate professors can take a point and turn it into a course  Professors can take a point and turn it into a career  Chairs have forgotten the point Experience Meets Evidence: Key Solutions  Clinicians need immediate access to the best evidence available at the point of patient care  All primary care clinicians must have the skills to integrate useful evidence with clinical judgment  Much of the evidence needed can only be generated from research in the primary care setting  Family Practice Inquiries Network: Translating Research into Practice, Generating Research from Practice The Family Practice Inquiries Network (FPIN) Our mission is to use information technology to:  Translate research into practice  Train all primary care clinicians as information masters  Generate original clinical research from practice What is The Family Practice Inquiries Network (FPIN)? ♦ A national consortium of academic and practicing family physicians, library scientists, informaticians, computer scientists and other clinicians dedicated to a common mission….… FPIN Background  Developed as one of seven objectives of the Center for Family Medicine Science in the Dept of Family and Community Medicine at the University of Missouri-Columbia  Now a national self-governing not for profit consortium More About the FPIN Mission ...to use information technology ♦ to translate research into practice by answering 80 percent of clinicians questions with the best available knowledge within 60 seconds of the clinicians’ time at the point of patient care. Case #1 ♦ A sixty two year old woman presents to her family physician for an annual exam. Both her mother and her sister died from breast cancer and she is quite anxious about her risk for developing breast cancer. She has read about tamoxifen and wants to know if her physician will prescribe it for her. ♦ Clinical Question: Does tamoxifen prevent breast cancer? Does tamoxifen prevent breast cancer? Go to the full document. Tamoxifen prevents breast cancer in women older than 60 years and in younger women with equally high risk because of breast disease and reproductive and family history, but there is no current evidence for or against long-term survival or overall health benefits. (Grade A Evidence) A 49% reduction in 5-year incidence of invasive and noninvasive breast cancer but increased risk for endometrial cancer, pulmonary emboli, deep vein thrombosis, and cataracts. The long-term benefits and overall health effects of tamoxifen for primary prevention of breast cancer remain unclear; the ongoing International Breast Cancer Intervention Study trial is designed to address this question. Table: Events in 5 years in 1000 women with intact uteri Document Type: Evidence Summary From: Family Practice Inquiries Network Clinical Inquiries Citation: Meriwether RA. J Fam Pract 2001 Dec;50(12):1023 [PubMed] Case #2 ♦ A thirty-three year old woman presented as a new patient to a family physician after having been diagnosed with Hepatitis C (HCV) by another physician and told that nothing could be done. She has heard that treatment is available and wants another opinion. ♦ Clinical Question: What are the current treatment recommendations for HCV? What are the current treatment and monitoring recommendations for hepatitis C virus? Go to the full document. Patients diagnosed with HCV should have serum liver function tests and get a baseline HCV RNA level (viral load), since treatment decisions are affected by these laboratory values. Genotype testing is indicated for treatment decisions and prognosis. Therapy with interferon and ribavirin (dual therapy) has been shown in randomized placebo-controlled trials to lead to sustained viral response in 30% to 50% of patients compared with 6% to 21% with PEG-interferon alpha-2b (Viraferson PEG) therapy only. Genotype 1 should be treated with dual therapy for 48 weeks and all other types treated for 24 weeks. Evidence is lacking on the optimum monitoring approach for patients taking dual therapy; consensus recommendations are given in the Table. Recent evidence shows that treatment with PEG-interferon alpha-2b and ribavirin with weight-based dosing achieved an 82% sustained viral response. Dual therapy (Grade A Evidence) All other recommendations (Grade D Evidence) Monitoring patients on dual therapy Document Type: Evidence Summary From: Family Practice Inquiries Network Clinical Inquiries Citation: Kivlahan C;Chavey W. J Fam Pract 2001 Nov;50(11):928-9 [PubMed] Case #3 ♦ The mother of a seven year old boy brings him to the family doctor’s office with his seventh episode of strep throat. She thinks he needs his tonsils taken out; both she and her husband had to have their tonsils removed when they were children. ♦ Clinical Question: What are the indications for tonsillectomy? What are the indications for tonsillectomy in children? Go to the full document. Tonsillectomy with or without adenoidectomy is minimally effective when combined with tympanostomy tube placement in preventing recurrent otitis media in the 3 years following surgery. The risks of surgery must be weighed against potential benefit. (Grade B Evidence) The evidence supporting tonsillectomy for recurrence of sore throat is controversial. There is insufficient evidence to recommend other potential indications. (Grade C Evidence) Table: Indications for Tonsillectomy Document Type: Evidence Summary From: Family Practice Inquiries Network Clinical Inquiries Citation: Neill RA;Scoville C;Belden J. J Fam Pract 2002 Apr;51(4):314 [PubMed] Case #4 ♦ A seventeen year old boy had to be medically evacuated from the village in Kenya where he was volunteering for the summer, because of severe right flank pain. Sonogram of the gallbladder & all blood tests were normal, but a dilated renal calyx was noted, raising the question of a renal stone causing obstruction of the urether. ♦ Clinical Question: What is the test of choice to rule out renal stone? What is the best test to diagnose urinary tract stones? Go to the full document. Over the past 3 years, helical (or spiral) computerized tomography (CT) has proved the best method of testing for urinary tract stones. All reviewed studies published since mid-1998 found helical CT scan to be the safest and most accurate test. (Grade A Evidence) Table: A profile of diagnostic tests for urinary tract stones Document Type: Evidence Summary From: Family Practice Inquiries Network Clinical Inquiries Citation: Lindbloom EJ;Chang SI. J Fam Pract 2001 Aug;50(8):657-8 [PubMed] Generating Research Priorities: The FPIN Priority Research Questions Project  Identify important clinical questions asked by practicing family physicians  Answer them with the best available evidence;  Prioritize those questions lacking adequate evidence  Facilitate PBRNs in conducting studies to provide the needed evidence Clinical Question: Should screening mammography be recommended for elderly women? Clinical Question: When is endoscopy beneficial in the management of gastroesophageal reflux disease? Clinical Question: What is the best approach to the evaluation of fatigue? Clinical Question: What are effective treatments for chronic fatigue syndrome? See Nude Sunbathers on the Beach Translating Research into Practice FPIN Information Systems will: ....answer 80% of the practicing family physician’s questions at the ―point of care‖ within 60 seconds with the most useful answers currently available The FPIN Mission …using information technology to:  Translate research into practice  Teach information mastery  Generate research from practice What are Ideal Answers? Usefulness = Relevance x Validity Effort Translating Research into Practice  Integrate research evidence into ideal answers  Answer questions that address the actual questions of practicing family physicians  Provide immediate access to those answers  Integrate those answers into the documentation and processes of care (automated reminders, quality improvement, etc) Clinical Inquiries as Ideal Answers 1. Questions asked by practicing FPs 2. Questions to answer are selected by practicing FPs 3. Systematic search for evidence (FPIN Librarian protocol) 4. Evidence based answer 5. Summary of evidence Clinical Inquiries as Ideal Answers Authoritative recommendations Clinical perspective Designed for use on handheld computers Written, peer reviewed & edited primarily by FPs 10. Currently being published or will be published in Journal of Family Practice and American Family Physician 6. 7. 8. 9. Organizational Structure of FPIN  Not for profit mutual benefit corporation  Self governing—board of directors  Voluntary membership  Three membership categories: – Founding Members – Organizational Members – Practice Based Research Network Members Founding Memberships of FPIN ♦ Founding Membership – – – – $150,000 or 1.0 FTE physician effort annually Minimum five year commitment Representative on FPIN Board of Directors May earn credits toward membership through serving as an organizational leader, editor, author, teacher, researcher, etc. Current Founding Members – – – – – – – – University of Missouri-Columbia University of Colorado University of Chicago University of North Carolina State University of New York-Syracuse Michigan State University University of Washington University of Wisconsin Organizational Membership in FPIN -Pay a membership fee pro-rated by the number of users of the FPIN Portal -May earn up to 50% discount off membership by serving as an author, peer reviewer, editor or clinical commentator Current Organizational Members Lancaster FP Residency Mercy Medical Center Northeast Iowa FP Residency NH- Dartmouth St. Joseph Regional FP Residency San Jacinto FP Residency UT Southwestern Medical College of Wisconsin Christiana Care Louisiana State University Wayne State University Current Status of FPIN  Eight university family medicine departments are Founding Members—serve as the Board of Directors  Eleven university family medicine departments and family practice residency programs are Organizational Members  Consortium of Academic Health Sciences Libraries  New textbook on Information Mastery Current Status of FPIN  Developing four web based courses on Information Mastery  Publishing Clinical Inquiries in the Journal of Family Practice  Member benefits: Scholarship, portal, discounts, collegiality  Open to additional Founding and Organizational Members  Developing Practice Based Research Membership Current Status of FPIN Among the FPIN Membership: -300 authors, peer reviewers, clinical commentators -38 medical librarians -18 member curriculum development group -Eight assistant editors -Three associate editors -Two managing editors -One editor in chief Current Status of FPIN FPIN Full Time Employees: Tonya Wolff—Executive Director Joan Nashelsky—Librarian Coordinator and Managing Editor Cortni Cross---Business Manager Heather Stewert—Membership Coordinator Contracted Services: Lanit Consulting--Software/Technology Support Current Status of FPIN ♦ Publishing ―Clinical Inquiries‖ in Journal of Family Practice (80)  Will begin publishing in American Family Physician in 2003  Will begin FPIN handheld project in 2003  Contract with Missouri Telehealth Project – Building membership management, editorial management and information delivery systems as dynamic, interactive and integrated web based databases, handheld platforms and wireless connectivity. Current Status of FPIN  Plan to increase to 10 Clinical Inquiries in JFP per issue  Plan to partner with an IT company and create the ―e-pocrates‖ family practice—‖e-text‖ for the handheld platform  CME conferences organized around Clinical Inquiries  Supplements and yearbook of Updated Clinical Inquiries  Help Desk Answers Experience and Evidence  Clinical judgment requires both  ―Clinical Jazz‖ Slawson & Shaunessy, JFP  We have more experience than evidence in family practice Experience and Evidence  Clinical judgment requires both  ―Clinical Jazz‖ Slawson & Shaunessy, JFP  We use more experience than evidence in family practice