Evidence-based risk communication: a systematic review.

BACKGROUND: Effective communication of risks and benefits to patients is critical for shared decision making. PURPOSE: To review the comparative effectiveness of methods of communicating probabilistic information to patients that maximize their cognitive and behavioral outcomes. DATA SOURCES: PubMed (1966 to March 2014) and CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials (1966 to December 2011) using several keywords and structured terms. STUDY SELECTION: Prospective or cross-sectional studies that recruited patients or healthy volunteers and compared any method of communicating probabilistic information with another method. DATA EXTRACTION: Two independent reviewers extracted study characteristics and assessed risk of bias. DATA SYNTHESIS: Eighty-four articles, representing 91 unique studies, evaluated various methods of numerical and visual risk display across several risk scenarios and with diverse outcome measures. Studies showed that visual aids (icon arrays and bar graphs) improved patients' understanding and satisfaction. Presentations including absolute risk reductions were better than those including relative risk reductions for maximizing accuracy and seemed less likely than presentations with relative risk reductions to influence decisions to accept therapy. The presentation of numbers needed to treat reduced understanding. Comparative effects of presentations of frequencies (such as 1 in 5) versus event rates (percentages, such as 20%) were inconclusive. LIMITATION: Most studies were small and highly variable in terms of setting, context, and methods of administering interventions. CONCLUSION: Visual aids and absolute risk formats can improve patients' understanding of probabilistic information, whereas numbers needed to treat can lessen their understanding. Due to study heterogeneity, the superiority of any single method for conveying probabilistic information is not established, but there are several good options to help clinicians communicate with patients. PRIMARY FUNDING SOURCE: None.

Disseminating context-specific access to online knowledge resources within electronic health record systems.

Clinicians' patient care information needs are frequent and largely unmet. Online knowledge resources are available that can help clinicians meet these information needs. Yet, significant barriers limit the use of these resources within the clinical workflow. Infobuttons are clinical decision support tools that use the clinical context (e.g., institution, user, patient) within electronic health record (EHR) systems to anticipate clinicians' questions and provide automated links to relevant information in knowledge resources. This paper describes OpenInfobutton (www.openinfobutton.org): a standards-based, open source Web service that was designed to disseminate infobutton capabilities in multiple EHR systems and healthcare organizations. OpenInfobutton has been successfully integrated with 38 knowledge resources at 5 large healthcare organizations in the United States. We describe the OpenInfobutton architecture, knowledge resource integration, and experiences at five large healthcare organizations.

Journal club for faculty or residents: a model for lifelong learning and maintenance of certification.

The journal club offers a model for lifelong learning and maintenance of certification (MOC) for residents and faculty staff. First, it sharpens participants' critical appraisal skills by providing a space to discuss relevant medical literature. Second, it motivates participants to seek new medical literature on their own using technology. Our model sets forth a four-year journal club curriculum that could be used as one continuous curriculum or in bits and pieces. In the first year, the focus is teaching residents how to read an article. The second year focuses on what is of interests to the reader. The third year applies the resident's appraisal skills to assigned articles to test whether they can determine which have reliable and valid findings and which are flawed. In the fourth year residents are asked to distinguish whether articles are well researched and referenced. Our model also motivates participants to read articles in faculty journal clubs throughout their career. In most academic settings category 1 continuing medical education (CME) credits can be awarded so journal club can have the added benefit of satisfying maintenance of certification CME credits. From journal club both residents and faculty can learn what is new and learn to apply this new information in their practice. Finally, because technology creates an overabundance of relevant medical literature, participants using our model can develop strong critical appraisal skills and methods for organizing the information they find that make this information readily available for future use and retrieval.

PubMed instruction for medical students: searching for a better way.

In 2007, Duke University Medical Center Library instituted an interactive, online PubMed tutorial and quiz for medical students to replace an in-person lecture. This article describes the events leading to this educational paradigm shift and how the tutorial was implemented. Important concerns in the switch to an online approach to PubMed training were student satisfaction and the extent to which searching skills would improve. To determine the effectiveness of the online model, two years of student quizzes and evaluations were examined. Results indicate that students benefit from and appreciate the interactive tutorial.

How to perform a literature search.

PURPOSE: Evidence based clinical practice seeks to integrate the current best evidence from clinical research with physician clinical expertise and patient individual preferences. We outline a stepwise approach to an effective and efficient search of electronic databases and introduce the reader to resources most relevant to the practicing urologist. MATERIALS AND METHODS: The need for additional research evidence is introduced in the context of a urological clinical scenario. This information need is translated into a focused clinical question using the PICOT (population, intervention, comparison, outcome and type of study) format. This PICOT format provides key words for a literature search of pre-appraised evidence and original research studies that address the clinical scenario. RESULTS: Available online resources can be broadly categorized into databases that focus on primary research studies, ie randomized, controlled trials, cohort studies, case-control or case series, such as MEDLINE and those that focus on secondary research that provides synthesis or synopsis of primary studies. Examples of such sources of pre-appraised evidence that are becoming increasingly relevant to urologists include BMJ Clinical Evidence, ACP Journal Club, The Cochrane Library and the National Guideline Clearinghouse. CONCLUSIONS: The ability to search the medical literature in a time efficient manner represents an important part of an evidence based practice that is relevant to all urologists. The use of electronic databases of pre-appraised evidence can greatly expedite the search for high quality evidence, which is then integrated with urologist clinical skills and patient individual circumstances.

Utilization of the PICO framework to improve searching PubMed for clinical questions.

BACKGROUND: Supporting 21st century health care and the practice of evidence-based medicine (EBM) requires ubiquitous access to clinical information and to knowledge-based resources to answer clinical questions. Many questions go unanswered, however, due to lack of skills in formulating questions, crafting effective search strategies, and accessing databases to identify best levels of evidence. METHODS: This randomized trial was designed as a pilot study to measure the relevancy of search results using three different interfaces for the PubMed search system. Two of the search interfaces utilized a specific framework called PICO, which was designed to focus clinical questions and to prompt for publication type or type of question asked. The third interface was the standard PubMed interface readily available on the Web. Study subjects were recruited from interns and residents on an inpatient general medicine rotation at an academic medical center in the US. Thirty-one subjects were randomized to one of the three interfaces, given 3 clinical questions, and asked to search PubMed for a set of relevant articles that would provide an answer for each question. The success of the search results was determined by a precision score, which compared the number of relevant or gold standard articles retrieved in a result set to the total number of articles retrieved in that set. RESULTS: Participants using the PICO templates (Protocol A or Protocol B) had higher precision scores for each question than the participants who used Protocol C, the standard PubMed Web interface. (Question 1: A = 35%, B = 28%, C = 20%; Question 2: A = 5%, B = 6%, C = 4%; Question 3: A = 1%, B = 0%, C = 0%) 95% confidence intervals were calculated for the precision for each question using a lower boundary of zero. However, the 95% confidence limits were overlapping, suggesting no statistical difference between the groups. CONCLUSION: Due to the small number of searches for each arm, this pilot study could not demonstrate a statistically significant difference between the search protocols. However there was a trend towards higher precision that needs to be investigated in a larger study to determine if PICO can improve the relevancy of search results.

Randomized trial for answers to clinical questions: evaluating a pre-appraised versus a MEDLINE search protocol.

OBJECTIVE: The paper compares the speed, validity, and applicability of two different protocols for searching the primary medical literature. DESIGN: A randomized trial involving medicine residents was performed. SETTING: An inpatient general medicine rotation was used. PARTICIPANTS: Thirty-two internal medicine residents were block randomized into four groups of eight. MAIN OUTCOME MEASURES: Success rate of each search protocol was measured by perceived search time, number of questions answered, and proportion of articles that were applicable and valid. RESULTS: Residents randomized to the MEDLINE-first (protocol A) group searched 120 questions, and residents randomized to the MEDLINE-last (protocol B) searched 133 questions. In protocol A, 104 answers (86.7%) and, in protocol B, 117 answers (88%) were found to clinical questions. In protocol A, residents reported that 26 (25.2%) of the answers were obtained quickly or rated as "fast" (<5 minutes) as opposed to 55 (51.9%) in protocol B, (P = 0.0004). A subset of questions and articles (n = 79) were reviewed by faculty who found that both protocols identified similar numbers of answer articles that addressed the questions and were felt to be valid using critical appraisal criteria. CONCLUSION: For resident-generated clinical questions, both protocols produced a similarly high percentage of applicable and valid articles. The MEDLINE-last search protocol was perceived to be faster. However, in the MEDLINE-last protocol, a significant portion of questions (23%) still required searching MEDLINE to find an answer.

askMEDLINE: a report on a year-long experience.

askMEDLINE is a free-text, natural language search tool for MEDLINE/PubMed. Since its introduction a year ago, more than 15,000 queries have been received, mostly in the form of questions or complex phrases. Questions on therapy were the most searched. We review our yearlong experience, an updated evaluation using 'gold standard' questions selected by EBM experts and discuss added features.

A Web-based compendium of clinical questions and medical evidence to educate internal medicine residents.

The authors designed an electronic database of clinical questions (CQs) and medical evidence and implemented it in 2001-02 at Duke University Medical Center and the Veterans Administration Medical Center in Durham, North Carolina. This Web-based data collection system is called the Critical Appraisal Resource (CAR) and is still in operation. This report is of ten months of the system's operation. During their medicine ward rotations, residents entered CQs into the CAR; they also entered Medline reference links and validated article summaries. Residents' utilization of the CAR database, Medline, and other electronic resources was prospectively measured. In addition, residents were prospectively surveyed regarding the impact of each question and associated reference on medical decision making for individual patients. Over ten months, residents entered 625 patient-based CQs into the CAR and were able to obtain useful information from the medical literature on 82% of the CQs they searched. The two most prevalent CQ types were therapy and diagnosis questions (53% and 22%). Sixty percent of the therapy articles considered useful were reports of randomized controlled trials. Residents obtained 77% of their useful data from Medline. They reported that obtaining useful data altered patient management 47% of the time. Residents used the CAR as a resource, searching the database for information 1,035 times over the study period. In summary, the use of an evidence-based critical appraisal resource led residents to engage the medical literature on behalf of their patients and influenced approximately half of their patient-care decisions. Residents benefited from questions previously searched by other residents, allowing them to address a wider spectrum of CQs during ward rotations.

Evidence-based medicine in anesthesiology.

PURPOSE OF REVIEW: The principles of evidence-based medicine are now being applied in anesthesiology and intensive care medicine. The purpose of this review is to acquaint practitioners with the fundamentals of evidence-based medicine and to provide examples of how these principles can be incorporated into clinicians' practice. RECENT FINDINGS: Outcomes research utilizing evidence-based approaches are manifest in several areas of anesthesiology and intensive care medicine. Several examples are cited from various sub-specialty areas, including pediatric, obstetric, and general anesthesia, as well as intensive care medicine. SUMMARY: Evidence-based medicine is the term used to describe a practice paradigm that emphasizes the use of the best evidence available in the medical literature in making treatment decisions about the care of patients. Evidence-based approaches to care integrate individual expertise with data from externally conducted systematic research. Although evidence-based medicine has its origins in the 'treating' and 'diagnosing' specialty of internal medicine, its tenets are applicable to 'non-therapeutic' specialties such as anesthesiology and intensive care medicine. This review illustrates how evidence-based principles can be incorporated into the practice of perioperative medicine.