Archive for the ‘Evidence-Based Medicine’ Category


UpToDate, Algorithms and NICE Standards

In Evidence-Based Medicine on July 7, 2011 by africker Tagged: , , ,

An interesting article in Forbes (NHS readers be aware – IE6 hates Forbes) describing UpToDate as “Medicine’s Killer App”.  It identifies some of the reasons that clinicians are so fond of what is essentially a textbook and adds an interesting perspective on some of the previous discussion around this product.

The UpToDate article is one of a series of four with the most interesting article for me being about Standards and practice.  This is well worth a read for considering how guidance may and may not be adopted and when considering the Quality standards under development at NICE.



Number Needed to Post and

In Eresources,Evidence-Based Medicine on March 30, 2011 by africker Tagged: ,

Terrible times at (the) Health Informaticist with no postings from any of us for more than a few months.  I wonder if there is a NNP Number Need to Post – how many authors do we need to get a regular blog post out?

I am going to try and gently get back into the habit. To that end…


A site I had not met before with an excellent clear presentation of Number Needed to Treat calculations.  See the strength of the evidence for an intervention and read on for more details of this evidence.   You can read more about it in this announcement from one of the creators.


Should we teach evidence based medicine or information management?

In Evidence-Based Medicine,How to work better on November 5, 2010 by Hanna Tagged: ,

So asks an article in Clinical Orthopaedics and Related Research this month. Evidence Based Medicine seeks to encourage the appraisal of the best evidence to answer clinical questions but this is not always practical in clinical practice: who has time to do a systematic review at the bedside?

The authors of the paper say that in order to triumph opinion and established methods in orthopaedic surgery clinicians need to be able to move beyond critical appraisal and know what sorts of information to use. The article distinguishes between ‘foraging’ and ‘hunting’ tools: ‘foraging’ tools are current awareness tools that alert a clinician to new resources in their field.

However, information obtained in this way rarely results in the clinician’s learning more than simply that the actual information exists (life would be so much easier if we could read something once, reflect on it, and thenremember it flawlessly when it is needed). Thus, a hunting tool is needed to retrieve relevant and valid information quickly when it is required in the care of patients. (page 2335-6)

These are clinical decision making aids and they summarise actions whilst including evidence quality gradings and take into account patient outcomes. This of course is not revolutionary, just interesting to read from a clinical point of view what library services are useful for and how to differentiate them and sell them in the language used by clinicians. Importantly the articles says that not all clinicians need to be fully competent in all 5 levels of EBM knowledge and practice (developing a quesiont, finding the evidence, evaluating the evidence, applying the evidence and reviewing ongoing practice) but in a competency based model of the 3 stages of information management they have different needs at different stages in their career or depending on their role. The information management framework says that they should at level 1 manage information at the point of care, at level 2 select the appropriate hunting tool and by level 3 they should be making patient-centered (and interestingly not evidence-centered) decisions. Perhaps it could be termed moving from the academic view of EBM to a more pragmatic applied view.

Orthopaedic surgeons work in a world in which access to medical information can provide rapid answers to queries. Taking that information access a step further would be to have access to high quality information that gives answers based upon EBM, that is relevant to the patient, has been analyzed and validated by EBM experts and is now ready to use. Information management is the engineering science that connects the surgeon to the high quality information when and where it’s needed. Working backward toward our orthopaedists in training, learning to apply information management to patient-centered care requires a shift. That shift is away from wrestling with the 5 steps of EBM and moving to the appropriate level of IM. (page 2638)


Cancer drug fund and public engagement

In Evidence-Based Medicine,Uncategorized on August 8, 2010 by Hanna Tagged: ,

The Lancet has a brilliant editorial arguing why the cancer drug fund (set up by the last government in fact but launched early by this one) is intellectually bankrupt. If NICE looks at clinical and cost effectiveness surely a special fund that gives out drugs to patients who have exhausted existing lines of treatment is a kick in the teeth for evidence based medicine? And what makes cancer patients special? Mike Richards’ report ‘Extent and causes of international variations in drug usage’ was used to back up the claim that the UK is slow to adopt new cancer drugs. Which indeed may be the case but the report did not examine whether the drugs being used were efficacious. There are a raft of interesting reasons contained in the report about why uptake of drugs varies and not just in cancer. So clinicians may be more averse to toxicity (or related to this can empathise with patients perhaps and recognise side effects may put people off treatment), clinicians may favour non-pharmacological approaches or else other countries such as the US use more new drugs because of supplier induced demand and incentives to prescribe.

And this is closely linked to what patients want and expect from a healthcare system. The new government asked people what they wanted from the NHS and also how to save money, it would be good if these were explicitly linked. For now patient choice seems to reign: thus homeopathy is to stay in the name of patient choice.


Clinical queries & custom filters in PubMed

In Evidence-Based Medicine,How to work better,Web 2.0 & all that,Website reviews on July 7, 2010 by Alan Lovell Tagged: , , , , , , ,

PubMed has a new clinical queries page, apparently. To be honest I used the old one so infrequently that it could have changed six months ago and I never would have noticed. I tend to use PubMed for quick and not so dirty searches of the literature but if I’m doing a “real search” I use Ovid because of its slight value-add functionality plus it has our company’s access to Embase. Perhaps because of this access to Ovid I’ve never really paid all that much attention to the development of PubMed which, particularly over the last six months or so, seems to be whizzing ahead.

Anyway, the clinical queries page is quite fun. You put in your term and get results for “clinical study categories”, “systematic reviews” (not really so much “systematic reviews”, more “aggregate research” or “tertiary research” or similar), and “medical genetics”; you can then click “see all” for, well, seeing all, and there are drop down menus for whether you want therapy or etiology etc, and broad or narrow filters. It’s easiest just to play with it. I like the fact that at the bottom of each list if you click the word “filter” it will show you the actual search string being used to filter your results (for therapy or etiology, broad or narrow etc) and the sensitivity/specificity scores of  said filters (precision would be helpful too) along with the reference to the original paper in which the filters were based. All nice and transparent, and helpful if you wish to translate e.g. the prognosis filter to use in another database.

Of course though many of us want to add our own favourite filters. I always had a rough idea you could do this but had never bothered to really look into it, but it’s an absolute breeze. Fortunately I don’t have to describe how to add your own filters as Laika has already done such a good job of it (with screenshots and everything), and you can now add up to 15 of your own favourite search strings. Not sure what to add? Your friends at CRD/InterTASC will help you out. Once you get started you’ll  be having such a whale of a time that you’ll be looking for excuses to do quick and, as mentioned before, not so very dirty searches in PubMed for all and sundry – dragging people in from the corridor – that sort of stuff. I’m sure you’ve been doing this for years, but it’s all new to me.

I’m really beginning to like PubMed. A big thank you to the US taxpayer.


New interfaces

In Evidence-Based Medicine,Information industry on April 15, 2010 by Hanna Tagged: , ,

 Jumps out from Cochrane Collaboration page now. Seems to be that you can’t log-in unless you go and try retrieving your results hmm.

OvidSP has been urging me to try their new interface.

It has a liking for small boxes. And looks quite smart with your saved searches in My Workspace which is now more prominent:

Anyone tried it for an actual search? Only other thing I noticed was it has a multi-field search but it may have had this in an earlier version…what else would people improve? I’m generally quite a big fan of Ovid and find it very user friendly. Worst database I have to use is HEED eek


Patient Safety – agencies of note

In Evidence-Based Medicine on March 26, 2010 by africker Tagged: ,

Recently pulled together details of a range of agencies involved in Patient Safety work.  Present here for peoples interest.  The patient safety agenda is another place where information professionals can definitely provide valuable support.

National Patient Safety Agency 

They say: We lead and contribute to improved, safe patient care by informing, supporting and influencing organisations and people working in the health sector.

 Products include:  Patient Safety Alerts, “Seven Steps to Patient Safety”, guidance on best practice and toolkits. 

 Sample project:  Matching Michigan

This is a patient safety project based on a model developed in the United States which, over 18 months, saved around 1,500 patient lives.  It took place at ICUs in Michigan and introduced measures that reduced central venous catheter (CVC) associated bloodstream infections.

 Patient Safety First Campaign

They say: Led by the service for the service, Patient Safety First has at its heart a vision of an NHS with no avoidable death and no avoidable harm.

Products include:  Generating involvement, interventions, implementation support tools, training / events

Sample project: High Risk Meds

This intervention programme addresses the four medicines responsible for the most incidents of severe harm (based on NPSA data).  Materials outline how to implement 6 core evidence based interventions and a further 9 additional measures. 

Linked bodies in other UK Home Nations

The Health Foundation

They say: The Health Foundation is an independent, charitable foundation working as a catalyst to improve the quality of healthcare in the UK and beyond.

We identify evidence about issues and solutions through research, commission improvement programmes to test ideas and build skills, promote our learning to policy makers and people in healthcare, and develop people to lead quality into the future. 

Products include:  Leadership development, patient safety programmes, comparative studies, clinician engagement

Sample project: Safer Clinical Systems

The programme aims to develop a set of strategies to improve patient safety building on those developed through the Safer Patients Initiative and other patient safety programmes. By testing and measuring their impact we will seek to fill the current gap in the evidence base.

We’ll develop a set of standard shared measures to demonstrate impact against. We’ll then share this knowledge and learning with the wider NHS.  Currently at proof of concept stage.

NHS Institute for Innovation and Improvement

They say : The NHS Institute for Innovation and Improvement supports the NHS to transform healthcare for patients and the public by rapidly developing and spreading new ways of working, new technology and world class leadership.

Products include : Productive programmes, Leading improvement training, trigger tools, huam factors work.

Sample project: BaSIS: Building Safety Improvement Skills

BaSIS is a package of interventions designed to enable junior doctors to become a force for safe practice by:

  • Giving them the skills they need to be safe
  • Empowering them to make improvements within their Trust

 WHO Patient Safety 

They say: The programme, WHO Patient Safety, aims to coordinate, disseminate and accelerate improvements in patient safety worldwide. It also provides a vehicle for international collaboration and action between WHO Member States, WHO’s Secretariat, technical experts, and consumers, as well as professionals and industry groups. Each year, WHO Patient Safety delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world.

Products include:  Research, Learning from error, patient safety curriculum for medical students,  5 moments for hand hygiene, patient safety checklists.

Sample project: Surgical Safety Checklist

The WHO Safe Surgery Saves Lives Checklist was created by an international group of experts gathered by the WHO with the goal of improving the safety of patients undergoing surgical procedures around the globe. Input from anesthesiologists, operating theatre nurses, surgeons, patients and other professionals was used in the development of this tool. Both small and large scale clinical testing of the checklist has been performed culminating in a multi-site pilot study with results published in the New England Journal of Medicine in January 2009

In sites that ranged from small district hospitals to large medical centers in diverse geographical settings, the use of a 19-item checklist was demonstrated to reduce the complications and mortality associated with a variety of surgical procedures by greater than 30 percent. The checklist has been designed to be simple to use and applicable in many settings. It is currently in active use in operating rooms around the world.

See alsoWHO Collaborating Centre for Patient Safety Solutions

Department of Health – Patient Safety

They say:  Ensuring the safety of everyone who comes into contact with health services is one of the most important challenges facing health care today.

Products include:  Good range of background documentation, clinical governance, antibiotic resistance, health care standards

Sample ProjectCleanyourhands

The Cleanyourhands campaign consists of posters, raising awareness guidance, promotion of the right hand hygiene for the right condition.

From April 2008, the campaign has been rolled out to NHS primary care, mental health, ambulance and care trusts in England and the one remaining trust not included in Wales (the ambulance service). Over 90% of eligible organisations have signed up for the campaign so far.

Independent evaluation of the campaign has concluded that it has been successful in changing the hand hygiene behaviour of healthcare staff in acute trusts. There has been a significant increase in the amount of alcohol handrub and soap being used in the NHS since the introduction of the campaign and the campaign is still considered a priority in approximately 80% of trusts.  Intensive auditing has demonstrated significant improvements in hand hygiene by clinical staff in hospitals.

Patient Safety Board

They say: Patient safety is an issue which concerns all those who care for patients and lies at the heart of medical practice. All surgeons have a primary responsibility to participate in established procedures and to develop new measures to improve patient safety: the Royal College of Surgeons of Edinburgh Patient Safety Committee is committed to improving standards through education and training and by supporting research into human factors which may prevent or mitigate patient harm.

Products include: Safer operative surgery, Non-Technical Skills (NOTSS), updates / publications

Sample Project:  NOTTS Masterclass

NOTSS is a behavioural marker system for surgeons. It allows consultant (attending) surgeons to give feedback to colleagues and trainees on non-technical aspects of performance such as situation awareness, decision making, teamwork, and leadership. It was designed to be used in the intraoperative environment (i.e. in the operating theatre) to guide observation, rating and feedback during clinical encounters.

Institute for Healthcare Improvement

They say : The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world.  Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.

Products Include:  Improvement Map, campaigns (eg 5 Million Lives), Open School (patient safety competencies)

Sample projectSafer Patients Network

Working with the Health Foundation.  Will sustain and strengthen the impact of the Safer Patients Initiative. Create opportunities to test and develop new approaches to patient safety – others within the network and the wider system can then take these forward. These sites will then offer coaching, mentoring and support in improving patient safety to the wider health system

Agency for Healthcare Research and Quality (US Dept Health & Human Services)

They say: The Agency for Healthcare Research and Quality’s (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ’s research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

Products include: National quality measures clearing house, patient safety tools, analysis of medical errors, quality indicators

Sample projectPatient Safety Network

Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings (“What’s New”), and a vast set of carefully annotated links to important research and other information on patient safety (“The Collection”). Supported by a robust patient safety taxonomy and web architecture, AHRQ PSNet provides powerful searching and browsing capability, as well as the ability for diverse users to customize the site around their interests (My PSNet).

Joint Commission

They say:  The Joint Commission is committed to improving health care safety. This commitment is inherent in its mission to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. At its heart, accreditation is a risk-reduction activity; compliance with standards is intended to reduce the risk of adverse outcomes.

Products include:  National patient safety goals, infection control, Speak up, universal protocol

Sample project:  “Do Not Use” list

A list of abbreviations that must not be used in patient notes due to potential for confusion.

Patient Safety Research Groups

 Various groups in UK Universities – non exhaustive list.

Imperial Centre for Patient Safety and Service Quality (CPSSQ)

Includes very useful database of patient safety projects

Lancaster Patient Safety Research Unit 

King’s Patient Safety & Service Quality Research

Patient Safety Research Group University of Aberdeen

Australian Commission on Safety & Quality in Healthcare

They say:  The Commission was established by the Australian, State and Territory Governments to develop a national strategic framework and associated work program that will guide its efforts in improving safety and quality across the health care system in Australia.

Products include:  Clinical handover, medication safety, information strategy, knowledge portal, patient identification

Sample project:  Recognising and Responding to Clinical Deterioration

The main initiatives in this program to support work at a national level include the development of:

  1. a nationally agreed consensus statement regarding the essential elements for recognising and responding to clinical deterioration.
  2. An implementation guide to support the consensus statement and provide information about how the elements within it can be put into practice for all patients across all acute settings.
  3. an evidence-based adult general observation chart that will incorporate features to support the identification of patients who are deteriorating, and prompt action to properly manage these patients.


‘Expert’ Opinion on ‘Current research’: mental fast food?

In Evidence-Based Medicine on March 19, 2010 by Danielle Tagged: , , , , ,

I work appraising references for inclusion in evidence summaries for a variety of health conditions. I often come across reviews with titles like ‘current research’. Or else I see studies with more benign or vague titles published in ‘Expert Opinion in _____’ [insert name of disease or branch of medicine in the blank] or ‘Current Opinion in _____’. I use the words current/expert/opinion as a red flashing light to indicate that a study is not a systematic review unless the abstract strongly indicates that indeed it is.

My feeling is that ‘current research’ CANNOT actually be searched, as so many abstracts claim. ‘Research papers’ can be searched, but searching only for current research is lazy and pointless. How many papers are churned out each year with this sort of scope? While I understand the current incentive (pun intended) to keep on churning, perhaps publishers (or somebody!) ought to raise the bar for what is publishable.

After all, didn’t the general public lose heart in the Dickensian serials and didn’t that lead to the lean, spare short story?

Putting the section heading ‘recent findings’ into a structured abstract may grab the eye, perhaps without cheapening the content of a study. I believe that perhaps it may be down to the branches of medicine to be choosy- some branches tend to market less in abstracts by declaring their study to be ‘non-randomised’ or ‘unblinded’. This is always a breath of fresh air.

As this is an opinion piece, I welcome your thoughts on whether ‘current research’ adds real value to your life or career.


The drugs don’t work

In Evidence-Based Medicine,Health industry on December 15, 2009 by Hanna Tagged: ,

The BMJ have a series of articles about neuraminidase inhibitors or Tamiflu and Relenza or panic-purchased anti-virals. For in at risk groups they reduce the duration of symptoms by between 0.5 and 2 days as opposed to between 0.5 and 1.5 days for healthy adults (not that much difference in my opinion). And yet this HTA assessment does distinguish between groups and says they are cost effective. NICE guidance recommended these drugs as options and ‘said that its recommendations about oseltamivir and zanamivir should not reduce efforts to give vaccination (also called the flu jab) to people for whom it is recommended in national guidelines’ so the government hand that feeds is not bitten.

Antidepressents have also come under fire although here it is less about political action before evidence and more the increasing effectiveness of the placebo. Recently the UK Government’s Science and Technology committee evidence check on homeopathy discussed the placebo effect and the ethics of giving placebo as a medicine…


NHS Evidence; Google without the good bits

In Evidence-Based Medicine,search engines,Web 2.0 & all that,Website reviews on September 24, 2009 by Alan Lovell Tagged: , , , , , , , , ,

Our other Alan wrote a piece a couple of posts ago on, amongst other things, this article in the Nursing Times. Basically it’s a press release for NICE, written by an implementation advisor for said large, powerful organisation. It describes how NHS Evidence will be so very useful for nurses, and I suppose it could be argued that it’s useful because the odd nurse (not literally you understand) may be flicking through the magazine, scan the article, and go and try out a bit of evidence hunting themselves. Surely a happy outcome.

But I fear that our odd nurse will only try out NHS Evidence once, maybe even twice, but probably not a third time. Why? Well, according to an issue of the Eyes on Evidence Newsletter (more PR from NICE) the top five most frequently used search terms were 1) asthma; 2) prostate AND cancer; 3) evidence; 4) flu OR influenza; 5) breastfeeding, so we get an idea of the level of sophistication behind most searches. Let’s try the top one, asthma. 5026 hits, including 516 guidelines and 1627 drug information pieces. You get the general idea. The first ‘guideline’ is  “Guidelines for the prevention, identification and management of occupational asthma: evidence review and recommendations”, a pretty hardcore 88 page PDF of an evidence review, complete with evidence tables, from the British Occupational Health Research Foundation. Not at all helpful, I would’ve thought, to our odd yet eager nurse. If s/he wanted a good review of what to with someone with asthma surely they’d just go to an evidence synthesis product, such as Clinical Evidence, CKS, Dynamed or the Map of Medicine.

The problem is that NHS Evidence’s obsession with Google means that their search engine suffers exactly the same problem as Google (too many hits) but does not have the same saving grace (that the one you really want is at the top). Plus, and this is still really the crux of my problem, I still don’t have a clue who NHS Evidence is meant to be for – neither, I think, do the people behind NHS Evidence. “All things to all people” often ends up as nothing to no-one.