Farewell then NLH

The National Library for Health is officially part of NICE from Wednesday. They have published their last newsletter.

Celebrating 10 years of National Library for Health

 

Articles include:

 

·         The NHS Institute for Innovation and Improvement bid farewell to the National Library for Health

·         What Will Happen To The National Library for Health

·         NHS Evidence Update

·         Specialist Libraries: April Annual Evidence Updates

·         Map of Medicine Update: Over 360 Map Pathways now available on NHS Choices website

·         Clinical Knowledge Summaries

·         TDAG Conference 2009

·         New Copyright Licensing Agency (CLA) Licence for the NHS in England:  Q&A

·         KM Specialist Library Update

“Make sure you are Evidence-based” (and up to date)

It seems like Wiley-Blackwell are seriously into EBM. Not only do they publish the Cochrane Library, EBM Guidelines, Essential Evidence Plus (whatever these last two are), but they also do the Evidence-Based Medicine series. I just got a mail shot from them – “Make sure you are Evidence-Based”. They have quite a range of books in the series, some of which seem to be a series of pragmatic, systematic-ish reviews of interventions for a condition, while others take on a slightly more educational role – how to go about formulating your question, doing your search, appraising the results etc. There are plenty of sample chapters to read, so you know what you’re getting. Of course, though, they are expensive. Evidence-based Cardiology is over £100. And given that EBM by its nature goes out of date pretty quickly (or it might not, but the point is you won’t know until you look) is it really sensible to spend your £100+ on a 2002 book called Evidence-Based […] and really kid yourself that you are, actually, Evidence-Based? Being evidence based seven years ago is hardly evidence based in my (much cheaper) book. I wonder how many they sell, and to whom?

Eminence-based Medicine?

According to the NICE website, guideline producers should be accredited.

The draft ‘Process manual for accrediting producers of guidance and recommendations for practice: a guide for producers and stakeholders’ describes the process for accrediting producers of guidance and recommendations for practice. It provides details on the scope for accreditation and what types of guidance producers are accredited, the criteria used to perform the accreditation assessment, the main steps in the process for reaching an accreditation decision and the notification and publication process of an accreditation decision.

This draft is out for consultation until 1st May 2009 so you may wish to leave your comments before then.

I witnessed an interesting email exchange in which one person questioned whether applying the ‘seal of recognition’ to institutions rather than individual guidelines, as NHS Evidence will do, was a return to ’eminence-based medicine’ instead of evidence-based medicine.

I think the commentator has a point as, in my experience of guideline-producing organisations, guidelines vary widely based on who is working on them and their commitment to the project.  Staff turnover is a constant threat. Before all that the guideline has to be scoped. If the scope is too broad, then the workload can easily become immense, leading to extra pressure on staff. I will not remark on project management or management of any kind.

I have not yet read the consultation document, but I will, and when I do I will consider how the recommendations affect the people creating the guidelines, running the searches and writing the reviews.  At work, it was often said that a NICE-quality guideline is the equivalent of 15-25 systematic reviews, yet the entire process takes 18 months with no ‘wiggle room’ for sick leave or annual leave.

The commentator suggests that the new recommendations seem ‘rigorous if time-consuming’.  In my personal opinion, I was always amazed that only one research fellow was assigned to each guideline, given the workload. Perhaps the consultation contains guidelines for increased staffing as well?

Datamining for terrorists and do doctors hate science?

Is datamining analogous to diagnostic testing? Scanning for disease brings up issues of false positives and false negatives, positive and negative predictive value as well as somewhere along the line thinking about costs, both monetary and social. Here Ben Goldacre has opened up a debate which some have said on his comments page is not valid. I remember coming across some interesting sociological articles about evidence based medicine and whilst it is admirable to think that maybe someone in another field has looked at this before perhaps it is foolish to lose all critical faculties in awe of something new.

And do doctors hate science? Well some of them obviously but this is to misjudge the interface between patients and doctors and then the scientific establishment – it is one thing to write guidelines based on science for example and another to implement them I know from my own work. Other boggers have said journalism is misrepresenting the situation and/or is not optimistic enough about the future which includes personalised medicine.

An interesting article in Practice Nurse (27/02/2009, pp.47-52) explores the partnership working now being pushed in the clinical relationship, is it possible or even desirable to work in partnership with patients if their desires are seemingly at odds with those of the clinician, the local practice guidance or society? There are some interesting examples of decision aids that aim to help patients make choices about their individual risks and the Picker Institute is flagged as a body providing data on patient experiences of medicine (new to me).

Coming soon….Cochrane Overviews of Reviews

In Issue 1 2009 of the Cochrane Library, the release notes point to a new type of review, an “Overviews of Reviews”. The aim of such a review is to “primarily to overview multiple Cochrane intervention reviews addressing the effects of two or more potential interventions for a single condition or health problem. Cochrane Overviews highlight the Cochrane reviews that address these potential interventions and summarize their results for important outcomes.” So rather than assessing a single intervention, these “umbrella” reviews will instead look at a condition and include more interventions. At the moment there’s one protocol included for this type of review and I’m a little confused about the value of them, given the criteria for inclusion and the search methods.

Looking at the methods section for Interventions for neovascular age-related macular degeneration, it states that relevant Cochrane reviews will be included as well as “Non-Cochrane reviews of randomised controlled trials (RCTs) of interventions not currently the subject of a Cochrane“. Although Cochrane Reviews are seen as a gold standard, what if there’s a non-Cochrane systematic review out there on the same subject which eclipses the Cochrane review in terms of search date, potentially including additional studies not included in older Cochrane Reviews?

Additionally, the same issue arises from the following criteria “Where there is overlap between Cochrane and non-Cochrane reviews, we will compare and comment on the findings, however, the Cochrane review only will be included in the overview.” , again, potentially excluding newer studies only found in non-Cochrane reviews in a summary of the systematic review evidence on a particular condition.

The search sources for non-Cochrane systematic reviews are pretty straightforward and systematic, but there is a date limit. “We will restrict our searches to January 2006 onwards. This is because we feel that reviews published before that time are likely to be out of date.”

This seems rather contradictory as ALL Cochrane reviews will be included regardless of age. Of course, we know that Cochrane reviews are more likely to be updated compared with those published in non-Cochrane journals but a quick scan down the list of Cochrane reviews on asthma reveals one “Last assessed as up-to-date: 2 March 1999“. To get into even deeper nitpicking, there’s currently a Cochrane review on Radiotherapy for neovascular age-related macular degeneration which falls into the scope of this review of reviews protocol. This review on radiotherapy was published in 2004 with search dates around May 2004. With this criteria, this review would be included but as I understand it, no other non-Cochrane reviews would be included even if they were published in the four and a half years subsequently and possibly include studies not in the Cochrane review.

I’ll reserve my judgement until the review is published. The description in the release notes does state that “Overviews of Reviews have also been developed outside the Library and can be viewed in the Evidence-Based Child Health Journal: A Cochrane Review Journal at http://www.evidence-basedchildhealth.com.”.

I should add at this stage that I probably have a conflict of interest as my “day job” is to find and assess systematic reviews and RCTs on a variety of topics for a regularly updated, evidence-based resource. If Cochrane were to start publishing overviews of reviews it would possibly make my life a little easier, though judging by these methods, it might be easier to ignore them at the moment as we would include ANY relevant, robust systematic review regardless of source. Although the aim in the release notes clearly states that highlighting Cochrane reviews is the main objective, if so, why bother including non-Cochrane reviews at all?

Updated CRD guidance on producing reviews in healthcare

The Centre for Reviews and Dissemination have updated and published their guide to producting systematic reviews. As well as the core principles, the guidance also contains chapters on reviews of prognostic tests and diagnostic tests (an rediscovered interest of mine since a study day in York in December..), public health, economic evaluations and adverse effects. It’s available in electronic book format, a downloadable pdf, or you can purchase a hard copy.

Doctors can now pretend to be Sherlock Holmes

A fun (!?) little book on Evidence-Based Medicine, “Evidence-Based Medicine in Sherlock Holmes’ Footsteps” by Jorgen Nordenstrom. Flicking through the first few pages accessible in the “open book” functionality it looks like a fairly normal but readable (and refreshingly short) book on EBM (you know, formulating a question, doing a search, appraising the evidence and applying to practice), just with a few nice pics from Sherlock Holmes novels and a rather contrived example from The Hound of the Baskervilles. Sir Arthur Conan Doyle studied medicine, don’t you know. He also thought that doctors (would) make good murderers.

‘The Evidence Gap’ – examples of interventions despite proof

It is often assumed that evidence-based medicine is all about fabulous new treatments, efficacious but expensive – are they good enough to justify the price tag? But a lot of the work is often around treatments, technologies and interventions that are far less sexy – stuff that’s done all over the country every day, even though there may be little or no evidence base for it.

The New York Times has a series of articles called ‘The Evidence Gap‘ that explores, as they put it, medical treatments used despite scant proof they work and examining steps toward medicine based on evidence. It’s not dryly written, it’s journalism (for better or for worse), and it’s certainly not all just about the science and the medicine. Instead, there’s lots on the culture of medicine and it’s practicioners, it’s researchers, marketeers, administrators, the pharmaceutical companies and of course patients. They are long enough articles to really explore some issues, and worth printing out for an interesting, easy but informative read on the commute home. Dare I opine that you wouldn’t get such quality journalism in the London Times?

NHS Evidence; something for everyone, not (apparently)

In April 2009, NHS Evidence will apparently be launched. An evidence advisory committee has been set up and the service is intended to be a unified evidence base for everyone in the NHS who makes decisions about treatments or the use of resources. It will also be available for use by patients. According to NICE It will include: 1) a fast, comprehensive search function, 2) access to a resource collating information on new drugs for commissioners, 3) a home page users can personalise. Sounds very much like the National Library for Health (NLH), I thought. I then realised that it was one of Darzi’s big ideas and is planned to replace the NLH (which up until recently the NHS has been spending lots of money on). So, I looked at the briefing document to get some more idea of just how NHS Evidence will be different (and presumably better) than the NLH; it says that:

NHS Evidence will consolidate information from a wide range of sources in one central portal, with a common point of access. The service will provide easy access to information that has traditionally been difficult to find, or available only by searching a variety of different sources, such as drug approval status. Furthermore, information included in the portal will not be limited to research evidence – the service will also aim to provide users with access to tools (such as service models and local policies) that they can use to apply the evidence in their day-to day work.

NHS Evidence will apparently not generate new content, rather it will act as a point of access to information including coverage of:

1) Clinical Evidence, including guidelines, systematic reviews, other synthesised content and primary research and ongoing trials

2) Practical Support, including service guidance, tools and models, care pathways, indicators & metrics and improvement information, local examples and tools

3) Drug and Device Information, including prescribing and safety information, NICE technology appraisals, significant new drugs and devices, diagnostics and interventional procedures

4) Non-Clinical Information, including social care information (assured by SCIE), public health information – evidence and practical support

Well, it’s certainly not a miserly set of aspirations. One thing that worries me a bit is that the document says that “NHS Evidence will be designed to meet the needs of users from across the NHS, including (but not restricted to) clinicians, nurses, pharmacists and commissioners” (i.e. pretty much everyone) followed a couple of sentences later with the statement that “NHS Evidence has a clear scope and objective. It is important that the service does not seek to be ’everything to everyone”. Hmm.

Anyway, the briefing document, of course, does not mention libraries or librarians, apart from the fact that it’s replacing the NLH. And it’s going to be run by NICE. Does that mean that librarians have just lost all control of the NHS online information service? I don’t know – let’s see, it’ll be with us in five months or so.

Published today: Just in Time Library Service RCT

A bit more self (and colleague!) promotion–and it fits right in with all this talk of BlackBerries.  Jessie McGowan has newly published, and led on, a randomised controlled trial about a project to provide 88 clinicians with information in 20 minutes or less via their BlackBerries and a web portal.

“A randomized controlled trial (RCT) was conducted between October 2005 and April 2006. A total of 1,889 questions were sent to the service by 88 participants. The object of the randomization was a clinical question. Each participant had clinical questions randomly allocated to both intervention (librarian information) and control (no librarian information) groups…The average time for JIT librarians to respond to all questions was 13.68 minutes/question (95% CI, 13.38 to 13.98). The average time for participants to respond their control questions was 20.29 minutes/question (95% CI, 18.72 to 21.86).”

The abstract also mentions that 63% of librarian provided information was highly positively rated as compared with only 15% of their own answers (to control questions) being highly positive.

This project was very enjoyable and challenging from a informationist’s point of view.   I enjoyed the diversity of the questions and getting out to meet the doctors in their offices in and around Ottawa.  It was interesting to see, firsthand, how behaviour change happens with trying to integrate a new, in many cases, bit of technology into clinical practice.  Especially when a colleague is right around the corner.  However, clinicians attempted to answer only 40% of their unanswered (or control) questions themselves so this suggests that an information service is quite useful.  In my opinion, it is important to take into account the proper marketing of such a service (which we did) and making sure it has a face (i.e. Tamara, Doug, me and Elise).

Pat yourselves on the back, everyone!

(by the way, the fulltext of the RCT is openly available on PLoS One).