week 2 dq 1

1578185 - McGraw-Hill Professional ©

CHAPTER 11 Practical Considerations of Incorporating

Evidence into Clinical Practice

J. Richard Pittman, Jr., MD

Mikhail Akbashev, MD

INTRODUCTION With over 21.5 million unique articles and more than 1 million randomized controlled trials indexed in MEDLINE as of 2014 and more than 1 million new publications published and indexed annually, clinicians now must process a vast volume of medical literature. Many clinicians feel like they are drowning in information. Hospitalists must balance the need to find relevant and accurate answers to their clinical questions with the need for efficiency in finding those answers to immediately guide high-quality care to multiple acutely ill patients. Formulating and answering questions efficiently and effectively will improve care and reduce the rates of consultation, testing, and potential errors.

The volume of data and limited time for searching for answers compound each other. A recent systematic review examining clinical questions raised by clinicians at the point of care found approximately one clinical question arises for every two patient encounters. Clinicians only pursued 51% of the questions raised and found answers to only 78% of those questions pursued. Studies reported the main barriers to seeking information included a clinician’s lack of time and a doubt that a useful answer existed. The state of relying on information already known prevails when the energy required to get a new

1578185 - McGraw-Hill Professional ©

answer outweighs the perceived benefit. Clinical inertia may be illustrated by considering the gap between the potential benefits of evidenced-based care and actual rates of implementation as in the treatment of heart failure with reduced ejection fraction (HFrEF). Optimal implementation of strong evidence-based therapies for HFrEF could save an estimated 35,000 to 117,000 thousand lives per year. See Chapter 129 (Heart Failure).

In an ideal practice setting, the majority of clinical questions would have a readily accessible, evidence-based answer. Clinicians would have current knowledge of guideline- based therapy and could apply pertinent point-of-care reminders from the electronic medical record for best practice for every patient under their care. As a result, patients would yield maximal benefit from clinical trials and guideline-driven information. This ideal state may not be attainable; however, clinicians may take steps toward better utilizing the evidence-based answers currently available to meaningfully impact clinical practice.

CURRENT CONSEQUENCES AND MOTIVATORS FOR CHANGE PRACTICING WITH OUTDATED INFORMATION

Relying on outdated information for patient care (ie, clinical inertia) may limit potential benefits of current therapies and expose patients to risks of disproven therapies. An example would be practicing based off outdated guidelines for the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults where a clinician tailors treatment and statin dosing based solely on the low-density lipoprotein cholesterol (LDL-C) levels rather than selecting a moderate- or high-intensity statin strategy based on ASCVD risk, an LDL-C ≥ 190 mg/dL, and/or the presence of diabetes as recommended in the current updated guidelines.

UTILIZING UNVERIFIED INFORMATION SOURCES

Clinicians may utilize unverified information sources. Examples of possible unverified information sources include seemingly more informed colleagues, television programming/advertisements, popular media, drug company representatives, and searching for “evidence” or answers to clinical questions using search engines that may provide information from unverified sources (eg, “Googling”). Heavy reliance on unverified information sources can significantly limit the quality of information with which a clinician practices and should be avoided if possible.

SEARCH SATISFACTION BIAS

Depending on a clinician’s comfort level with evidence-based medicine and available search tools and time, a clinician may only read article summaries or conclusions from abstracts. This represents a form of search satisfaction bias. When an answer is found to a clinical question that is frequently encountered in a clinician’s scope of practice, the clinician might jump to apply this answer to all subsequent patients without fully assessing the validity and quality of the source or considering the applicability of this information to the individual patient.

EVIDENCE-BASED PRACTICE IMPROVES PATIENT OUTCOMES

1578185 - McGraw-Hill Professional ©

Perhaps the strongest and most important motivator for change should be the fact that evidence- or guideline-based practice has been shown to improve patient outcomes across a wide spectrum of illnesses.

SOLUTIONS TO INCORPORATE EVIDENCE INTO CLINICAL PRACTICE Solutions should take into consideration how a clinician might encounter information during the flow of practice. “Keeping up” with the literature is increasingly difficult, and staying abreast of important developments that may not directly relate to patients that the clinician is actively managing. “Keeping up” single-source publications from an area of clinical focus are useful, but they may narrow a clinician’s awareness of broader advances across different disciplines. There are numerous methods to “keep up” with the literature that transcend traditional postal mail by utilizing e-mail or designated applications for mobile devices. Users sign up for these “keeping up” resources as reputable and reliable evidence sent to them from trusted sources. These tools may help clinicians keep up with a particular field or topic by organizing information by discipline, relevance to that discipline, and newsworthiness or impact level. This information may be delivered to an e- mail inbox, a website, or to a discrete mobile application. The focus below will be on free resources available or those included with professional society memberships common for most hospital medicine providers.

Advantages of push resources available for most hospital medicine providers include:

Preset, reliable stream of information lowers the energy required to incorporate new information into clinical practice, leaving a clinicianless subject to clinical inertia or anchoring. Many of the tools are free and can focus on a specific discipline or a topic. The volume of information presented can be adjusted based on clinician desire or tolerance. The frequency of the delivery of this information can be customized. Article summaries by colleagues trained in evidence-based analysis can be accessed and can raise awareness of potential inclusion biases.

Disadvantages include:

These streams may become overwhelming if the amount and frequency of content is not properly customized to the individual clinician preferences. There is a risk of attending a conference or reading a publication on mobile resources that may be tempting to clinicians to sign up for too many resources at one time. Selection methodology for choosing the articles presented may not always be clear.

Suggestions

1. Setting up digital resources. It may be helpful for a clinician to initially take consider what information he or she needs and the areas of knowledge deficiencies (eg, original research manuscripts, clinical updates, and guidelines). Any individual clinician may not be aware of each of her or his personal deficiencies, especially since “blind spots” are by definition not seen. Thoughtful attention to one’s knowledge base, deficiencies, and practice gaps may lead to crucial first digital

1578185 - McGraw-Hill Professional ©

steps for change. In addition, a comparison of professional needs and knowledge gaps should be made with regards to any resources a clinician is actively subscribed. A busy clinician should pay careful attention to cutting down on infrequently used resources prior to subscribing to new ones.

Consideration should be made for an individual clinician’s preferred method of receiving information. Some like information to come straight to their e-mail with a link to a website while others prefer opening a designated application on their device(s). E-mails clutter e-mail inboxes, but most people regularly check e-mail. Mobile applications clutter your devices while also continuing to collect new material unnoticed to the clinician. This can be corrected by removing unused applications that clutter mobile devices while also taking steps to become familiar with how applications work and aggregate information. Most tools discussed in this chapter strive to deliver information in a way that best fits the workflow of different clinicians (Table 11-1). The key is for any individual practitioner to identify resources most convenient and reliable for that individual clinician.

TABLE 11-1 Example Digital Resources for “Keeping Up”

E-mail/Website-Based Website Link BMJ Evidence Updates https://plus.mcmaster.ca/evidenceupdates/ ACP Journal Club http://annals.org/journalclub.aspx NEJM Journal Watch www.jwatch.org PubMed—My NCBI http://www.ncbi.nlm.nih.gov/pubmed/ Application-Based (App) Website Link Docphin https://www.docphin.com/ Read by QXMD http://www.qxmd.com/apps/read-by-qxmd-

app Doximity https://www.doximity.com/

Once an account is setup for the any of the resources, the next step is to select specialty and topic preferences. Once these steps are completed, the information will then be sent either via e-mail or to a mobile application depending on which resource is selected (Figure 11-1).

1578185 - McGraw-Hill Professional ©

Figure 11-1 Screenshot of BMJ evidence updates. This is an example of a free online “keeping up” resource which allows users filter paper alerts by topic, relevance and newsworthiness, to narrow to a manageable amount.

A critical step is to then monitor the usefulness of information and then after a period of time (eg, a couple of weeks or a month) go back into the tool and adjust the settings or unsubscribe from the resource based on its helpfulness or not.

2. Schedule time for new reading. A seemingly simple step, but one that can make a large difference in “keeping up” is to schedule time for new reading. Carrying a paper or virtual file with articles, presentations, and/or books may make a half an hour before rounds, between appointments, or while sitting in carpool lines a lot more productive.

3. Attend institutional conferences. Attending institutional conferences (eg, Grand Rounds, noon conferences) is an excellent way for a clinician to acquire new information while also providing the opportunity to spark conversations and clinical questions with colleagues. Volunteering to present a topic at conference promotes expertise acquisition of new and updated clinical knowledge.

4. Participate in professional societies and their scientific meetings. Scientific meetings hosted by medical professional societies are designed to help clinicians stay abreast of the ever-changing information and also to offer credit for Continuing Medical Education.

5. Encourage a culture of learning. Activities such as journal club, case conference, and clinical updates in hospital medicine at hospitalists’ sites of practice can be an effective way to promote a culture of learning, which can help providers further keep up with the flow of new information.

6. Utilize the electronic health record. Perhaps the most pertinent time to receive updated information on any treatment or diagnostic test is at the time of ordering the treatment or test. Recent advances and expansions in electronic health records (EHR) offer a limited opportunity for “just-in time” learning about specific medical concepts. Many EHRs incorporate evidence-based recommendations into order sets, as well as linking users to literature regarding updated recommendations. A recent meta-analysis showed improvement in both efficiency and adherence to guidelines

1578185 - McGraw-Hill Professional ©

through use of EHR. Similarly, a study of an older computer support tool for antibiotic management found a dramatic decrease in pharmacy antibiotic expenditures and mortality rates over a 6-year period. A systematic review of 68 controlled trials of computer decision support systems found the majority of the trials demonstrated benefit in physician performance and patient outcomes. Multiple health systems have implemented quality improvement projects to adhere to core measures using order sets within the EHRs with great success.

QUICK QUESTION

The context is essential for any clinical question. The ideal “quick question” resource would be readily available at the point of care, pertinent to the patient, with specific, actionable information that is quickly and reliably accessed. Unlike the “keeping up” resources previously discussed, these “quick questions” need to be answered for a real patient right now. That is why using these types of resources is essential in day-to-day patient care. Fortunately, multiple resources exist including current textbooks, database search tools such as Trip Database, popular portable resources such as UpToDate or Dynamed, and large databases like PubMed. These resources have been developed to answer specific, patient-related questions. Hospitalists should check with their institutional subscriptions first and utilize these before personally enrolling in subscriptions that may be expensive.

Developing “quick questions” require clinicians to stop their flow of work and look for an answer. Cumbersome retrieval of information may lead to clinical inertia. Initial searching using summary resources, such as textbooks or review articles, can be efficient and more likely to yield pertinent answers. However, these resources are subject to authorship biases. Important articles could potentially be omitted while smaller studies maybe overly emphasized in recommendations. Summary resources can also be delayed in incorporating the most recent study results, even sometimes those of large pivotal studies. Many clinicians start with a Google search with Wikipedia as the top listed initial resource. This may often be a quick and satisfying way to answer simple medical definition questions such as “what is an antimitochondrial antibody.” Mainstream publicly available search engines such as Google or Yahoo can offer fast and free searches but often are less reliable and may not provide a robust and accurate answer to clinical questions as would more rigorously vetted medical resources, such as AccessMedicine, ClincialKey (formerly MD Consult), DynaMed, Medscape (a.k.a. eMedicine), UpToDate and a growing list of other compiled medical summary resources and reviews (Table 11-2). These resources have made incorporation of new information a priority.

TABLE 11-2 Example Digital Resources for Answering Clinical Questions

Resource (Publisher) Description CME AccessMedicine

McGraw-Hill

Compendium of rapidly searchable medical textbooks

Yes

Clinical Key (a.k.a. MDConsult)

Automated evidence search engine, allow users to search the primary medical literature, guidelines and standard textbooks

Yes

1578185 - McGraw-Hill Professional ©

Elsevier Dynamed

EBSCO Health

Collection of evidence-based summary reviews on common clinical topics; presented in bulleted format with specific citations and assessment of evidence quality for recommendations. Systematic rapid inclusion of newly published high-quality evidence, including systematic reviews

Yes

Essential Evidence Plus

Wiley

Search engine to browse guidelines and systematic reviews; integrated with other resources such as calculators, coding helper, or decision support tools

Yes

Medscape (a.k.a. eMedicine)

WebMD

Compilation of summaries by specialists in the field; includes new article formats

Yes

PubMed Clinical Queries

NIH

Indexed database of articles from a multitude of medical journals

No

TRIP Database (Translating Research Into Practice)

TRIP

Automated evidence search engine of primary studies, guidelines, textbooks and other clinical resources with filters available; scores articles based on how recent, pertinence, and publication source

No

Up-To-Date

Wolters Kluwer

Evidence-based online textbook. Compendium of expert written invited reviews on a broad array of topics; evidenced based and graded recommendations, primarily prose and directive in nature

Yes

Suggestions

Despite the apparent limitations, actively and efficiently searching for answers to clinical queries is an essential part of patient care. Overcoming clinical inertia to identify and explore questions is the first step. This may be as simple as an index card with questions for the day or lunches with colleagues to discuss cases. Having identified questions, a clinician needs to formulate the question as specifically as possible and identify an efficient search strategy (Figure 11-2).

1578185 - McGraw-Hill Professional ©

Figure 11-2 An effective search strategy for answering clinical questions.

Many hold to dogma and use PubMed as an initial search. This often yields a time- consuming search, with many published articles to sift through, and challenges finding relevant studies efficiently. This also has been shown to take 41% longer (29 vs 17 minutes) than UpToDate searches in a cohort of resident physicians. Furthermore, a study of 54 medical students, residents, and faculty searching multiple methodologies to answer critical-care-related questions showed that users most frequently searched Google first (45% of the time), with Google and UpToDate providing faster answers than PubMed (3.8 vs 3.3 vs 4.4 minutes, respectively). Importantly, Google and UpToDate were more likely to lead to a correct answer than PubMed (60% vs 70% vs 36%, respectively). The highest value first resource is often a compiled resource such as Dynamed or UpToDate, but multiple resources are available from various publishing organizations (Table 11-2).

Regardless of the initial search strategy, there are often clinical situations that require more nuanced answers and specific expertise. These questions should be very concrete and specific. A standard “PICO” (Patient, Intervention, Comparison, Outcome) format identifies the pertinent parts of a question (eg, “What is the effect of 23-valent pneumococcal polysaccharide vaccine versus placebo on mortality in patients with systolic heart failure exacerbations?” or “What is the relative risk of bleeding with rivaroxaban versus warfarin in patients with venous thromboembolism?”). For questions too specific or narrow to be found in summarized resources, a primary literature search may be preferred. PubMed offers free access to users, and its “Clinical Queries” search option quickly filters results for clinical and systematic review articles. Other electronic resources like TRIP (Translating Research into Practice) database can quickly filter studies indexed in MEDLINE, guidelines and other resources, and it also ranks them on quality and type of study. Guideline searches may be completed through the National Guideline Clearinghouse (http://www.guideline.gov), which is a resource maintained by the U.S. Department of Health and Human Services. This resource facilitates comparison of guidelines on topics published from different societies (eg, breast cancer screening guidelines from American College of Physicians versus American College of Obstetrics

1578185 - McGraw-Hill Professional ©

and Gynecology). Although somewhat cumbersome to use initially, it is readily updated. Actively recruiting clinical trials are indexed in the registry ClinicalTrials.gov (https://clinicaltrials.gov), provided by the U.S. National Institutes of Health.

Although there are advantages and disadvantages to the different resources, the least useful resource is the unavailable resource. For this reason, clinicians should find the resources available at their home institutions. Clinicians should identify clinical questions and explore the available resources to find answers. Ideally, a query should obtain a high- quality answer in less than 5 minutes.

STORAGE FOR FUTURE REFERENCE

A challenge of the digital and increasingly paperless work environment is how to keep up with the materials that an individual clinician would like to save for future reference. Mobile technology can really help take busy clinicians far beyond the traditional physical file cabinet into a system that can travel on mobile devices with certain ones that can even help create bibliographies if needed.

Many digital storage solutions follow the “freemium” model. “Freemium” is a pricing strategy that refers to an initial free price for the limited use of an application that then tiers to paid subscriptions for heavier use. The real advantage of the digital storage solutions is their use of storing files virtually in the “cloud.” The “cloud” refers to the storage of files in a server (ie, high-capacity computer) that is connected to a clinician’s personal computer or mobile device via the Internet. The advantages of this include an online backup and the ability to synchronize files across multiple devices with very little effort. Many of these services allow a clinician to keep a copy of the files on a computer or mobile devices so these files can be accessed even when not connected to the Internet. These systems retrieve information by storing text documents that can be searched using terms that obtain results based not just on the title of the file but also from the text of the document. This allows use of these resources with almost no organization necessary.

With a digital storage solution, the important tactile experience of touching and annotating the original article is lost. The clinician must convert from paper to digital files, name folders, and move documents to the folders that have been created. A similar effort would be required to set up a new file cabinet, but many struggle to invest the time into a similar digital system. Theoretically, this digital storage solution is still a mechanical system that could fail.

Suggestions

1. Understand the cloud Many clinicians already have user accounts for cloud-based storage solutions but are simply unaware that they do. Programs such as Dropbox, Google Drive, Box, Evernote, OneDrive, and iCloud all meet the definition for cloud- based storage solutions. If a clinician already has one of these accounts, then it may be best for that clinician to first explore all the features of that solution, before considering others (Table 11-3).

TABLE 11-3 Example Cloud-Based Storage Solutions

Platform Cost/Memory Pros Cons Box.com Free up to 10 Gb, then Only solution that Web editing,

1578185 - McGraw-Hill Professional ©

$10/mo for 100 Gb advertises HIPAA complaint for enterprise clients; great amount free; can edit documents on web, make comments, and assign tasks to documents

commenting, and tagging have some flaws that limit their usefulness

Dropbox Free up to 2 Gb, $10/mo 1 Terabyte of storage

Established company; cross platform with easy sharing and well- integrated into mobile devices

Small amount of data free

Evernote Free up to 60 Mb data transfer per mo, then $45/per y for heavier use

Accepts multiple types of inputs including audio, photos, scanned documents, and web clips; advanced organization with notebooks and tagging

Best use requires some organization

Google drive 15 Gb free, paid plans for 100 Gb per mo

Best for working on files with other users, even simultaneously; great if you use Android mobile device(s)

Navigation of the drive is somewhat nonintuitive

Microsoft Onedrive

Free up to 7 Gb Ideal if heavy user of Microsoft® Office, especially on a windows platform computer

 

While the solutions can be accessed through websites using a web browser, most also offer applications that can be downloaded and placed on personal computers and mobile devices that allow for more convenient access of their stored files. The applications work by turning files and folders meant for storage into ones that are automatically synchronized and immediately uploaded to the cloud, which allows them to thereby be available from anywhere.

2. Use cloud-based storage After gaining an understanding of the “cloud,” clinicians should strongly consider using cloud-based storage in their practice.

In general, any of these cloud-based storage solutions will work to get started, so once a choice is made regarding which one to use then time must be invested by users in order to learn how to use all of the features. Many have “getting started” videos which can be viewed on their respective websites. Once a clinician is familiar with the tool, time should be set aside for at least an hour or two to allow for some files or articles to be moved over to the cloud folders. Investing time up front will allow a busy clinician to get the most of out of the system and generally be better organized moving forward in clinical practice. Choosing a system-based

1578185 - McGraw-Hill Professional ©

organization (eg, cardiology, gastroenterology, infectious diseases, and so on.) versus by more specific topic areas (eg, heart failure, cirrhosis, pneumonia, and so on.) depends on the file contents and personal preferences of the individual clinician.

The next time a clinical question comes up about the topic previously searched and saved in this storage system, the clinician can simply check the system rather than doing another search.

3. Comply with patient confidentiality As with any new developments or advances in technology that affects or modifies a clinician’s practice, care should be taken to assure the safety and protection of a patient’s confidentiality. Most cloud resources are not compliant with the Health Insurance Portability and Accountability Act (HIPAA). As such, patient or personal health information should not be stored on these digital and cloud-based drives. The notable exception is “enterprise services” provided by the digital platform Box, but it should be noted the “personal service” of Box is not HIPAA compliant.

4. Annotate articles Some clinicians prefer to read paper articles, which then allows for highlighting or annotating. Digital versions of these articles often allow of highlighting or annotating as well depending on the viewer used on a computer or mobile device. This latter way of reviewing articles allows the clinician to more easily save notes taken right inside the cloud-based storage solution being used. For those who still prefer the paper version to initially review an article, clinicians should consider document scanner to convert the annotated paper version of the article into a digital one which can then be stored in these cloud-based storage platforms. The scanner that uses “Optical Character Recognition” or OCR to turn the documents scanned into a text searchable document after storage provides optimal functionality. At the time of this chapter being drafted, Evernote is the only one of the cloud-based solutions that has annotation (eg, highlighting) or drawing built into its system. Many of these other platforms can integrate easily with software/application viewers or readers (eg, “Portable Document Format” or PDF) which are available on most mobile devices.

CULTURAL CHANGE

Fostering a culture of education, accountability for actions, and support for evidence- based, high-quality care can encourage all clinicians to keep learning for better patient care. Although intangible personal attributes contribute greatly to culture, leadership can adjust policy to achieve desired outcomes by nurturing a workplace of collaboration, learning, open feedback, and accountability. A supportive, collaborative environment encourages clinicians to discuss individual studies or publications, treatment decisions on complicated cases, and even to work together on quality improvement and system-based projects. Impediments to collaboration among hospitalist groups include provider scheduling and workload. Seven-day-cycled schedules may isolate providers to those other providers on for the same shifts only. Potential interventions to improve collaboration could include standardized work schedules, physician lounges, physician cafeterias, grouped offices, and consideration of patient census caps.

Open feedback also plays an important role in incorporating evidence and improving patient care. Increasing isolation of physicians and high workload limits the available time to discuss the management of individual patients and/or to follow up on subsequent care

1578185 - McGraw-Hill Professional ©

while off-service. Handoffs could be an opportunity for colleagues to review care and potentially notify providers of updates in hospital medicine or new literature. In order to be successful, this should be done in a collegial manner with adequate time allotted. Hospitalists should be encouraged to both give and request feedback regularly. Morbidity and mortality conferences may also offer an opportunity to discuss updates in new literature using a pertinent clinical case. “Word of mouth” spread of information is a pertinent and powerful way to share medical information and encourage a culture that strives to keep up with the literature.

CONCLUSION The volumes of literature and increasing demands on physician time have complicated the process of finding and incorporating evidence into clinical practice. Multiple new methods exist to receive new evidence on pertinent topics in manageable volumes. Compiled review resources are significantly quicker and more reliable initial resources than primary literature searches for most clinical questions. Cloud-based storage options offer the advantages of better search-ability and portability over filing cabinets and stacks of printed manuscripts and journals; most cloud storage options are not HIPAA compliant but are good for storing medical references. Simple steps can be taken to foster a positive learning culture at a hospitalist’s respective institution (eg, starting a journal club or scheduling lunchtime discussions of current topics). Some hospitalists may pursue resources to better keep up, while others may inquire at their institution for “quick question” resources. Some clinicians may already be inundated with what they have collected and need to invest in a cloud-based resource to decrease the stress every time they ask, “Where is that article?” Encouraging a work culture shift toward addressing gaps may help clinician scope with information overload. Even the most current or seemingly up-to-date clinicians started one step at a time and invested continued effort.

SUGGESTED READINGS Banzi R, et al. Speed of updating online evidence based point of care summaries:

prospective cohort analysis. BMJ. 2011;343:d5856. Campanella P, et al. The impact of electronic health records on healthcare quality: a

systematic review and meta-analysis. Eur J Public Health. pii:ckv122 [Epub]; Jun 30, 2015.

Del Fiol G, et al. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Intern Med. 2014;74:710-718.

Elliott DJ, et al. Effect of hospitalist workload on quality and efficiency of care. JAMA Intern Med. 2014;174:786-793.

Hunt DL, et al. Effects of computer-based clinical decision support systems