Middle East Fertility Society Journal, Vol. 10, No. 2, 2005, pp. 163-166
EVIDENCE-BASED MEDICINE CORNER
Information mastery: "Finding the gold"
Abdelhamid Attia, M.D.
Professor of Obstetrics & Gynecology
and secretary general of the center of evidence-Based Medicine, Cairo University
Code Number: md05028
Physicians rely on their knowledge and experience in solving their patient's problems. If their knowledge and experience did not help they try to do some readings, usually in a non systematic way, or ask peers or senior colleagues to reach a consensus about their patient's problems. Unfortunately neither of the aforementioned methods proved optimum to keep up-to-date or to help physicians provide their patients with the best available care.
Knowledge of best treatment declines since the year of graduation (1) as, by passage of time, we tend to forget what we have learnt. Meanwhile, there is an information explosion and the amount of medical information is increasing beyond any one's ability to follow. The doubling time of medical information, by 1991 standards, has been estimated to be 19 years (2) and probably it has declined to 10 years now. Textbooks need long time to be written, edited, revised, and printed before it reaches our libraries. By the time we need them a good deal of their information is already outdated. Medical journals are so numerous so that one for sure loses track of new innovations and research as they arise. Experts and experience are not always helpful especially with controversial issues and with new treatment modalities and new techniques that appear every day.
Thus, the exponential increase in medical knowledge and the incompetence of our traditional ways of practicing medicine has created a need for a new way to practice medicine and to keep our knowledge up to date. This new paradigm of practicing medicine has been called evidence-based medicine that simply means the integration of best research evidence with clinical expertise and patients values in direct patient's care (3).
In our daily practice we need information for one of two purposes either to keep up-to-date with new developments relevant to our practice or to seek for answers to our patient-specific problems. However, with more than 20,000 biomedical journals in print and more than 5000 articles published every day we are left in a dilemma. Where to look for information and how to reach it in an easy way given the short time that we all have? This is the scope of information mastery.
Information mastery is a way to deal with information overload. It leads ultimately to improvement in both the quality of care for patients and the quality of life for doctors.
Medical information is useful to our practice only if it is relevant i.e. suites our practice and our patients, valid i.e. methodologically and scientifically sound, and does not consume too much time to be found. Original research, as typically published, is not useful for the care of patients until it has been summarized in some way.
The usefulness of medical information has been described in an equation form (4) as follows:
Usefulness of information = Relevance x
The goal of medical research on therapeutic interventions is to study their effect on certain outcomes that are important to patients and hence to clinicians (patient-oriented outcomes). However, the majority of published research addresses intermediate outcomes that are important from the disease point of view (disease-oriented outcomes). For example a research that studies the effect of a new Selective Estrogen Receptor Modulator (SERM) on the ovulation rate in PCO patients or on the level of CA125 in patients suffering from endometriosis is "disease oriented" and does not give strong evidence to be used in clinical practice. Such evidence is known as disease oriented evidence (DOE). Research that addresses disease-oriented evidence, in spite of being "promising", may not prove effective in actual practice. It might be logic that drugs that increase ovulation rates in anovulatory infertile women would increase pregnancy rates as well. However, the same drug might have an anti-estrogenic effect on the endometrium or cervical mucous rendering it ineffective as far as pregnancy is concerned. That's why research addressing disease oriented outcomes is considered intermediate research that is not enough to give solid evidences for our practice. Paying much time reading such research is not to the best of our practice, patient's care, or the best investment of our time. This type of research is very common and usually brought to our attention by pharmaceutical representatives promoting for their drugs. Such evidence is often misleading and generally should be considered premature.
On the other hand, a research that studies the effect of a new SERM on pregnancy rate in PCO patients or on pain score in patients suffering from endometriosis is "patient oriented" and gives a strong evidence to be used in clinical practice. Such evidence is known as patient oriented evidence that matters (POEMs) (4). Researches addressing patient oriented evidence are "gold" and should be searched for and read as such type of research has a direct implication on our practice.In a six months survey of 90 journals, 8047 articles were found among them only 213 articles were POEMs4 which means that more than 97% of the published literature addresses disease oriented evidence (DOEs) and only less than 3% of it addresses patient oriented evidence (POEMs). This gives us an idea on the amount of effort that can be saved when trying to keep up-to-date with the literature.
Thus, rather than reading every thing or beginning with a time-consuming validity assessment, it is advised to read the abstract to find out whether the outcomes are patient-oriented and whether the conclusion recommends a change to your current practice. If either answer is no, you can stop and skip reading the article (4).
With the appearance of new interventions, researches are designed to study its effects on certain disorders. These researches are done on a "sample" of the population. Results obtained from the sample are used as estimates to the effect of the intervention on the whole population. So, for research results to be applied to the whole population, the research should reflect the truth i.e. should be free from bias. Assessment of the degree of bias, to accept or to reject the results of a research is known as validity assessment.
Assessment of the validity of information (scientific and methodological quality) needs certain skills and knowledge about study design and methodology and critical appraisal of scientific research. Generally speaking evidence obtained for therapeutic interventions, to be used in clinical practice, should come from at least one large randomized controlled trial (RCT) with proper methodology. Critical appraisal modules for RCTs are present that allows practitioners to appraise therapeutic research. It worth mentioning here that assessment of validity of 4235 research articles published in 30 journals, among them are the BMJ, JAMA, NEJM, and Lancet, showed that only 20% of the published research met the validity criteria (5).
Work is the time spent to search for and appraise the required information. New sources of medical information and electronic retrieval systems minimize the time needed to search for information. Meanwhile it provides it in a "finished" ready to use format after being tested for its relevance and validity.
NEW SOURCES FOR MEDICAL INFORMATION
From the above we conclude that not all published research is relevant or valid to our practice. Thus primary research should go in a process of "filtration" before adopting its results in the management of patients. In other words scientific research should be evaluated for its relevance and validity, and irrelevant or invalid research must be ignored and not to waste time reading it. In this manner the unnecessarily huge medical literature can be summarized in few articles that are of prime importance to our practice. Fortunately enough, there are new sources for medical information that do the hard work for us. These sources are mostly internet based so that it can be continuously updated. The common theme in these sites is the presence of experts who search primary research, test it for its relevance and critically appraise its validity. Following any of those sites would provide clinicians with the most up-to-date relevant and valid information.
The first and most important is the Cochrane Database of Systematic Reviews (CDSR) published by the Cochrane Library6 that can be accessed through the internet. Reviewers in the Cochrane Library use the highest methodological rigor in searching, appraising, and analyzing randomized controlled trials to generate systematic reviews in various topics relevant to every day practice. Each systematic review aims at answering a single question such as "does adding metformin to clomiphene citrate increase the pregnancy rate in anovulatory infertile women?" Three volunteer reviewers work together in a single review and 7 experienced professionals edit proof it. Results are pooled together in a meta-analysis and a single estimate is obtained from all relevant and valid studies addressing the same topic. Moreover, reviews are updated regularly whenever new studies arise. If the review was not updated within a reasonable period of time, it is withdrawn from the library.
The second important source is clinical evidence (7). It provides a concise account of the current state of: knowledge, ignorance, and uncertainty about the prevention and treatment of common and important clinical conditions. This web site is updated biannually. It might be astonishing to the readers to know that in a study on the most commonly used drugs in clinical practice, 48% of the drugs were found to be of unknown effectiveness and only 15% of them are of proven efficacy (8).
One last but not least source of up-to-date information is the excellent and free service provided by the British Medical Journal Publishing Group and the Health Information Research Unit at McMaster University which is called the BMJ updates plus (9). Subscribers to this free service receive tailored notifications about important advances in their specialty to keep up with the most important "needed to know" studies and reviews as soon as they are published. Expert research staffs revise more than 120 journals, critically appraise more than 50,000 articles published in these journals around the year to select around 3000 article that pass the appraisal filter to be sent to a panel of clinicians all over the world who assess their relevance to their clinical practice. Only articles that pass the appraisal and relevance filter, around 3-5 articles per month, are sent to subscribers' email addresses to keep up-to-date with information that are essential for clinical practice. The web site contains also a searchable database containing all the assessed articles.
In conclusion, the amount of new medical information is huge. Meanwhile, not all what is published is valid or relevant to clinicians. Research needs to be filtered, appraised, and summarized before it can be applied in practice. The new sources of information allow for "information mastery" through which busy clinicians can find highly valid and relevant information with the least amount of work.
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