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Brian Haynes
Health Information Research Unit
Dept of Clinical Epidemiology and Biostatistics
McMaster University
KNOWLEDGE IS THE ENEMY OF
DISEASE
50%
33%
Current guideline adherence for diabetes
Intervention:
Ophthalmology assessment 46% - 80%
Proteinuria assessment 35% - 82%
Foot assessment 30% - 72%
HbA1c 16% - 87%
Cholesterol assessment 55% - 68%
Smoking status assessment 25% - 87%
In all, 73% of microalbuminuric
patients were not on ACE-I/ARB.
Hypertensive type II diabetic
patients were often left untreated
and only a minority of those treated
were optimally controlled. The
importance of an elevated systolic
pressure is underestimated and the
number of antihypertensive drugs
prescribed, insufficient. Screening
and treatment of albuminuria are
inadequate.
The routine application of what
we know can prevent or minimise:
decision makers
application a
generation synthesis policy
5
c b
4 decisions
3
1 2
Knowledge Translation
MRC
Steps
CIHR from evidence generation to clinical application
Steps: 1. generation of evidence from research; 2. evidence summary and
synthesis; 3. forming clinical policy; 4. application of policy; 5. individual
clinical decisions, including a) patients circumstances, b) patients wishes,
and c) evidence from research
Step 1. Generating Research Evidence
Barrier Solutions
Barrier Solutions
1995 reviews
Barrier Solutions
problems in national drug and
developing technology assessment
evidence-based agencies
clinical and health local leadership
policy
Step 4. Applying evidence in practice
Barrier Solutions
poor access to development and
current best testing of information
evidence and systems that integrate
guidelines evidence and guidelines
with patient care
(eg Diabetes In-
CHARGE)
The McMaster PLUS project
~2,500 articles/y
50,000 articles/y meet critical appraisal
from 120 journals and content criteria
(95% noise reduction)
McMaster PLUS Project
Clinical Relevancy Filter (MORE)
1. Bohlius
J, et al.
Erythropoietin for patients with malignant disease.
Cochrane Database Syst Rev 2004;(3):CD003407.
We hope that you will find these articles of value in your clinical practice.
2 left study
Intervention
Randomization to 2 different trial interfaces
SelfServeVersion FullServeVersion
Ovid Ovid
Stat!Ref Stat! Ref
Pyramid of Evidence Pyramid of Evidence
PLUSEmailAlerts
PLUSSearchEngine
PLUS Preliminary Findings:
% of Participants Using PLUS by Month
Baseline (5 mo) Self-serve vs Full-serve Full-Serve
70
Percentage Using PLUS
60
50
40
30
20
10
Relative increase 58.7%, P=0.001
RCT begins Control cross-over begins
0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
03 03 04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05
Month
Self-serve Full-Serve
Free EBM literature updating service
http://www.bmjupdates.com
Free at www.bmjupdates.com!
(sponsored by BMJ Publishing Group)
Step 4. Applying evidence in practice
Barrier Solution
ineffectual continuing effective continuing
education education and quality
improvement programs for
practitioners
Step 4. Applying evidence in clinical
decisions
Barrier Solution
ignorance about shift a portion of health
barriers and their investment from services to
solutions quality improvement
WHO estimates US$100B/yr for
health-related research
Barrier Solutions
not having the Computerized decision
right information at support
the right time
Effects of Computerized
Clinical Decision Support Systems
on Practitioner Performance and
Patient Outcomes
A Systematic Review
DepartmentsofClinicalEpidemiologyandBiostatistics,McMasterUniversity
DepartmentsofMedicine,McMasterUniversity,UniversityofToronto,and
UniversityofWesternOntario
DepartmentofBiostatisticsandEpidemiology,UniversityofWesternOntario
OUTPUT
Recommendations
delivered to health
Outcomes care provider
Directly by computer
Provider performance
integrate into By pager
Patient outcomes
workflow By extra research staff
By existing health care staff
Are CDSSs
clinically effective?
Did CDSS improve practitioner
performance?
100 studies
counting positive results on 50% outcomes measured
Examined in 97 studies,
63 cited improvement (65%)
In 16 of 21 (76%) reminder systems
In 24 of 37 (65%) disease management systems
In 19 of 29 (66%) drug dosing or prescribing systems
In 4 of 10 (38%) diagnostic systems
Did CDSS improve patient
outcome?
Update 100 studies
Examined in 52 studies,
7 cited improvement (13%)
Barrier Solutions
low patient adoption of effective
adherence to strategies to assist
treatments patients to follow
evidence-based health care
The weakest links
Policy - especially at the local level
Coordination - 4P
Helping practitioners to recommend
effective treatments
Helping patients to follow effective
treatments
The strongest link
Evidence-based textbooks
Summaries
Evidence-based journal
Synopses abstracts
Systematic reviews
Syntheses
Studies
Original journal articles
KNOWLEDGE IS THE ENEMY OF
DISEASE