Clinical questions raised by clinicians at the point of care: a systematic review

Information-seeking behaviour of primary care clinicians in Singapore at the point-of-care: A qualitative study

BACKGROUND

Clinicians' information-seeking behaviours impact patient care quality. Earlier studies indicated that barriers to accessing information deter clinicians from seeking answers to clinical questions.

OBJECTIVES

To explore primary care clinicians' information-seeking behaviour at point-of-care, focusing on when and how they seek answers to clinical questions.

METHODS

Semi-structured interviews were conducted with 45 clinicians after clinical sessions to investigate their information-seeking habits. Follow-up interviews were conducted after a week for those intending to address unanswered queries.

RESULTS

Two thirds of clinicians encountered questions during care, with nearly three quarters resolving them during the session. Colleagues, guidelines and online platforms were common information sources, with smartphones being used to access Google, WhatsApp or UpToDate®. Facilitators included reliable sources and the drive to confirm knowledge, while barriers included ineffective search methods and high workload. Despite challenges, most clinicians expressed satisfaction with their information-seeking process.

DISCUSSION

The findings underscore the increasing use of smartphones for accessing clinical information among Singaporean primary care clinicians and suggest the need for tailored training programmes and guidelines to optimise information-seeking practices.

CONCLUSION

Insights from this study can inform the development of training programmes and guidelines aimed at improving information-seeking practices among primary care clinicians, potentially enhancing patient care quality.

Identifying primary care clinicians' preferences for, barriers to, and facilitators of information-seeking in clinical practice in Singapore: a qualitative study

BACKGROUND

The growth of medical knowledge and patient care complexity calls for improved clinician access to evidence-based resources. This study aimed to explore the primary care clinicians' preferences for, barriers to, and facilitators of information-seeking in clinical practice in Singapore.

METHODS

A convenience sample of ten doctors and ten nurses was recruited. We conducted semi-structured face-to-face in-depth interviews. The interviews were recorded, transcribed verbatim, and analysed using thematic content analysis.

RESULTS

Of the 20 participants, eight doctors and ten nurses worked at government-funded polyclinics and two doctors worked in private practice. Most clinicians sought clinical information daily at the point-of-care. The most searched-for information by clinicians in practice was less common conditions. Clinicians preferred evidence-based resources such as clinical practice guidelines and UpToDate®. Clinical practice guidelines were mostly used when they were updated or based on memory. Clinicians also commonly sought answers from their peers. Furthermore, clinicians frequently use smartphones to access the Google search engine and UpToDate® app. The barriers to accessing clinical information included the lack of time, internet surfing separation of work computers, limited search functions in the organisation's server, and limited access to medical literature databases. The facilitators of accessing clinical information included convenience, easy access, and trustworthiness of information sources.

CONCLUSION

Most primary care clinicians in our study sought clinical information at the point-of-care daily and reported increasing use of smartphones for information-seeking. Future research focusing on interventions to improve access to credible clinical information for primary care clinicians at the point-of-care is recommended.

TRIAL REGISTRATION

This study has been reviewed by NHG Domain Specific Review Board (NHG DSRB) (the central ethics committee) for ethics approval. NHG DSRB Reference Number: 2018/01355 (31/07/2019).

Integrating Medical Librarians Into Infectious Disease Rounding Teams: Survey Results From a Pilot Implementation Study

Medical librarians participating as infectious disease rounding team members add value by facilitating knowledge acquisition and dissemination and by improving clinical decision making. This pilot study implementing medical librarians on infectious disease rounding teams was a well-received and beneficial intervention to study participants.

A comprehensive review on the biomedical frontiers of nanowire applications

This comprehensive review examines the immense capacity of nanowires, nanostructures characterized by unbounded dimensions, to profoundly transform the field of biomedicine. Nanowires, which are created by combining several materials using techniques such as electrospinning and vapor deposition, possess distinct mechanical, optical, and electrical properties. As a result, they are well-suited for use in nanoscale electronic devices, drug delivery systems, chemical sensors, and other applications. The utilization of techniques such as the vapor-liquid-solid (VLS) approach and template-assisted approaches enables the achievement of precision in synthesis. This precision allows for the customization of characteristics, which in turn enables the capability of intracellular sensing and accurate drug administration. Nanowires exhibit potential in biomedical imaging, neural interfacing, and tissue engineering, despite obstacles related to biocompatibility and scalable manufacturing. They possess multifunctional capabilities that have the potential to greatly influence the intersection of nanotechnology and healthcare. Surmounting present obstacles has the potential to unleash the complete capabilities of nanowires, leading to significant improvements in diagnostics, biosensing, regenerative medicine, and next-generation point-of-care medicines.

Modelling of physicians' clinical information-seeking behaviour in Iran: a grounded theory study

OBJECTIVES

Exploring clinical information-seeking behaviour (CISB) and its associated factors contributes to its theoretical advancement and offers a valuable framework for addressing physicians' information needs. This study delved into the dimensions, interactions, strategies and determinants of CISB among physicians at the point of care.

DESIGN

A grounded theory study was developed based on Strauss and Corbin's approach. Data were collected by semistructured interviews and then analysed through open, axial and selective coding.

SETTING

The study was conducted at academic centres affiliated with Isfahan University of Medical Sciences.

PARTICIPANTS

This investigation involved recruiting 21 specialists and subspecialists from the academic centres.

RESULTS

The findings revealed that physicians' CISB encompassed multiple dimensions when addressing clinical inquiries. Seven principal themes emerged from the analysis: 'clinical information needs', 'clinical question characteristics', 'clinical information resources', 'information usability', 'factors influencing information seeking', 'action/interaction encountering clinical questions' and 'consequences of CISB'. The core category identified in this study was 'focused attention'.

CONCLUSIONS

The theoretical explanation demonstrated that the CISB process was interactive and dynamic. Various stimuli, including causal, contextual and intervening conditions, guide physicians in adopting information-seeking strategies and focusing on resolving clinical challenges. However, insufficient stimuli may hinder physicians' engagement in CISB. Understanding CISB helps managers, policy-makers, clinical librarians and information system designers optimally implement several interventions, such as suitable training methods, reviewing monitoring and evaluating information systems, improving clinical decision support systems, electronic medical records and electronic health records, as well as monitoring and evaluating these systems. Such measures facilitate focused attention on clinical issues and promote CISB among physicians.

Question answering systems for health professionals at the point of care-a systematic review

OBJECTIVES

Question answering (QA) systems have the potential to improve the quality of clinical care by providing health professionals with the latest and most relevant evidence. However, QA systems have not been widely adopted. This systematic review aims to characterize current medical QA systems, assess their suitability for healthcare, and identify areas of improvement.

MATERIALS AND METHODS

We searched PubMed, IEEE Xplore, ACM Digital Library, ACL Anthology, and forward and backward citations on February 7, 2023. We included peer-reviewed journal and conference papers describing the design and evaluation of biomedical QA systems. Two reviewers screened titles, abstracts, and full-text articles. We conducted a narrative synthesis and risk of bias assessment for each study. We assessed the utility of biomedical QA systems.

RESULTS

We included 79 studies and identified themes, including question realism, answer reliability, answer utility, clinical specialism, systems, usability, and evaluation methods. Clinicians' questions used to train and evaluate QA systems were restricted to certain sources, types and complexity levels. No system communicated confidence levels in the answers or sources. Many studies suffered from high risks of bias and applicability concerns. Only 8 studies completely satisfied any criterion for clinical utility, and only 7 reported user evaluations. Most systems were built with limited input from clinicians.

DISCUSSION

While machine learning methods have led to increased accuracy, most studies imperfectly reflected real-world healthcare information needs. Key research priorities include developing more realistic healthcare QA datasets and considering the reliability of answer sources, rather than merely focusing on accuracy.

The lack of head-to-head randomised trials and the consequences for patients and national health service: The case of non-small cell lung cancer

INTRODUCTION

To introduce a drug to the market, it's not mandatory for it to be more effective and safer than the current treatment for the same condition. Consequently, head-to-head studies between the two best treatments for the same condition are not required, and this could result in a lack of information for patients, clinicians, and decision-makers. This study aims to evaluate the presence of head-to-head studies among the drugs used for the treatment of non-small cell lung cancer (NSCLC).

METHODS

Taking into account the National Comprehensive Cancer Network (NCCN) guidelines updated to 2022, which list all available treatments for each NSCLC subtype, the search engine Pubmed and the platform clinicaltrials.gov were consulted to find all completed and ongoing head-to-head studies among various treatments for NSCLC.

RESULTS

Among the anti-EGFR (epidermal growth factor receptor) drugs, 7 studies were found, with 6 completed and 5 registrational for drug commercialisation. No completed study to date has compared osimertinib and afatinib. For anti-ALK (anaplastic lymphoma kinase) drugs, 7 studies were found, with 5 completed. Alectinib, brigatinib, and lorlatinib have no completed comparison studies, but all were compared with crizotinib. Among various immunotherapy-based regimens, 5 studies were found, with only 1 completed. Therapeutic regimens based on pembrolizumab, atezolizumab, or the combination of nivolumab/ipilimumab have not been compared in studies published to date.

CONCLUSION

There are few head-to-head studies comparing treatments for NSCLC; there are no such studies between the latest generation of drugs. Consequently, ambiguous areas exist due to the lack of comparative studies among the available evidence, preventing the clinician's choice of the most effective treatment and risking the patient receiving suboptimal therapy. Simultaneously, the price of the drug cannot be determined correctly, relying only on indirect evaluations from different trials. To dispel this uncertainty, it would be desirable to initiate a process that brings together the demands derived from clinical practice and clinical research to provide clinicians and patients with the best possible evidence.

Organizing and Sharing Medical Knowledge Among Anesthesiology and Intensive care Residents: Evaluating Existing Practices and the Feasibility of Implementing a Dedicated Multiplatform Application

Treating patients with up-to-date medical knowledge is an ongoing goal for healthcare workers and implies efficient knowledge management at the point of care. Widely available mobile wireless technologies influence practices but a significant gap remains between technological possibilities and actual usage. The purpose of this study was to analyze residents' baseline practices in managing medical knowledge and to evaluate the use and impact of an innovative multiplatform application dedicated to anesthesiology and intensive care residents. This study took place in Rennes Teaching Hospital and comprised two distinct surveys. First, in April 2018, all residents received a ten-items online survey focusing on managing medical knowledge. Then, through a second online survey constituted of ten items, we sought to assess the use of a new multiplatform cloud-based application named "DansMaBlouse", dedicated to sharing and indexing medical knowledge, in anesthesiology and intensive care residents. Among 148 residents that answered the evaluation survey, the most sought out pieces of information in clinical setting were a phone or fax number (74%), drugs' characteristics (68%) and expert guidelines (57%). The main sources were senior staff (68%), medical databases (60%) and an Internet search engine (59%). Computers and smartphones were more frequently used than bound paper notebooks. After implementation of the multiplatform application DansMaBlouse, fifty-nine (82%) of the 72 residents that answered the evaluation survey reported using the application and 39% used it more than ten times. Among application users, 90% found it easy to use and 92% agreed that it improved point-of-care access to knowledge. Accessing appropriate medical knowledge at the point of care remains an issue for residents and can be improved by a multiplatform application combining personal and shared up-to-date resources.

quEHRy: a question answering system to query electronic health records

OBJECTIVE

We propose a system, quEHRy, to retrieve precise, interpretable answers to natural language questions from structured data in electronic health records (EHRs).

MATERIALS AND METHODS

We develop/synthesize the main components of quEHRy: concept normalization (MetaMap), time frame classification (new), semantic parsing (existing), visualization with question understanding (new), and query module for FHIR mapping/processing (new). We evaluate quEHRy on 2 clinical question answering (QA) datasets. We evaluate each component separately as well as holistically to gain deeper insights. We also conduct a thorough error analysis for a crucial subcomponent, medical concept normalization.

RESULTS

Using gold concepts, the precision of quEHRy is 98.33% and 90.91% for the 2 datasets, while the overall accuracy was 97.41% and 87.75%. Precision was 94.03% and 87.79% even after employing an automated medical concept extraction system (MetaMap). Most incorrectly predicted medical concepts were broader in nature than gold-annotated concepts (representative of the ones present in EHRs), eg, Diabetes versus Diabetes Mellitus, Non-Insulin-Dependent.

DISCUSSION

The primary performance barrier to deployment of the system is due to errors in medical concept extraction (a component not studied in this article), which affects the downstream generation of correct logical structures. This indicates the need to build QA-specific clinical concept normalizers that understand EHR context to extract the "relevant" medical concepts from questions.

CONCLUSION

We present an end-to-end QA system that allows information access from EHRs using natural language and returns an exact, verifiable answer. Our proposed system is high-precision and interpretable, checking off the requirements for clinical use.

Deep Learning to Refine the Identification of High-Quality Clinical Research Articles from the Biomedical Literature: Performance Evaluation

BACKGROUND

Identifying practice-ready evidence-based journal articles in medicine is a challenge due to the sheer volume of biomedical research publications. Newer approaches to support evidence discovery apply deep learning techniques to improve the efficiency and accuracy of classifying sound evidence.

OBJECTIVE

To determine how well deep learning models using variants of Bidirectional Encoder Representations from Transformers (BERT) identify high-quality evidence with high clinical relevance from the biomedical literature for consideration in clinical practice.

METHODS

We fine-tuned variations of BERT models (BERT_BASE, BioBERT, BlueBERT, and PubMedBERT) and compared their performance in classifying articles based on methodological quality criteria. The dataset used for fine-tuning models included titles and abstracts of >160,000 PubMed records from 2012-2020 that were of interest to human health which had been manually labeled based on meeting established critical appraisal criteria for methodological rigor. The data was randomly divided into 80:10:10 sets for training, validating, and testing. In addition to using the full unbalanced set, the training data was randomly undersampled into four balanced datasets to assess performance and select the best performing model. For each of the four sets, one model that maintained sensitivity (recall) at ≥99% was selected and were ensembled. The best performing model was evaluated in a prospective, blinded test and applied to an established reference standard, the Clinical Hedges dataset.

RESULTS

In training, three of the four selected best performing models were trained using BioBERT_BASE. The ensembled model did not boost performance compared with the best individual model. Hence a solo BioBERT-based model (named DL-PLUS) was selected for further testing as it was computationally more efficient. The model had high recall (>99%) and 60% to 77% specificity in a prospective evaluation conducted with blinded research associates and saved >60% of the work required to identify high quality articles.

CONCLUSIONS

Deep learning using pretrained language models and a large dataset of classified articles produced models with improved specificity while maintaining >99% recall. The resulting DL-PLUS model identifies high-quality, clinically relevant articles from PubMed at the time of publication. The model improves the efficiency of a literature surveillance program, which allows for faster dissemination of appraised research.

A Study of Factors Influencing the Volume of Responses to Posts in Physician Online Community

Today's diverse health needs place greater demands on physicians. However, individual doctors have limited capabilities and may encounter many unsolvable medical problems. The physician online community provides a platform for physicians to communicate with each other and help each other. Physicians can post for help about problems they encounter at work. The number of responses to physicians' posts is critical to whether or not the problem is resolved. This study collected information on 13,226 posts from a well-known physician online community in China to analyze the factors that influence the number of post replies. In the analysis of the post content of the physician online community, this study innovatively introduces word usage features in the medical field. TextMind was used to extract the rate of several types of words in posts that frequently appear when describing medical information. Ultimately, we found that the rate of time words, visual words, auditory words, and physiological process words used in posts had a positive and significant effect on the number of post responses. A series of new post features has been found to have an impact on the number of post replies in physician online communities. This finding is beneficial for physicians to quickly obtain peer assistance through online platforms, increasing the likelihood of solving workplace challenges and improving physician care, as well as the success of physician online communities.

Physicians' Perspectives on a Multi-Dimensional Model for the Roles of Electronic Health Records in Approaching a Proper Differential Diagnosis

Many healthcare organizations have adopted Electronic Health Records (EHRs) to improve the quality of care and help physicians make proper clinical decisions. The vital roles of EHRs can support the accuracy of diagnosis, suggest, and rationalize the provided care to patients. This study aims to understand the roles of EHRs in approaching proper differential diagnosis and optimizing patient safety. This study utilized a cross-sectional survey-based descriptive research design to assess physicians' perceptions of the roles of EHRs on diagnosis quality and safety. Physicians working in tertiary hospitals in Saudi Arabia were surveyed. Three hundred and fifty-one participants were included in the study, of which 61% were male. The main participants were family/general practice (22%), medicine, general (14%), and OB/GYN (12%). Overall, 66% of the participants ranked themselves as IT competent, most of the participants underwent IT self-guided learning, and 65% of the participants always used the system. The results generally reveal positive physicians' perceptions toward the roles of the EHR system on diagnosis quality and safety. There was a statistically significant relationship between user characteristics and the roles of the EHR by enhancing access to care, patient-physician encounter, clinical reasoning, diagnostic testing and consultation, follow-up, and diagnostic safety functionality. The study participants demonstrate positive perceptions of physicians toward the roles of the EHR system in approaching differential diagnosis. Yet, areas of improvement in the design and using EHRs are emphasized.

Performance of a Web-Based Reference Database With Natural Language Searching Capabilities: Usability Evaluation of DynaMed and Micromedex With Watson

BACKGROUND

Evidence-based point-of-care information (POCI) tools can facilitate patient safety and care by helping clinicians to answer disease state and drug information questions in less time and with less effort. However, these tools may also be visually challenging to navigate or lack the comprehensiveness needed to sufficiently address a medical issue.

OBJECTIVE

This study aimed to collect clinicians' feedback and directly observe their use of the combined POCI tool DynaMed and Micromedex with Watson, now known as DynaMedex. EBSCO partnered with IBM Watson Health, now known as Merative, to develop the combined tool as a resource for clinicians. We aimed to identify areas for refinement based on participant feedback and examine participant perceptions to inform further development.

METHODS

Participants (N=43) within varying clinical roles and specialties were recruited from Brigham and Women's Hospital and Massachusetts General Hospital in Boston, Massachusetts, United States, between August 10, 2021, and December 16, 2021, to take part in usability sessions aimed at evaluating the efficiency and effectiveness of, as well as satisfaction with, the DynaMed and Micromedex with Watson tool. Usability testing methods, including think aloud and observations of user behavior, were used to identify challenges regarding the combined tool. Data collection included measurements of time on task; task ease; satisfaction with the answer; posttest feedback on likes, dislikes, and perceived reliability of the tool; and interest in recommending the tool to a colleague.

RESULTS

On a 7-point Likert scale, pharmacists rated ease (mean 5.98, SD 1.38) and satisfaction (mean 6.31, SD 1.34) with the combined POCI tool higher than the physicians, nurse practitioner, and physician's assistants (ease: mean 5.57, SD 1.64, and satisfaction: mean 5.82, SD 1.60). Pharmacists spent longer (mean 2 minutes, 26 seconds, SD 1 minute, 41 seconds) on average finding an answer to their question than the physicians, nurse practitioner, and physician's assistants (mean 1 minute, 40 seconds, SD 1 minute, 23 seconds).

CONCLUSIONS

Overall, the tool performed well, but this usability evaluation identified multiple opportunities for improvement that would help inexperienced users.

Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis

OBJECTIVE

To evaluate the comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and World Health Organization's International Clinical Trials Registry Platform from database inception to 20 February 2022.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials of analgesic medicines (eg, non-steroidal anti-inflammatory drugs, paracetamol, opioids, anti-convulsant drugs, skeletal muscle relaxants, or corticosteroids) compared with another analgesic medicine, placebo, or no treatment. Adults (≥18 years) who reported acute non-specific low back pain (for less than six weeks).

DATA EXTRACTION AND SYNTHESIS

Primary outcomes were low back pain intensity (0-100 scale) at end of treatment and safety (number of participants who reported any adverse event during treatment). Secondary outcomes were low back specific function, serious adverse events, and discontinuation from treatment. Two reviewers independently identified studies, extracted data, and assessed risk of bias. A random effects network meta-analysis was done and confidence was evaluated by the Confidence in Network Meta-Analysis method.

RESULTS

98 randomised controlled trials (15 134 participants, 49% women) included 69 different medicines or combinations. Low or very low confidence was noted in evidence for reduced pain intensity after treatment with tolperisone (mean difference -26.1 (95% confidence intervals -34.0 to -18.2)), aceclofenac plus tizanidine (-26.1 (-38.5 to -13.6)), pregabalin (-24.7 (-34.6 to -14.7)), and 14 other medicines compared with placebo. Low or very low confidence was noted for no difference between the effects of several of these medicines. Increased adverse events had moderate to very low confidence with tramadol (risk ratio 2.6 (95% confidence interval 1.5 to 4.5)), paracetamol plus sustained release tramadol (2.4 (1.5 to 3.8)), baclofen (2.3 (1.5 to 3.4)), and paracetamol plus tramadol (2.1 (1.3 to 3.4)) compared with placebo. These medicines could increase the risk of adverse events compared with other medicines with moderate to low confidence. Moderate to low confidence was also noted for secondary outcomes and secondary analysis of medicine classes.

CONCLUSIONS

The comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain are uncertain. Until higher quality randomised controlled trials of head-to-head comparisons are published, clinicians and patients are recommended to take a cautious approach to manage acute non-specific low back pain with analgesic medicines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019145257.

Clinical questions in primary care: Where to find the answers - a cross-sectional study

Introduction

Clinicians raise at least one question for every two patients they see, but search for an answer to less than half of these questions, and rarely use evidence-based resources. One barrier to evidence-based practice is doubt that the search would yield an answer, and we found insufficient evidence to refute this concern. This study aims to identify what proportion of clinical questions in primary care can be answered with online evidence-based practice resources, and what proportion of these can be answered with pre-appraised evidence.

Materials and methods

Cross-sectional study in two primary care practices. The inclusion criteria were family doctors, generalists and residents working in 2 selected practices. We collected a total of 238 questions from 19 family medicine specialists, 9 family medicine residents and 3 generalist doctors. Doctors were asked to record any clinical question that arose during 4 days of appointments. The primary outcome was the proportion of clinical questions answered with online evidence-based practice resources. The secondary outcome was the level of evidence needed to reach to find the answers (clinical summaries, systematic guidelines, systematic reviews or primary studies), according to Haynes’ pre-appraised evidence pyramid model.

Results

191 of the 206 valid clinical questions could be answered with online evidence-based practice resources (92.7% [95% CI 88.3%-95.9%]). Most of these questions (90.8% CI 95% 85.9%-94.4%) were successfully answered using clinical summaries (BMJ Best Practice, DynaMed or UpToDate), with a median search time of 4 minutes (range 1–16.5).

Conclusions

Contrary to clinician’s beliefs, the majority of clinical questions can be answered with online evidence-based practice resources, and most of them with pre-appraised evidence. This study could encourage family doctors to increase the use of clinical summaries. Furthermore, these results highlight the importance of teaching how to search for and apply pre-appraised evidence.

[Point-of-care information in GP practices: Results of a survey among German GP specialists and GP trainees]

BACKGROUND

Specific questions often arise in the context of consultations regarding, for example, diagnostics and therapeutic management. This case-specific search for information is referred to as point-of-care information. In recent years, it has been influenced by an increase in digitalization and by the development of medical expert systems providing information for medical professionals. Data on the search behavior of German general practitioners (GPs) using digital media for obtaining point-of-care information have so far not been available. The aims of this study were to describe occasion-related point-of-care information as a function of the continuing education status and to identify requirements for online research platforms.

METHODS

In a cross-sectional survey, 829 GP specialists (FÄ) and 475 physicians in training (ÄiW) were invited to answer a self-developed, partially standardized questionnaire.

RESULTS

In total, 356 questionnaires were returned (response rate: 27%). Of these, 241 (68%) were answered by FÄ and 110 (31%) by ÄiW; five participants did not provide information on their specialist status. 66% of the FÄ and 89% of the ÄiW look up information every day. 46% of the FÄ and 73% of the ÄiW use their smartphone for this purpose. Both groups most often search for medical content (94%) and for information on medications (84%). Medical expert systems are more often used by ÄiW than by FÄ; 59% of the FÄ and 82% of the ÄiW are willing to pay a fee for these services. A quick overview and relevance of information were perceived as important criteria for good information sources.

DISCUSSION

German GPs frequently search for occasion-related information. There are generation-related differences regarding, among other things, the use of and the receptiveness to fee-based expert systems. The clarity of presentation and the relevance of the information provided are important requirements of effective information platforms.

CONCLUSION

The quick search for evidence-based information relevant to clinical practice presents a challenge, particularly in broad-range specialties such as general medicine. Web-based sources are becoming increasingly popular in this regard - a trend likely to intensify in future generations of physicians. This offers great potential for medical expert systems and app-based access to best-practice guidelines. These formats should be further developed in collaboration with scientific professional societies.

Doctor! Did you Google my symptoms? A qualitative study of patient perceptions of doctors' point-of-care information seeking

OBJECTIVE

To explore patient perceptions regarding doctors' information seeking during consultations.

DESIGN AND SETTING

Qualitative interviews with participants from six general practice waiting rooms in South East Queensland, Australia. Participants were asked about their experiences and opinions, and to comment on short videos of simulated consultations in which a doctor sought information. The interviews were analysed through a process of iterative thematic analysis using the framework of Braun and Clarke.

PARTICIPANTS

The 16 participants were purposively sampled including 5 men and 11 women from a diverse range of educational and age groups.

RESULTS

How a doctor's need to look up information impacted patient impressions of competence and trust was an overarching theme. The four dominant themes include: the trust a patient has in the doctor before the consultation, whether the doctor is expected to know the answer to a question without searching, has the doctor added value to the consultation by searching and the consultation skills used in the process.

CONCLUSIONS

Patient trust is fundamental to positive perceptions of general practitioners' information seeking at the point-of-care. Communication is key to building this trust. Understanding the patient's agenda, listening, assessing thoroughly and being honest and transparent about the need to seek information all contribute to a positive experience.

BioADAPT-MRC: adversarial learning-based domain adaptation improves biomedical machine reading comprehension task

MOTIVATION

Biomedical machine reading comprehension (biomedical-MRC) aims to comprehend complex biomedical narratives and assist healthcare professionals in retrieving information from them. The high performance of modern neural network-based MRC systems depends on high-quality, large-scale, human-annotated training datasets. In the biomedical domain, a crucial challenge in creating such datasets is the requirement for domain knowledge, inducing the scarcity of labeled data and the need for transfer learning from the labeled general-purpose (source) domain to the biomedical (target) domain. However, there is a discrepancy in marginal distributions between the general-purpose and biomedical domains due to the variances in topics. Therefore, direct-transferring of learned representations from a model trained on a general-purpose domain to the biomedical domain can hurt the model's performance.

RESULTS

We present an adversarial learning-based domain adaptation framework for the biomedical machine reading comprehension task (BioADAPT-MRC), a neural network-based method to address the discrepancies in the marginal distributions between the general and biomedical domain datasets. BioADAPT-MRC relaxes the need for generating pseudo labels for training a well-performing biomedical-MRC model. We extensively evaluate the performance of BioADAPT-MRC by comparing it with the best existing methods on three widely used benchmark biomedical-MRC datasets-BioASQ-7b, BioASQ-8b and BioASQ-9b. Our results suggest that without using any synthetic or human-annotated data from the biomedical domain, BioADAPT-MRC can achieve state-of-the-art performance on these datasets.

AVAILABILITY AND IMPLEMENTATION

BioADAPT-MRC is freely available as an open-source project at https://github.com/mmahbub/BioADAPT-MRC.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Making National Cancer Institute-Designated Comprehensive Cancer Center Knowledge Accessible to Community Oncologists via an Online Tumor Board: Longitudinal Observational Study

BACKGROUND

Expert knowledge is often shared among multidisciplinary academic teams at tumor boards (TBs) across the country, but these conversations exist in silos and do not reach the wider oncology community.

OBJECTIVE

Using an oncologist-only question and answer (Q&A) website, we sought to document expert insights from TBs at National Cancer Institute-designated Comprehensive Cancer Centers (NCI-CCCs) to provide educational benefits to the oncology community.

METHODS

We designed a process with the NCI-CCCs to document and share discussions from the TBs focused on areas of practice variation on theMednet, an interactive Q&A website of over 13,000 US oncologists. The faculty translated the TB discussions into concise, non-case-based Q&As on theMednet. Answers were peer reviewed and disseminated in email newsletters to registered oncologists. Reach and engagement were measured. Following each Q&A, a survey question asked how the TB Q&As impacted the readers' practice.

RESULTS

A total of 23 breast, thoracic, gastrointestinal, and genitourinary programs from 16 NCI-CCC sites participated. Between December 2016 and July 2021, the faculty highlighted 368 questions from their TBs. Q&As were viewed 147,661 times by 7381 oncologists at 3515 institutions from all 50 states. A total of 277 (75%) Q&As were viewed every month. Of the 1063 responses to a survey question on how the Q&A affected clinicians' practices, 646 (61%) reported that it confirmed their current practice, 163 (20%) indicated that a Q&A would change their future practice, and 214 (15%) reported learning something new.

CONCLUSIONS

Through an online Q&A platform, academics at the NCI-CCCs share knowledge outside the walls of academia with oncologists across the United States. Access to up-to-date expert knowledge can reassure clinicians' practices, significantly impact patient care in community practices, and be a source of new knowledge and education.

Physician Assistant Student Training in Question Formulation: A Quasi-Experiment

PURPOSE

To measure improvement in evidence-based practice (EBP) question formulation skills in physician assistant (PA) students using a new approach that included a rubric.

METHODS

Quasi-experiment study design featuring pre- and posttests in which the participants are their own controls using a paired t-test to measure skills improvement.

RESULTS

Physician assistant students increased their skills in formulating EBP questions by a statistically significant margin.

CONCLUSIONS

This new approach to teaching EBP question formulation with its rubric offers a vehicle for training PA students in question formulation skills that is potentially more versatile than the conventional PICO (Population, Intervention, Comparison, and Outcomes) approach.

OB-Newborn TEACH Cards: A Curricular Tool for Maternal-Child Rotations That Influences Patient Care

INTRODUCTION

Evidence-based medicine (EBM) teaching is most successful when integrated with patient care, but finding time for teaching on inpatient rotations is difficult. Obstetrics (OB)-Newborn TEACH (Teaching Evidence-based medicine And Clinical topics in the Hospital) Cards is a curricular tool for efficient teaching sessions on maternity care rotations. We evaluated the impact of OB-Newborn TEACH Cards on resident EBM attitudes and skills, exposure to clinical topics, and patient management.

METHODS

OB-Newborn TEACH Cards includes 56 cards on obstetrics and newborn topics with background and foreground discussion questions. Residents on a family medicine maternal-child service completed pre- and postrotation surveys to assess the cards' impact on EBM attitudes and skills. Faculty and residents also completed point-of-care surveys to assess the self-reported influence on management decisions.

RESULTS

Of 24 potential resident participants, 58% completed pre- and postrotation surveys, which showed significant increase in perceived EBM skills like applying evidence to a clinical scenario (P=.04), but a decrease in reported attitudes that EBM is realistic (P=.028) and useful (P=.025). Residents agreed the cards exposed them to a variety of topics. Point-of-care surveys (n=58) indicated that 57% of the time respondents used a card to learn about a topic not related to a specific patient. When used to learn about specific patients, the cards influenced self-reported patient care 44% of the time.

CONCLUSION

OB-Newborn TEACH Cards are a promising inpatient teaching tool for improving perceived EBM clinical application, exposing residents to maternal-child topics, and influencing patient care decisions.

Successes, lessons and opportunities: 15-year follow-up of an integrated evidence-based medicine curriculum

In 2005, the Department of Family Medicine at the University of Alberta introduced an evidence-based practice curriculum into the 2-year Family Medicine Residency Program. The curriculum was based on best available evidence, had multiple components and was comprehensive in its approach. It prioritised preappraised summary evidence over in-depth evidence appraisal. This paper describes the lessons learnt over the past 15 years including components that were eventually discontinued. We also discuss additions to the programme including the development of accessible, preappraised, summarised resources. We review the difficulties associated with evaluation and the incorporation of evidence-based practice into all aspects of residency training. Future directions are discussed including the incorporation of shared decision-making at the point of care.

Data Consult Service: Can we use observational data to address immediate clinical needs?

OBJECTIVE

A number of clinical decision support tools aim to use observational data to address immediate clinical needs, but few of them address challenges and biases inherent in such data. The goal of this article is to describe the experience of running a data consult service that generates clinical evidence in real time and characterize the challenges related to its use of observational data.

MATERIALS AND METHODS

In 2019, we launched the Data Consult Service pilot with clinicians affiliated with Columbia University Irving Medical Center. We created and implemented a pipeline (question gathering, data exploration, iterative patient phenotyping, study execution, and assessing validity of results) for generating new evidence in real time. We collected user feedback and assessed issues related to producing reliable evidence.

RESULTS

We collected 29 questions from 22 clinicians through clinical rounds, emails, and in-person communication. We used validated practices to ensure reliability of evidence and answered 24 of them. Questions differed depending on the collection method, with clinical rounds supporting proactive team involvement and gathering more patient characterization questions and questions related to a current patient. The main challenges we encountered included missing and incomplete data, underreported conditions, and nonspecific coding and accurate identification of drug regimens.

CONCLUSIONS

While the Data Consult Service has the potential to generate evidence and facilitate decision making, only a portion of questions can be answered in real time. Recognizing challenges in patient phenotyping and designing studies along with using validated practices for observational research are mandatory to produce reliable evidence.

Clinical Questions Asked by Long-Term Care Providers Through eConsult: A Retrospective Study

Introduction

eConsult allows primary care providers (PCPs) to access timely specialist advice and informs patient care. To understand the use of eConsult in long-term care (LTC) settings, we examined the clinical content and types of questions asked by LTC PCPs.

Methods

A descriptive, retrospective study of eConsults submitted through the Champlain BASE™ eConsult Service between January 1, 2017, and December 31, 2018, by LTC PCPs was conducted. Cases were classified using validated taxonomies. Descriptive statistics were generated for content and question type classifications, service utilization data, and close-out survey responses.

Results

22 LTC PCPs submitted 113 eConsults. They sought advice about drug treatment (58%), diagnosis (44%), and management (38%) in a breadth of clinical areas, often skin-related (39%). Long-term care PCPs frequently asked more than one question type (42%). They received advice within 1 week (91%) and rated eConsult as very helpful and educational. Three case examples are presented.

Conclusion

This study demonstrates the type of advice LTC PCPs are seeking through eConsult and its usefulness in this setting. Long-term care stakeholders are encouraged to consider implementing eConsult in other regions, as a means to improve access to timely specialist advice, support clinical decision-making, and improve residents’ quality of life.

Evaluation of a guidelines website capitalizing on Finnish content and Belgium interface: A pilot study in French general practice

No reference point-of-care, web-based medical compendium is available in general practice in France. We have then conducted the experimentation of EBMPracticeNet, a Belgian website of guidelines translated and adapted from the Finnish EBM Guidelines. We collected data from three sources: (i) the website logbook; (ii) a search-specific assessment questionnaire; (iii) a global assessment questionnaire. A cumulative number of 262 (62.8%) physicians performed at least one search on the website and clicked on average 5.9 times per month. Physicians globally got an accurate answer (74.2%). They found the information provided by the website reliable (92.2%) and useful for practice (78.6%). They perceived the website ergonomics as good. The main reported barriers were the time and effort required to find an accurate answer and the uneven relevance of the information retrieved. Improvements should focus on guidelines indexing and their adaptation to the French context, and training physicians to search medical databases.

A mixed methods study on medicines information needs and challenges in New Zealand general practice

BACKGROUND

Medicines are central to healthcare in aging populations with chronic multi-morbidity. Their safe and effective use relies on a large and constantly increasing knowledge base. Despite the current era of unprecedented access to information, there is evidence that unmet information needs remain an issue in clinical practice. Unmet medicines information needs may contribute to sub-optimal use of medicines and patient harm. Little is known about medicines information needs in the primary care setting. The aim of this study was to investigate the nature of medicines information needs in routine general practice and understand the challenges and influences on the information-seeking behaviour of general practitioners.

METHODS

A mixed methods study involving 18 New Zealand general practitioner participants was undertaken. Quantitative data were collected to characterize the medicines information needs arising during 642 consultations conducted by the participants. Qualitative data regarding participant views on their medicines information needs, resources used, challenges to meeting the needs and potential solutions were collected by semi-structured interview. Integration occurred by comparison of results from each method.

RESULTS

Of 642 consultations, 11% (n = 73/642) featured at least one medicines information need. The needs spanned 14 different categories with dosing the most frequent (26%) followed by side effects (15%) and drug interactions (14%). Two main themes describing the nature of general practitioners' medicines information needs were identified from the qualitative data: a 'common core' related to medicine dose, side effects and interactions and a 'perplexing periphery'. Challenges in the perplexing periphery were the variation in information needs, complexity, 'known unknowns' and 'unknown unknowns'. Key factors affecting general practitioners' strategies for meeting medicines information needs were trust in a resource, presence of the patient, how the information was presented, scarcity of time, awareness of the existence of a resource, and its accessibility.

CONCLUSIONS

General practitioners face challenges in meeting wide-ranging medicines information needs in patients with increasingly complex care needs. Recognising the challenges and factors that influence resource use in practice can inform optimisation of medicines information support resources. Resources for general practitioners must take into account the complexity and time constraints of real-world practice. An individually responsive approach involving greater collaboration with pharmacists and specialist medicines information support services may provide a potential solution.

Addressing Disparities in Physician Access to Information in Support of Evidence-based Practice

The purpose of this study is to determine if Minnesota physicians have access to information resources needed to support evidence-based practice (EBP), which supports a culture of safety and patient-centered care. A survey was used to determine Minnesota physicians' need for, and access to, evidence-based clinical information. A total of 877 responses (6.4% response rate) were included in the data analysis. Participants spent 24 min daily seeking answers to clinical questions and averaged 4.41 questions per day that could not be immediately answered. Physicians reported high levels of information needs met (85.8%), though they reported limited access to drug resources, citation databases, systematic reviews, and full-text books and articles. Results also showed use of unreliable sources to support decision-making. A key finding was the extent to which workplace affiliation broadens disparities in information access. National and regional approaches can work to support EBP by reducing the information gap caused by workplace affiliation and other barriers. Further research should be done to identify partnerships, funding, infrastructure, and support to address these gaps.

Barriers and facilitators to clinical information seeking: a systematic review

OBJECTIVE

The study sought to identify barriers to and facilitators of point-of-care information seeking and use of knowledge resources.

MATERIALS AND METHODS

We searched MEDLINE, Embase, PsycINFO, and Cochrane Library from 1991 to February 2017. We included qualitative studies in any language exploring barriers to and facilitators of point-of-care information seeking or use of electronic knowledge resources. Two authors independently extracted data on users, study design, and study quality. We inductively identified specific barriers or facilitators and from these synthesized a model of key determinants of information-seeking behaviors.

RESULTS

Forty-five qualitative studies were included, reporting data derived from interviews (n = 26), focus groups (n = 21), ethnographies (n = 6), logs (n = 4), and usability studies (n = 2). Most studies were performed within the context of general medicine (n = 28) or medical specialties (n = 13). We inductively identified 58 specific barriers and facilitators and then created a model reflecting 5 key determinants of information-seeking behaviors: time includes subthemes of time availability, efficiency of information seeking, and urgency of information need; accessibility includes subthemes of hardware access, hardware speed, hardware portability, information restriction, and cost of resources; personal skills and attitudes includes subthemes of computer literacy, information-seeking skills, and contextual attitudes about information seeking; institutional attitudes, cultures, and policies includes subthemes describing external individual and institutional information-seeking influences; and knowledge resource features includes subthemes describing information-seeking efficiency, information content, information organization, resource familiarity, information credibility, information currency, workflow integration, compatibility of recommendations with local processes, and patient educational support.

CONCLUSIONS

Addressing these determinants of information-seeking behaviors may facilitate clinicians' question answering to improve patient care.

Why are they not accessing it? User barriers to clinical information access

The Medical Library Association's InSight Initiative provides an open and collaborative environment for library and industry partners to discuss vexing problems and find solutions to better serve their users. The initiative's fifth summit, continuing work from the previous summit, focused on understanding how users discover and access information in the clinical environment. During the summit, participants were divided into working groups and encouraged to create a tangible product as a result of their discussions. At the end of the summit, participants established a framework for understanding users' pain points, discussed possible solutions to those points, and received feedback on their work from an End User Advisory Board comprising physicians, clinical researchers, and clinical faculty in biomedicine. In addition to the pain point framework, participants are developing MLA InSight Initiative Learning content with modules to educate librarians and publishers about critical aspects of user behavior. The 2020 Insight Initiative Fall Forum will serve as a virtual home for constructive dialogue between health sciences librarians and publishers on improving discovery and access to information.

Question formulation skills training using a novel rubric with first-year medical students

Objective:

The authors used an assessment rubric to measure medical students' improvement in question formulation skills following a brief evidence-based practice (EBP) training session conducted by a health sciences librarian.

Method:

In a quasi-experimental designed study, students were assessed using a rubric on their pre-instructional skills in formulating answerable EBP questions, based on a clinical scenario. Following their training, they were assessed using the same scenario and rubric. Student pre- and post-test scores were compared using a paired t-test.

Results:

Students demonstrated statistically significant improvement in their question formulation skills on their post-instructional assessments. The average score for students on the pre-test was 45.5 (SD 11.1) and the average score on the post-test was 65.6 (SD 5.4) with an average increase of 20.1 points on the 70-point scale, p<0.001.

Conclusion:

The brief instructional session aided by the rubric improved students' performance in question formulation skills.

The Online Health Information Needs of Family Physicians: Systematic Review of Qualitative and Quantitative Studies

Background

Digitalization and the increasing availability of online information have changed the way in which information is searched for and retrieved by the public and by health professionals. The technical developments in the last two decades have transformed the methods of information retrieval. Although systematic evidence exists on the general information needs of specialists, and in particular, family physicians (FPs), there have been no recent systematic reviews to specifically address the needs of FPs and any barriers that may exist to accessing online health information.

Objective

This review aims to provide an up-to-date perspective on the needs of FPs in searching, retrieving, and using online information.

Methods

This systematic review of qualitative and quantitative studies searched a multitude of databases spanning the years 2000 to 2020 (search date January 2020). Studies that analyzed the online information needs of FPs, any barriers to the accessibility of information, and their information-seeking behaviors were included. Two researchers independently scrutinized titles and abstracts, analyzing full-text papers for their eligibility, the studies therein, and the data obtained from them.

Results

The initial search yielded 4541 studies for initial title and abstract screening. Of the 144 studies that were found to be eligible for full-text screening, 41 were finally included. A total of 20 themes were developed and summarized into 5 main categories: individual needs of FPs before the search; access needs, including factors that would facilitate or hinder information retrieval; quality needs of the information to hand; utilization needs of the information available; and implication needs for everyday practice.

Conclusions

This review suggests that searching, accessing, and using online information, as well as any pre-existing needs, barriers, or demands, should not be perceived as separate entities but rather be regarded as a sequential process. Apart from accessing information and evaluating its quality, FPs expressed concerns regarding the applicability of this information to their everyday practice and its subsequent relevance to patient care. Future online information resources should cater to the needs of the primary care setting and seek to address the way in which such resources may be adapted to these specific requirements.

CERC: an interactive content extraction, recognition, and construction tool for clinical and biomedical text

Background

Automated summarization of scientific literature and patient records is essential for enhancing clinical decision-making and facilitating precision medicine. Most existing summarization methods are based on single indicators of relevance, offer limited capabilities for information visualization, and do not account for user specific interests. In this work, we develop an interactive content extraction, recognition, and construction system (CERC) that combines machine learning and visualization techniques with domain knowledge for highlighting and extracting salient information from clinical and biomedical text.

Methods

A novel sentence-ranking framework multi indicator text summarization, MINTS, is developed for extractive summarization. MINTS uses random forests and multiple indicators of importance for relevance evaluation and ranking of sentences. Indicative summarization is performed using weighted term frequency-inverse document frequency scores of over-represented domain-specific terms. A controlled vocabulary dictionary generated using MeSH, SNOMED-CT, and PubTator is used for determining relevant terms. 35 full-text CRAFT articles were used as the training set. The performance of the MINTS algorithm is evaluated on a test set consisting of the remaining 32 full-text CRAFT articles and 30 clinical case reports using the ROUGE toolkit.

Results

The random forests model classified sentences as “good” or “bad” with 87.5% accuracy on the test set. Summarization results from the MINTS algorithm achieved higher ROUGE-1, ROUGE-2, and ROUGE-SU4 scores when compared to methods based on single indicators such as term frequency distribution, position, eigenvector centrality (LexRank), and random selection, p < 0.01. The automatic language translator and the customizable information extraction and pre-processing pipeline for EHR demonstrate that CERC can readily be incorporated within clinical decision support systems to improve quality of care and assist in data-driven and evidence-based informed decision making for direct patient care.

Conclusions

We have developed a web-based summarization and visualization tool, CERC (https://newton.isye.gatech.edu/CERC1/), for extracting salient information from clinical and biomedical text. The system ranks sentences by relevance and includes features that can facilitate early detection of medical risks in a clinical setting. The interactive interface allows users to filter content and edit/save summaries. The evaluation results on two test corpuses show that the newly developed MINTS algorithm outperforms methods based on single characteristics of importance.

Analgesic medicines for adults with low back pain: protocol for a systematic review and network meta-analysis

BACKGROUND

There is limited evidence for the comparative effectiveness of analgesic medicines for adults with low back pain. This systematic review and network meta-analysis aims to determine the analgesic effect, safety, acceptability, effect on function, and relative rank according to analgesic effect, safety, acceptability, and effect on function of a single course of [an] analgesic medicine(s) or combination of these medicines for people with low back pain.

METHODS

We will include published and unpublished randomised trials written in any language that compare an analgesic medicine to either another medicine, placebo/sham, or no intervention in adults with low back pain, grouped according to pain duration: acute (fewer than 6 weeks), sub-acute (6 to 12 weeks), and chronic (greater than 12 weeks). The co-primary outcomes are pain intensity following treatment and safety (adverse events). The secondary outcomes are function and acceptability (all-cause dropouts). We will perform a network meta-analysis to compare and rank analgesic medicines. We will form judgements of confidence in the results using the Confidence in Network Meta-Analysis (CINeMA) methodology.

DISCUSSION

This network meta-analysis will establish which medicine, or combination of medicines, is most effective for reducing pain and safest for adults with low back pain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019145257.

Quick Response Codes: An Innovative Approach to Just-in-Time Education

BACKGROUND

Many nurses are digital natives who have grown up with advanced technology. Bedside competence is essential, and written policies and procedures guide our practice. Newer learning styles, time constraints, and available personnel may be barriers to historical approaches to information dissemination.

METHODS

Quick Response code technology was incorporated to provide just-in-time resources that can be readily accessed at the point of care.

RESULTS

Nurses have incorporated Quick Response codes in novel ways to provide quick resources in a dynamic environment. Examples include orientation documents, educational rollouts, infrequently used and high-risk equipment, and leadership updates.

IMPLICATIONS

Bedside nurses in our institution have embraced this technology. Benefits include engagement, increased knowledge, and a sense of value among our nursing team.

Agreement between ranking metrics in network meta-analysis: an empirical study

OBJECTIVE

To empirically explore the level of agreement of the treatment hierarchies from different ranking metrics in network meta-analysis (NMA) and to investigate how network characteristics influence the agreement.

DESIGN

Empirical evaluation from re-analysis of NMA.

DATA

232 networks of four or more interventions from randomised controlled trials, published between 1999 and 2015.

METHODS

We calculated treatment hierarchies from several ranking metrics: relative treatment effects, probability of producing the best value [Formula: see text] and the surface under the cumulative ranking curve (SUCRA). We estimated the level of agreement between the treatment hierarchies using different measures: Kendall's τ and Spearman's ρ correlation; and the Yilmaz [Formula: see text] and Average Overlap, to give more weight to the top of the rankings. Finally, we assessed how the amount of the information present in a network affects the agreement between treatment hierarchies, using the average variance, the relative range of variance and the total sample size over the number of interventions of a network.

RESULTS

Overall, the pairwise agreement was high for all treatment hierarchies obtained by the different ranking metrics. The highest agreement was observed between SUCRA and the relative treatment effect for both correlation and top-weighted measures whose medians were all equal to 1. The agreement between rankings decreased for networks with less precise estimates and the hierarchies obtained from [Formula: see text] appeared to be the most sensitive to large differences in the variance estimates. However, such large differences were rare.

CONCLUSIONS

Different ranking metrics address different treatment hierarchy problems, however they produced similar rankings in the published networks. Researchers reporting NMA results can use the ranking metric they prefer, unless there are imprecise estimates or large imbalances in the variance estimates. In this case treatment hierarchies based on both probabilistic and non-probabilistic ranking metrics should be presented.

Personal, technical and organisational factors affect whether physicians seek answers to clinical questions during patient care: a literature review

BACKGROUND

Numerous questions are generated for physicians during patient care. Facilitators and barriers affect the physicians' clinical information-seeking behaviour. While most health studies have focused on barriers, few have dealt with facilitators.

OBJECTIVE

This review aimed to identify facilitators in physicians' information-seeking behaviour to help respond to clinical questions raised during patient care.

METHODS

A narrative review was conducted, and 9 databases were searched. Selection criteria included original articles in the context of patient care and full-text articles published in the English language from 2002 to 2019. The articles were selected and analysed by group discussions.

RESULTS

Analysis of studies disclosed personal, technical and organisational facilitators including 26 themes. Internet utilisation and information searching skills, more available time, personal interests and knowing preferred sites or textbooks were among the personal factors. The most common technical factors included providing navigation support, and ease of searching and finding needed information. The most commonly reported factors at the organisational level are closeness to Internet facility and access during the consultation.

CONCLUSION

Information systems designers, health service managers and librarians may need to work together to provide systems and settings that encourage doctors to seek information to answer their clinical questions during patient care.

Characterizing physicians' information needs related to a gap in knowledge unmet by current evidence

OBJECTIVE

The study sought to explore information needs arising from a gap in clinicians' knowledge that is not met by current evidence and identify possible areas of use and target groups for a future clinical decision support system (CDSS), which will guide clinicians in cases where no evidence exists.

MATERIALS AND METHODS

We interviewed 30 physicians in a large academic medical center, analyzed transcripts using deductive thematic analysis, and developed a set of themes of information needs related to a gap in knowledge unmet by current evidence. We conducted additional statistical analyses to identify the correlation between clinical experience, clinical specialty, settings of clinical care, and the characteristics of the needs.

RESULTS

This study resulted in a set of themes and subthemes of information needs arising from a gap in current evidence. Experienced physicians and inpatient physicians had more questions and the number of questions did not decline with clinical experience. The main areas of information needs included patients with comorbidities, elderly and children, new drugs, and rare disorders. To address these questions, clinicians most often used a commercial tool, guidelines, and PubMed. While primary care physicians preferred the commercial tool, specialty physicians sought more in-depth knowledge.

DISCUSSION

The current medical evidence appeared to be inadequate in covering specific populations such as patients with multiple comorbidities and elderly, and was sometimes irrelevant to complex clinical scenarios. Our findings may suggest that experienced and inpatient physicians would benefit from a CDSS that generates evidence in real time at the point of care.

CONCLUSIONS

We found that physicians had information needs, which arose from the gaps in current medical evidence. This study provides insights on how the CDSS that aims at addressing these needs should be designed.

Physicians perspectives about medical sources of information: protocol for an overview of systematic reviews

Introduction

Despite the growing availability of evidence and sources of information, it is not clear what are the physicians preferences for filling gaps in their medical knowledge.

Objective

To summarize the available evidence about physicians preferences and perceived barriers and facilitators about sources of information.

Methods

We will undertake an overview of systematic reviews according to PRISMA guidelines. We will search Epistemonikos from inception until March 2019. We will also search PROSPERO, and we will perform a forward citation search in Scopus. Inclusion criteria will consider systematic reviews (qualitative, quantitative, or mixed methods) focusing on physicians preferences about sources of information, as well as perceived barriers and facilitators. Two authors will independently screen and select records for inclusion. We will appraise the quality of included systematic reviews using the Joanna Briggs Institute checklist, and the overlap of primary studies according to the corrected covered area formula. We will conduct a narrative synthesis of quantitative data and a thematic analysis of qualitative findings.

Discussion

We expect that our findings will contribute to improving the evidence-based general practice by identifying physicians perspectives about different sources of medical information.

Interest of a general practitioner pharmacovigilance network to provide drug information: A comparative study in France

INTRODUCTION

Since 2015, Toulouse University PharmacoVigilance Center (TUPVC) set up a pharmacovigilance (PV) general practitioner (GP) network, called PharmacoMIP-MG. A clinical research assistant (CRA) moves to the office of GPs included in the PharmacoMIP-MG network (PMIP-GPs). There, he collects the adverse drug reaction (ADR) reports and drug-related questions. This additional support is not available to GPs not included in the PV network (NoPMIP-GPs) who have to ask drug questions spontaneously to the TUPVC.

OBJECTIVE

The objective of this study was to compare the number and characteristics of drug questions between PMIP-GPs and NoPMIP-GPs.

METHODS

All questions asked by GPs to the TUPVC from 01 Jan 2015 to 31 Dec 2017 were reviewed. Questions were classified into two groups: "general" and "related to a patient". The "related to a patient" category was divided in three subgroups: "ADRs", Drug-Drug Interactions and "Drug Management". Drugs were classified according to anatomical therapeutic chemical (ATC) classification. For comparisons, Wilcoxon test, Chi² test or Fisher test were used.

RESULTS

During the study period, the CRA collected 293 questions from the 165 PMIP-GPs. TUPVC received 333 questions asked spontaneously by the 3400 NoPMIP-GPs. PMIP-GPs asked significantly 3 times more questions than NoPMIP-GPs. Most of the GP questions were classified in the "related to a patient" category (74.9%). When we compared the proportion of "related to a patient" to "general" questions, there was no statistically significant difference between PMIP-GPs and NoPMIP-GPs. PMIP-GPs asked more questions about "ADRs", but less on "Drug Management" and or "Drug-Drug Interactions". The drugs most frequently involved were amiodarone, rivaroxaban and levothyroxine.

CONCLUSION

This is the first study about GPs' drug-related questions asked to a PV center. We found that an organization, such as a CRA-GP "face to face" visit, increased the number of drug questions. This kind of organization should be developed in order to improve independent drug information outreach.

Internists' Misconceptions About PPIs: Increasing Knowledge and Implementing Guidelines

Misconceptions about proton-pump inhibitor (PPI) adverse effects were common among internists, and many had changed prescribing. Among 4 scenarios representing a risk spectrum for upper gastrointestinal bleeding, 86% of physicians properly chose discontinuing PPI for a minimum-risk patient with previous gastroesophageal reflux disease, but 79% inappropriately chose discontinuing PPI for a high-risk patient with a peptic ulcer history taking low-dose aspirin. Physician self-assessment is often inaccurate. Time barriers to learning and unanswered clinical questions, especially drug issues, are common. Unscientific information can influence both physicians and patients. Strategies for increasing the guideline implementation include making scientific information available more rapidly and systematically monitoring guideline use.

Translating Clinical Questions by Physicians Into Searchable Queries: Analytical Survey Study

BACKGROUND

Staying up to date and answering clinical questions with current best evidence from health research is challenging. Evidence-based clinical texts, databases, and tools can help, but clinicians first need to translate their clinical questions into searchable queries. MacPLUS FS (McMaster Premium LiteratUre Service Federated Search) is an online search engine that allows clinicians to explore multiple resources simultaneously and retrieves one single output that includes the following: (1) evidence from summaries (eg, UpToDate and DynaMed), (2) preappraised research (eg, EvidenceAlerts), and (3) non-preappraised research (eg, PubMed), with and without validated bibliographic search filters. MacPLUS FS can also be used as a laboratory to explore clinical questions and evidence retrieval.

OBJECTIVE

Our primary objective was to examine how clinicians formulate their queries on a federated search engine, according to the population, intervention, comparison, and outcome (PICO) framework. Our secondary objective was to assess which resources were accessed by clinicians to answer their questions.

METHODS

We performed an analytical survey among 908 clinicians who used MacPLUS FS in the context of a randomized controlled trial on search retrieval. Recording account log-ins and usage, we extracted all 1085 queries performed during a 6-month period and classified each search term according to the PICO framework. We further categorized queries into background (eg, "What is porphyria?") and foreground questions (eg, "Does treatment A work better than B?"). We then analyzed the type of resources that clinicians accessed.

RESULTS

There were 695 structured queries, after exclusion of meaningless queries and iterations of similar searches. We classified 56.5% (393/695) of these queries as background questions and 43.5% (302/695) as foreground questions, the majority of which were related to questions about therapy (213/695, 30.6%), followed by diagnosis (48/695, 6.9%), etiology (24/695, 3.5%), and prognosis (17/695, 2.5%). This distribution did not significantly differ between postgraduate residents and medical faculty physicians (P=.51). Queries included a median of 3 search terms (IQR 2-4), most often related to the population and intervention or test, rarely related to the outcome, and never related to the comparator. About half of the resources accessed (314/610, 51.5%) were summaries, 24.4% (149/610) were preappraised research, and 24.1% were (147/610) non-preappraised research.

CONCLUSIONS

Our results, from a large sample of real-life queries, could guide the development of educational interventions to improve clinicians' retrieval skills, as well as inform the design of more useful evidence-based resources for clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02038439; https://www.clinicaltrials.gov/ct2/show/NCT02038439.

Clinical information seeking behavior of physicians: A systematic review

INTRODUCTION

Physicians encounter a large number of questions during patient care. Therefore, finding high-quality evidence provides a good opportunity to improve patient care and continue learning.

OBJECTIVES

The present study aims to obtain a comprehensive understanding of the physicians' clinical information-seeking behavior.

METHODS

A systematic review was conducted according to the PRISMA guidelines. The Web of Science, PubMed, Scopus, ProQuest, Emerald, Wiley Online Library, Science Direct, Cochrane Library, and Embase databases were systematically searched based on the defined criteria. The inclusion criteria were the original articles in the context of patient care and full-text articles published in English from 2002 to 2017. The articles were reviewed, selected, and analyzed in group discussions.

RESULTS

Seventy-three articles met the study criteria. Therapy, diagnosis, and epidemiology ranked the highest ones among physicians' information needs. The mean frequency of questions raised during patient care was varied from 0.18 to 1.5 per patient, and the percentage of questions answered ranged between 22.8 and 93 %. The time taken to find the answers to the questions was between 2 to 32 min. Consultation with colleagues, alongside reviewing journal articles, Internet websites, textbooks, and MEDLINE/PubMed were the most frequently used sources reported in the retrieved articles. Further, common search strategies used by physicians included keywords, Boolean operators, similar medical terms, and advanced search. In addition, lack of time, and information searching skills and the unawareness of accessible sources were the most frequent barriers while easily searching and finding information and summaries and synthesized evidence-based materials mainly facilitated information seeking.

CONCLUSIONS

Physicians increasingly encounter clinical point-of-care questions. However, the facilitation of accessing online information sources has not enabled the physicians to find answers to many of their questions. Considering the fact that they often refer to colleagues, Internet websites, and databases to find answers, the quality of information should be improved by evaluating the physicians' information-seeking behavior in the first stage, and developing information technology in a point-of-care environment, integrating EHR systems to communicate with colleagues, and accessing databases in the second stage.

Generating comparative evidence on new drugs and devices before approval

Fewer than half of new drugs have data on their comparative benefits and harms against existing treatment options at the time of regulatory approval in Europe and the USA. Even when active-comparator trials exist, they might not produce meaningful data to inform decisions in clinical practice and health policy. The uncertainty associated with the paucity of well designed active-comparator trials has been compounded by legal and regulatory changes in Europe and the USA that have created a complex mix of expedited programmes aimed at facilitating faster access to new drugs. Comparative evidence generation is even sparser for medical devices. Some have argued that the current process for regulatory approval needs to generate more evidence that is useful for patients, clinicians, and payers in health-care systems. We propose a set of five key principles relevant to the European Medicines Agency, European medical device regulatory agencies, US Food and Drug Administration, as well as payers, that we believe will provide the necessary incentives for pharmaceutical and device companies to generate comparative data on drugs and devices and assure timely availability of evidence that is useful for decision making. First, labelling should routinely inform patients and clinicians whether comparative data exist on new products. Second, regulators should be more selective in their use of programmes that facilitate drug and device approvals on the basis of incomplete benefit and harm data. Third, regulators should encourage the conduct of randomised trials with active comparators. Fourth, regulators should use prospectively designed network meta-analyses based on existing and future randomised trials. Last, payers should use their policy levers and negotiating power to incentivise the generation of comparative evidence on new and existing drugs and devices, for example, by explicitly considering proven added benefit in pricing and payment decisions.

Prescriber-Initiated Engagement of Pharmacists for Information and Intervention in Programs of All-Inclusive Care for the Elderly

Little is known about the types of drug information inquiries (DIIs) prescribers caring for older adults ask pharmacists during routine practice. The objective of this research was to analyze the types of DIIs prescribing clinicians of Programs of All-Inclusive Care for the Elderly (PACE) made to clinical pharmacists during routine patient care. This was a retrospective analysis of documented pharmacists' encounters with PACE prescribers between March through December, 2018. DIIs were classified using a developed taxonomy that describes prescribers' motivations for consulting with pharmacists and their drug information needs. Prescribers made 414 DIIs during the study period. Medication safety concerns motivated the majority of prescribers' inquiries (223, 53.9%). Inquiries received frequently involved modifying drug therapy (94, 22.7%), identifying or resolving adverse drug events (75, 18.1%), selecting or adjusting doses (61, 14.7%), selecting new drug therapies (57, 13.8%), and identifying or resolving drug interactions (52, 12.6%). Central nervous system medications (e.g., antidepressants and opioids), were involved in 38.6% (n = 160) of all DIIs. When answering DIIs, pharmacists made 389 recommendations. Start alternative medications (18.0%), start new medications (16.7%), and change doses (12.1%) were the most frequent recommendations rendered. Prescribers implemented at least 79.3% (n = 268) of recommendations based on pharmacy records (n = 338 verifiable recommendations). During clinical practice, PACE prescribers commonly ask pharmacists a variety of DIIs, largely related to medication safety concerns. In response to these DIIs, pharmacists provide medication management recommendations, which are largely implemented by prescribers.

Content analysis of clinical questions from Australian general practice which are prioritised for answering: identifying common question types and perceived knowledge gaps

Perceived knowledge gaps in general practice are not well documented but must be understood to ensure relevant and timely evidence for busy general practitioners (GPs) which reflects their diverse and changing needs. The aim of this study was to classify the types of questions submitted by Australian GPs to an evidence-based practice information service using established and inductive coding systems. We analysed 126 clinical questions submitted by 53 Australian GPs over a 1.5-year period. Questions were coded using the International Classification of Primary Care (ICPC-2 PLUS) and Ely and colleagues' generic questions taxonomy by two independent coders. Inductive qualitative content analysis was also used to identify perceived knowledge gaps. Treatment (71%), diagnosis (15%) and epidemiology (9%) were the most common categories of questions. Using the ICPC-2 classification, questions were most commonly coded to the endocrine/metabolic and nutritional chapter heading, followed by general and unspecified, digestive and musculoskeletal. Seventy per cent of all questions related to the need to stay up-to-date with the evidence, or be informed about new tests or treatments (including complementary and alternative therapies). These findings suggest that current guideline formats for common clinical problems may not meet the knowledge demands of GPs and there is gap in access to evidence updates on new tests, treatments and complementary and alternative therapies. Better systems for 'pulling' real-time questions from GPs could better inform the 'push' of more relevant and timely evidence for use in the clinical encounter.

Efficiency as a determinant of loyalty among users of a Community of Clinical Practice: a comparative study between the implementation and consolidation phases

BACKGROUND

A community of clinical practice called the Online Communication Tool between Primary and Hospital Care (ECOPIH) was created to enable primary care and specialist care professionals to communicate with each other in order to resolve real clinical cases, thereby improving communication and coordination between care levels. The present work seeks to analyse whether ECOPIH makes it possible to reduce the number of referrals. To that end, the objectives are: (1) To find out the degree of loyalty among ECOPIH users, by comparing the medical professionals' profiles in the tool's implementation phase to those in its consolidation phase. (2) To evaluate the degree of fulfilment of users' expectations, by establishing the determining factors that had an influence on the physicians' intention to use ECOPIH in the implementation phase and observing whether its use had an effective, direct impact on the number of patient referrals that primary care physicians made to specialist care professionals.

METHODS

Two studies were conducted. Based on a survey of all the physicians in a Primary Care area, Study 1 was a descriptive study in ECOPIH's implementation phase. Study 2 was a randomised intervention study of ECOPIH users in the tool's consolidation phase. The results from both studies were compared. Various bivariate and multivariate statistical techniques (exploratory factor analysis, cluster analysis, logistic regression analysis and ANOVA) were used in both studies, which were conducted on a sample of 111 and 178 physicians, respectively.

RESULTS

We confirmed the existence of an ECOPIH user profile stable across both phases: under-50-year-old women. Regarding the second objective, there were two particular findings. First, the discriminant factors that had an influence on greater ECOPIH use were habitual Social media website and app use and Perceived usefulness for reducing costs. Second, PC professionals who were ECOPIH members made fewer referrals to SC professionals in Cardiology, Endocrinology and Gastroenterology than older PC professionals who were not ECOPIH members.

CONCLUSIONS

The use of a community of clinical practice by primary care and specialist care professionals helps to reduce the number of referrals among medical professionals.