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5S Model Systems Summaries Synopses Syntheses Studies

Searching for the best evidence

Doctors apparently find answers to only a minority of the questions that arise during consultations. Very few questions would be answered during the consultation itself. Most questions are about treatment and are complex, simultaneously inquiring about individual patients and particular areas of knowledge. For the questions that are answered, information is obtained from colleages. Some refer to textbooks and others seek online resources.

Success in delivering evidence-based health care relies heavily on the ready availability of current best evidence about diagnosis, treatment, and prevention of health problems. Ideally these should be tailored to the characteristics and context of the individual patient /population and the resource of the provider. Existing information resources fall short of this idealistic condition.

There is evidence that clinicians are using point-of-care online information systems when they are available [30] and report subesequent benefits to decision making and patients.

Providers and consumers can help themselves to the best current evidence by recognising the most evolved information services in the topic areas of concern to them.

The 5S model [28] [27] provides a model for organisation of evidence based information services.

The 5S approach to evidence-based information access

SYSTEMS SUMMARIES SYNTHESES SYNOPSES STUDIES

Begin the search for evidence to guide clinical decisions at the highest possible level in the 5S pyramid of evidence.

Limitations of the model
a) Higher you go up in the pyramid, fewer are the resources. Although the number of summaries are growing, there will be fewer than 200-300 clinical topics in any one resource because of the cost that needs to keep the full topics up to date.
b) Information processing takes time. From original studies to summaries takes time
c) Reviews of diagnoses, prognoses and aetiology are scarce.
d) Sometimes syntheses may disagree with each other
e) Lower in the pyramid you get a more diverse range of clinical problems

SYSTEMS

The ideal. A perfect evidence-based clinical information system would integrate and concisely summarise all relevant and important research evidence about a clinical problem, and would automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information.

It is important to note that such a system would not tell decision-makers what to do. These judgments need to integrate the system’s evidence with the patient’s circumstances and wishes. The system’s role would be to ensure that the cumulative research evidence concerning the patient’s problem is immediately at hand. Further, to maximise speed of use, our first point of interaction would be a short synopsis, but links to syntheses and then to original studies would be provided so that we could drill down as deeply as needed to verify the accuracy, currency, and details of the synopsis.

The present state of evolution. Current systems don’t reach this level of perfection as yet in commercially available software applications, but production models exist for parts of such systems. Electronic medical record systems with computerised decision support rules have been shown in randomised trials to improve the process and sometimes the outcome of care. However, these systems cover a limited range of clinical problems, are not necessarily based on current best evidence, and are mainly “homebuilt” and thus are not easily transferred to most practice settings.

Internet-based “aggregators” provide a special “5S supermarket” service in providing access to evidence-based information.

CIAP-NSW provides access to a huge collection of texts, journals, and databases, including systems such as Ovid’s Medline, Embase & PsycInfo primary databases, Evidence Based Medicine Reviews (EBMR) providing access to the Cochrane Library, ACP Journal Club, and the Database of Abstracts of Reviews of Evidence (DARE). CIAP even integrates books and other internet aggregators such as Medscape into a single Unified Search Environment (USE)

SUMMARIES

Summaries integrate the best available evidence from the lower layers (drawing on syntheses - systematic reviews - as much as possible) to provide a full range of evidence cencerning management options for a given health problem [29].

The lower layers (Synopses, Syntheses & Studies) most often examine only one aspect of management (e.g. specific drug or drug class such as ACE inhibitors) leaving decision makers to do their own integration.

Summaries should include details of the retrieval process used to find best evidence; the appraisal process for rating the quality of evidence should be explicit and auditable; key references should be provided for all care recommendations; the date of most recent updating should be stated; and updating should be done frequently enough to assure that important new evidence has not been neglected.

Two examples of summaries are Clinical Evidence and PIER. Australian eTG comes close to this kind of EBM summaries. UpToDate is another popular source of summarised evidence, but it is not explicit about the processes it uses to ensure that all relevant evidence is reviewed, assessed, and included.

The problem with all summaries is that it takes time for the summaries to be authored. It takes at least six months or more from a primary study to a summary.

SYNOPSES

What busy practitioner has time to use evidence-based resources if the evidence is presented in its original form or even as detailed systematic reviews? Although these detailed articles and reviews are essential building blocks, they are often too heavy to lift on the run. The perfect synopsis of a review or original study would provide only, and exactly, enough information to support a clinical action. The declarative title for each abstract that appears in ACP Journal Club and Evidence Based Medicine represents an attempt at this.

For example, “Review: low-molecular-weight heparin is effective and safe in the acute coronary syndromes”. In some circumstances, this title provides enough information to allow the decision-maker either to proceed, assuming familiarity with the nature of the intervention and its alternatives, or to look further for the details, which, for an ideal synopsis, are immediately at hand. The full abstract for this item is in ACP Journal Club, with an abstract and commentary on one page, accessible in the original print issue or electronically. Electronic access is definitely the best way to go for all these resources.