Stephen A. Martin, MD, EdM

Patients who suffer a stroke rarely have just one vascular risk factor. Therefore, the approach to secondary stroke prevention must be multifactorial. In fact, it has been estimated that 80% of recurrent strokes could be prevented through the application of a comprehensive, multifactorial approach that includes lifestyle modification and optimal medical management.¹ Such an achievement would save millions of people from disability and functional decline, as well as millions of dollars in related medical costs.

The initial approach to patients with stroke is focused on stabilization and a rapid work-up to identify the most likely etiology. Common causes of stroke include large artery atherosclerosis, cardiac emboli, and small vessel disease; less common causes include dissection, aortic emboli, and non-atherosclerotic vascular disease. If a complete diagnostic work-up is unrevealing, the stroke is said to be cryptogenic. Determining the correct etiology of a stroke is paramount to preventing secondary stroke (FIGURE^2-13).

Effective secondary prevention strategies designed to prevent a stroke or transient ischemic attack (TIA) in a patient with a known history of either event include lifestyle modifications, medications, and when appropriate, mechanical interventions. As a primary care physician (PCP), you are uniquely positioned to spearhead the prevention of secondary strokes: Not only are you at the forefront of prevention and the use of techniques such as motivational interviewing, but you also have longstanding relationships with many of your patients. In fact, the success of many interventions is improved by the informed, enduring, and trusting nature of relationships between patients and their PCPs.

In the first part of this 2-part series, we focused on subacute stroke management and outlined the recommended work-up for subacute stroke/TIA (see “Stroke: A road map to subacute management,” 2017;66:366-374). In this part, we focus on secondary prevention. The more common modifiable conditions encountered in primary care are discussed here, while many of the more rare etiologies (hypercoagulable states, sickle cell disease, and vasculitis) are outside the scope of this article.

Lifestyle interventions: Target tobacco use, obesity, alcohol intake

Lifestyle modifications can have a positive impact on many of America’s most prevalent diseases, and stroke is no exception.¹⁴ Many of the disease states identified as risk factors for stroke (type 2 diabetes, hypertension, dyslipidemia) are exacerbated by tobacco use, obesity, and excessive alcohol intake.

Does your patient smoke? Up to 25% of all strokes are directly attributable to cigarette smoking.¹⁵ Smoking raises an individual’s risk for stroke in a dose-dependent fashion.^15,16 One study demonstrated that, compared to never-smokers, women ages 15 to 49 years who smoked a half-pack per day had an odds ratio for ischemic stroke of 2.2; those who smoked 2 packs per day had an odds ratio of 9.1.¹⁷ After cessation, stroke risk generally returns to baseline within 5 years.¹⁶ Thus, smoking cessation is among the most significant steps a patient can take to reduce the risk of both primary and secondary stroke.

Is your patient overweight? While obesity in and of itself is a risk factor for stroke, a focus on nutrition and physical activity as mechanisms for weight loss is far superior to focusing on either element alone. Physical activity—consisting of at least 40 minutes of moderate intensity aerobic exercise 3 to 4 times per week—and a diet that emphasizes fruits and vegetables, whole grains, and healthy fats, have both independently demonstrated benefits in secondary stroke prevention and are important parts of American College of Cardiology (ACC)/American Heart Association (AHA) guidelines.^2,3

It’s estimated that 80% of recurrent strokes could be prevented through the application of a comprehensive, multifactorial approach that includes optimal medical management.

The Mediterranean Diet, which emphasizes consumption of fruits and vegetables, legumes, tree nuts, olive oil, and lean protein, has long been associated with cardiovascular benefit.¹⁸ One prospective, randomized, single-blinded trial involving approximately 600 patients that looked at secondary prevention of coronary heart disease found that following the diet significantly reduced mortality compared with a usual prudent post-infarct diet (number needed to treat [NNT]=30 over 4 years).¹⁹

Is alcohol consumption an issue? Chronic heavy alcohol intake contributes to the development of hemorrhagic and ischemic stroke through multiple mechanisms, including alcohol-induced hypertension, alcoholic cardiomyopathy, and atrial fibrillation (AF). Light or moderate alcohol consumption has a paradoxical mild protective effect on ischemic stroke, thought to possibly be mediated by an increase in high-density lipoprotein (HDL) level and mild antiplatelet effect.³

AHA/American Stroke Association (ASA) guidelines indicate that no more than one standard drink per day for women and 2 drinks per day for men is reasonable.³ Counsel patients who drink in excess of this about the benefits of decreasing alcohol intake or abstaining altogether.

Choosing medications to manage BP, cholesterol, and clotting

Optimize blood pressure control. Blood pressure (BP) plays a critical role in both the management and prevention of stroke and is considered to be the most important modifiable risk factor in both primary and secondary stroke prevention.²⁰ In the first 24 to 48 hours following a cerebral ischemic event that is not eligible for thrombolysis, permissive hypertension (treating BP only if it exceeds 220/120 mm Hg unless there is a concurrent medical illness that requires you do so) is appropriate, as hypotension or rapid fluctuations in BP can be harmful.²¹

This flexibility does not continue into the subacute phase of management (at a minimum, after the initial 48 hours) or into secondary prevention. Initiation and titration of oral agents to gradually achieve a BP <140/90 mm Hg or a reduction of 10/5 mm Hg for patients already within optimal range are the most widely recognized goals.^3,20 Patients with stroke secondary to small vessel disease may benefit from an even lower goal of <130/<80 mm Hg.¹¹ Encourage patients to monitor their BP at home for added accuracy and consistency.²²

Pharmacologic BP management is appropriate for patients who are consistently above optimal range despite attempting recommended lifestyle modifications. The data are relatively consistent with respect to the effects of different drug classes after a stroke: beta-blockers have no effect on any outcome; thiazide diuretics significantly reduce stroke and total vascular events; angiotensin-converting enzyme (ACE) inhibitors significantly reduce myocardial infarction (MI); and the combination of an ACE inhibitor and thiazide diuretic reduces stroke, MI, and combined vascular events.⁴

This has led many stroke specialists to recommend the combination of an ACE inhibitor or angiotensin II receptor blocker (ARB) and a thiazide diuretic as a first-line approach to secondary stroke prevention rather than a beta-blocker (assuming there is no additional indication for a beta-blocker). Similarly, there is ample evidence to show that the magnitude of BP reduction is proportional to the reduction in recurrent vascular events.³

Make use of statin therapy—regardless of LDL. The SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial⁵ explored the potential role of statin medication for secondary stroke prevention. Researchers randomly assigned almost 5000 participants who’d had a stroke or TIA one to 6 months before study entry (but had no known history of coronary artery disease) to placebo or a high-intensity statin (80 mg/d atorvastatin). The statin group demonstrated a 4.9-year absolute risk reduction in fatal or nonfatal recurrent stroke of 1.9% (NNT=53).

Given these findings and those from other studies, the AHA and ASA recommend treating patients with stroke or TIA presumed to be of atherosclerotic origin with high-intensity statin therapy, regardless of low-density lipoprotein (LDL) level.³ Of note, statins are not indicated for the secondary prevention of hemorrhagic stroke.

Select antiplatelet therapy based on ischemic stroke subtype. Investigators are still trying to determine the optimal antiplatelet for secondary stroke prevention; it is likely that the ideal choice depends largely on the etiology of the stroke. Trials that did not select patients based on subtype of ischemic stroke have not shown a long-term benefit from dual antiplatelet therapy (clopidogrel and aspirin),^23,24 and one double-blind, multicenter trial involving more than 3000 patients with recent stroke secondary to small vessel disease demonstrated harm from such therapy in terms of a significantly increased risk of bleeding and death.⁶

Smoking cessation is among the most significant steps a patient can take to reduce the risk of both primary and secondary stroke.

However, a 2011 study compared aggressive medical management (aspirin 325 mg/d plus clopidogrel 75 mg/d for 90 days) alone to aggressive medical management plus percutaneous transluminal angioplasty and stenting (PTAS). The study involved almost 500 patients who'd had a recent TIA or stroke attributed to intracranial atherosclerotic stenosis. The authors found that the 30-day rate of stroke or death was 14.7% in the PTAS group vs 5.8% in the medical management group.²⁵

Similarly, a randomized double-blind, placebo-controlled trial published in 2013 involving over 5000 patients in China found that short-term use of dual antiplatelets (clopidogrel and aspirin for the first 21 days after an ischemic event, followed by aspirin monotherapy for 90 days) had an absolute risk reduction of 3.5% without increasing the risk of major bleeding in patients with high-risk TIA or minor stroke.²⁶

All stroke patients who do not have an indication for oral anticoagulation should be placed on long-term daily aspirin (75-325 mg); research has shown that lower doses are as effective as higher doses but with a lower risk of adverse gastrointestinal effects, including bleeding.^3,20 Aspirin 81 mg/d is a common effective dose.

For patients who cannot tolerate aspirin due to allergy, clopidogrel 75 mg/d is a reasonable alternative. Long-term studies of aspirin vs clopidogrel⁷ and clopidogrel vs extended-release dipyridamole⁸ showed no difference in secondary stroke prevention. The International Stroke Trial²⁷ and Chinese Acute Stroke Trial²⁸ both indicate that aspirin should be started as soon as possible after the onset of an acute stroke.

This special population should probably get antiplatelets, too. One recent study explored the use of an antiplatelet vs anticoagulation therapy for stroke patients with carotid artery dissection. The CADISS (Cervical Artery Dissection in Stroke Study) trial²⁹ randomized 250 patients with extracranial carotid and vertebral artery dissection with onset of symptoms within the previous 7 days to either antiplatelet or anticoagulation therapy and found no difference in the primary outcomes of recurrent stroke or death. The study also demonstrated a low risk of recurrent stroke in this population, which was 2% at 3-month follow-up.

Most patients with cervical artery dissection, therefore, are now treated with antiplatelet therapy. That said, situations may still arise in which anticoagulation can be considered, and consultation with a neurologist for guidance on choice of therapy is recommended.

Is an anticoagulant in order? Which agent, when

The most common cause of cardioembolic stroke is AF, which accounts for at least 15% of ischemic strokes, a number that rises in those over the age of 80.^20,30,31 A meta-analysis of more than 28,000 patients with non-valvular AF demonstrated that warfarin reduced the risk of stroke by 64%.³²

All ischemic stroke patients who do not have an indication for oral anticoagulation should be placed on long-term daily aspirin.

The rate of intracerebral hemorrhages during oral anticoagulation ranges from 0.3% to 0.6% per year.³³ The risk of bleeding complications can be mitigated by keeping international normalized ratios ≤3.0, maintaining good BP control, and avoiding concurrent use of antiplatelets in the absence of a clear indication for them.³³

Several risk assessment scores, such as the HAS-BLED,³⁴ can help with estimating the risk of hemorrhagic complications, although these scores have their limitations.^35,36 Even in an older population (mean age 83 years) with a high risk for falls, warfarin provided a net benefit in a composite endpoint of out-of-hospital death or hospitalization for stroke, MI, or hemorrhage in a retrospective study of over 1200 Medicare beneficiaries.³⁷

AF is not the only cause of cardioembolic stroke to consider. Additional high-risk factors warranting anticoagulation include rheumatic mitral valve disease, the presence of mechanical aortic or mitral valves, known mural thrombus, and acute anterior ST segment elevation myocardial infarctions (STEMIs) with resulting anterior apical dyskinesis/akinesis and concurrent ischemic stroke/TIA.³ (The specific management of each of these situations is beyond the scope of this paper.)

The choice of anticoagulation agent is based on multiple factors, including cost, risk of non-reversible bleeding, drug interactions, renal function, and patient preference. Approved options currently include warfarin/­vitamin K antagonist therapy, apixaban, rivaroxaban, dabigatran and edoxaban.³ Choice of therapy will continue to evolve as reversal agents, such as idarucizumab, are developed. Idarucizumab, a reversal agent for dabigatran, received approval from the US Food and Drug Administration in October 2015.³⁸

When to start anticoagulation. There are limited data regarding the optimal timing of initiation of anticoagulation following a stroke; however, a recent multicenter prospective study supported the common practice of initiating anticoagulation therapy within 4 to 14 days of the event.³⁹ Individual patient factors must be taken into consideration, including the size of the stroke (the larger the stroke, the higher the risk for hemorrhagic transformation), BP control, any additional risk factors for bleeding, and the estimated risk of early recurrent stroke.

Bridging patients onto anticoagulation with unfractionated or low-molecular-weight heparin in the setting of acute stroke is not recommended.⁴⁰ Results from randomized controlled trials involving unfractionated heparin, heparinoids, and low-molecular-weight heparin have not reported any benefit to these agents over aspirin at preventing early stroke recurrence.^27,41,42

For immobile or hospitalized patients. Subcutaneous heparin for the prevention of deep vein thrombosis (DVT) during immobility and hospitalization is recommended.⁴³ Patients who cannot tolerate anticoagulation should be maintained on low-dose antiplatelet therapy. Experts do not recommend dual treatment with aspirin and anticoagulation in most cases. However, recent coronary artery stent placement does require temporary dual treatment, with duration dependent on the type of stent placed.

A role for glycemic control? Still to be determined

The specific role of diabetic management in secondary stroke prevention remains unclear. The 2008 ACCORD trial,⁴⁴ a randomized study involving over 10,000 patients with a median glycated hemoglobin level of 8.1%, investigated intensive hyperglycemic control (targeting a glycated hemoglobin level <6.0% vs <7.9%) as a means of decreasing cardiovascular risk. However, the trial ended 17 months early because of an increase in all-cause mortality in the intensive treatment arm compared with the standard management group. The same trial was also unable to demonstrate a decrease in stroke risk with a decrease in A1c.⁴⁴

More recently, the IRIS (Insulin Resistance Intervention after Stroke) trial⁴⁵ (2016) found a 2.8% absolute risk reduction in stroke or MI among participants who had a stroke or TIA in the previous 6 months who were treated with pioglitazone vs placebo over 4.8 years (NNT=36). Participants were required to have insulin resistance, but were excluded if they had diabetes. The authors did, however, report a notable increase in the risk of bone fractures requiring surgery or hospitalization in the pioglitazone arm (5.1% vs 3.2%; number needed to harm [NNH]=53).

Treat patients with stroke or TIA presumed to be of atherosclerotic origin with high-intensity statin therapy, regardless of low-density lipoprotein level.

The impact this single study should have on standard secondary prevention is not yet clear. The authors concluded, “It seems reasonable to consider individual treatment preference and risk of drug-related adverse events in addition to potential benefits when making patient-specific decisions regarding therapy.”⁴⁵

Determining whether mechanical interventions are needed

Almost all conditions leading to stroke warrant active medical management, but a few benefit from procedural intervention, as well.

Extracranial carotid atherosclerosis. Carotid endarterectomy or carotid artery stenting is recommended as secondary prevention for patients with a history of stroke or TIA who have ipsilateral high-grade extracranial carotid stenosis of 70% to 99% and, in some cases, 50% to 69%.^3,9,20 In patients with mild non-disabling stroke, the optimal timing for these procedures is within 2 weeks of the ischemic event. A delay of 6 weeks is generally preferred for moderate or larger strokes to allow for some healing of the injured brain.

The choice of procedure is based on risk profile, with the most important factor being age. For patients >70 years, endarterectomy is preferred because stenting is associated with an increased risk of stroke.^3,9,10 Experts do not recommend either procedure for patients who have had a severe disabling stroke. Generally speaking, these procedures have higher rates of success when they are performed in centers that perform a higher number of these procedures.¹⁰

Vertebrobasilar atherosclerosis. Due to generally good compensatory blood flow of the contralateral vertebral artery in the setting of vertebral artery stenosis, and an unacceptably high complication rate of angioplasty and stenting in the basilar artery, medical management is typically the first-line approach. If a patient has recurrent symptoms in the setting of optimal medical management and a focal lesion that is amenable to an endovascular intervention (most commonly a vertebral artery origin high-grade stenosis), angioplasty and stenting may be considered.¹⁰

Intracranial atherosclerosis. Similarly, medical management is the preferred strategy for intracranial atherosclerosis. Angioplasty and/or stenting are reserved for complex cases or recurrence despite adherence to secondary stroke prevention measures. Ideally, these patients should be managed with long-term aspirin 81 mg/d, adjunctive clopidogrel 75 mg/d for 90 days post stroke, a high-intensity statin, BP optimization, and any relevant lifestyle interventions.¹³

Patent foramen ovale. Research to date has not shown that closure of a patent foramen ovale (PFO) is superior to medical therapy for secondary stroke prevention in patients <60 years with cryptogenic stroke.^12,46,47 The decision to anticoagulate these patients should be based on the presence or absence of a DVT and not on a PFO alone. In patients with an identified DVT and a contraindication to oral anticoagulation, inferior vena cava filter placement should be considered. For patients with ongoing prothrombotic risk thought to increase the chances of future paradoxical embolism, closure of the PFO may be considered.

CORRESPONDENCE
Stephen A. Martin, MD, EdM, Barre Family Health Center, 151 Worcester Road, Barre, MA 01005; [email protected].

Patients who suffer a stroke rarely have just one vascular risk factor. Therefore, the approach to secondary stroke prevention must be multifactorial. In fact, it has been estimated that 80% of recurrent strokes could be prevented through the application of a comprehensive, multifactorial approach that includes lifestyle modification and optimal medical management.¹ Such an achievement would save millions of people from disability and functional decline, as well as millions of dollars in related medical costs.

The initial approach to patients with stroke is focused on stabilization and a rapid work-up to identify the most likely etiology. Common causes of stroke include large artery atherosclerosis, cardiac emboli, and small vessel disease; less common causes include dissection, aortic emboli, and non-atherosclerotic vascular disease. If a complete diagnostic work-up is unrevealing, the stroke is said to be cryptogenic. Determining the correct etiology of a stroke is paramount to preventing secondary stroke (FIGURE^2-13).

Effective secondary prevention strategies designed to prevent a stroke or transient ischemic attack (TIA) in a patient with a known history of either event include lifestyle modifications, medications, and when appropriate, mechanical interventions. As a primary care physician (PCP), you are uniquely positioned to spearhead the prevention of secondary strokes: Not only are you at the forefront of prevention and the use of techniques such as motivational interviewing, but you also have longstanding relationships with many of your patients. In fact, the success of many interventions is improved by the informed, enduring, and trusting nature of relationships between patients and their PCPs.

In the first part of this 2-part series, we focused on subacute stroke management and outlined the recommended work-up for subacute stroke/TIA (see “Stroke: A road map to subacute management,” 2017;66:366-374). In this part, we focus on secondary prevention. The more common modifiable conditions encountered in primary care are discussed here, while many of the more rare etiologies (hypercoagulable states, sickle cell disease, and vasculitis) are outside the scope of this article.

Lifestyle interventions: Target tobacco use, obesity, alcohol intake

Lifestyle modifications can have a positive impact on many of America’s most prevalent diseases, and stroke is no exception.¹⁴ Many of the disease states identified as risk factors for stroke (type 2 diabetes, hypertension, dyslipidemia) are exacerbated by tobacco use, obesity, and excessive alcohol intake.

Does your patient smoke? Up to 25% of all strokes are directly attributable to cigarette smoking.¹⁵ Smoking raises an individual’s risk for stroke in a dose-dependent fashion.^15,16 One study demonstrated that, compared to never-smokers, women ages 15 to 49 years who smoked a half-pack per day had an odds ratio for ischemic stroke of 2.2; those who smoked 2 packs per day had an odds ratio of 9.1.¹⁷ After cessation, stroke risk generally returns to baseline within 5 years.¹⁶ Thus, smoking cessation is among the most significant steps a patient can take to reduce the risk of both primary and secondary stroke.

Is your patient overweight? While obesity in and of itself is a risk factor for stroke, a focus on nutrition and physical activity as mechanisms for weight loss is far superior to focusing on either element alone. Physical activity—consisting of at least 40 minutes of moderate intensity aerobic exercise 3 to 4 times per week—and a diet that emphasizes fruits and vegetables, whole grains, and healthy fats, have both independently demonstrated benefits in secondary stroke prevention and are important parts of American College of Cardiology (ACC)/American Heart Association (AHA) guidelines.^2,3

It’s estimated that 80% of recurrent strokes could be prevented through the application of a comprehensive, multifactorial approach that includes optimal medical management.

The Mediterranean Diet, which emphasizes consumption of fruits and vegetables, legumes, tree nuts, olive oil, and lean protein, has long been associated with cardiovascular benefit.¹⁸ One prospective, randomized, single-blinded trial involving approximately 600 patients that looked at secondary prevention of coronary heart disease found that following the diet significantly reduced mortality compared with a usual prudent post-infarct diet (number needed to treat [NNT]=30 over 4 years).¹⁹

Is alcohol consumption an issue? Chronic heavy alcohol intake contributes to the development of hemorrhagic and ischemic stroke through multiple mechanisms, including alcohol-induced hypertension, alcoholic cardiomyopathy, and atrial fibrillation (AF). Light or moderate alcohol consumption has a paradoxical mild protective effect on ischemic stroke, thought to possibly be mediated by an increase in high-density lipoprotein (HDL) level and mild antiplatelet effect.³

AHA/American Stroke Association (ASA) guidelines indicate that no more than one standard drink per day for women and 2 drinks per day for men is reasonable.³ Counsel patients who drink in excess of this about the benefits of decreasing alcohol intake or abstaining altogether.

Choosing medications to manage BP, cholesterol, and clotting

Optimize blood pressure control. Blood pressure (BP) plays a critical role in both the management and prevention of stroke and is considered to be the most important modifiable risk factor in both primary and secondary stroke prevention.²⁰ In the first 24 to 48 hours following a cerebral ischemic event that is not eligible for thrombolysis, permissive hypertension (treating BP only if it exceeds 220/120 mm Hg unless there is a concurrent medical illness that requires you do so) is appropriate, as hypotension or rapid fluctuations in BP can be harmful.²¹

This flexibility does not continue into the subacute phase of management (at a minimum, after the initial 48 hours) or into secondary prevention. Initiation and titration of oral agents to gradually achieve a BP <140/90 mm Hg or a reduction of 10/5 mm Hg for patients already within optimal range are the most widely recognized goals.^3,20 Patients with stroke secondary to small vessel disease may benefit from an even lower goal of <130/<80 mm Hg.¹¹ Encourage patients to monitor their BP at home for added accuracy and consistency.²²

Pharmacologic BP management is appropriate for patients who are consistently above optimal range despite attempting recommended lifestyle modifications. The data are relatively consistent with respect to the effects of different drug classes after a stroke: beta-blockers have no effect on any outcome; thiazide diuretics significantly reduce stroke and total vascular events; angiotensin-converting enzyme (ACE) inhibitors significantly reduce myocardial infarction (MI); and the combination of an ACE inhibitor and thiazide diuretic reduces stroke, MI, and combined vascular events.⁴

This has led many stroke specialists to recommend the combination of an ACE inhibitor or angiotensin II receptor blocker (ARB) and a thiazide diuretic as a first-line approach to secondary stroke prevention rather than a beta-blocker (assuming there is no additional indication for a beta-blocker). Similarly, there is ample evidence to show that the magnitude of BP reduction is proportional to the reduction in recurrent vascular events.³

Make use of statin therapy—regardless of LDL. The SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial⁵ explored the potential role of statin medication for secondary stroke prevention. Researchers randomly assigned almost 5000 participants who’d had a stroke or TIA one to 6 months before study entry (but had no known history of coronary artery disease) to placebo or a high-intensity statin (80 mg/d atorvastatin). The statin group demonstrated a 4.9-year absolute risk reduction in fatal or nonfatal recurrent stroke of 1.9% (NNT=53).

Given these findings and those from other studies, the AHA and ASA recommend treating patients with stroke or TIA presumed to be of atherosclerotic origin with high-intensity statin therapy, regardless of low-density lipoprotein (LDL) level.³ Of note, statins are not indicated for the secondary prevention of hemorrhagic stroke.

Select antiplatelet therapy based on ischemic stroke subtype. Investigators are still trying to determine the optimal antiplatelet for secondary stroke prevention; it is likely that the ideal choice depends largely on the etiology of the stroke. Trials that did not select patients based on subtype of ischemic stroke have not shown a long-term benefit from dual antiplatelet therapy (clopidogrel and aspirin),^23,24 and one double-blind, multicenter trial involving more than 3000 patients with recent stroke secondary to small vessel disease demonstrated harm from such therapy in terms of a significantly increased risk of bleeding and death.⁶

Smoking cessation is among the most significant steps a patient can take to reduce the risk of both primary and secondary stroke.

However, a 2011 study compared aggressive medical management (aspirin 325 mg/d plus clopidogrel 75 mg/d for 90 days) alone to aggressive medical management plus percutaneous transluminal angioplasty and stenting (PTAS). The study involved almost 500 patients who'd had a recent TIA or stroke attributed to intracranial atherosclerotic stenosis. The authors found that the 30-day rate of stroke or death was 14.7% in the PTAS group vs 5.8% in the medical management group.²⁵

Similarly, a randomized double-blind, placebo-controlled trial published in 2013 involving over 5000 patients in China found that short-term use of dual antiplatelets (clopidogrel and aspirin for the first 21 days after an ischemic event, followed by aspirin monotherapy for 90 days) had an absolute risk reduction of 3.5% without increasing the risk of major bleeding in patients with high-risk TIA or minor stroke.²⁶

All stroke patients who do not have an indication for oral anticoagulation should be placed on long-term daily aspirin (75-325 mg); research has shown that lower doses are as effective as higher doses but with a lower risk of adverse gastrointestinal effects, including bleeding.^3,20 Aspirin 81 mg/d is a common effective dose.

For patients who cannot tolerate aspirin due to allergy, clopidogrel 75 mg/d is a reasonable alternative. Long-term studies of aspirin vs clopidogrel⁷ and clopidogrel vs extended-release dipyridamole⁸ showed no difference in secondary stroke prevention. The International Stroke Trial²⁷ and Chinese Acute Stroke Trial²⁸ both indicate that aspirin should be started as soon as possible after the onset of an acute stroke.

This special population should probably get antiplatelets, too. One recent study explored the use of an antiplatelet vs anticoagulation therapy for stroke patients with carotid artery dissection. The CADISS (Cervical Artery Dissection in Stroke Study) trial²⁹ randomized 250 patients with extracranial carotid and vertebral artery dissection with onset of symptoms within the previous 7 days to either antiplatelet or anticoagulation therapy and found no difference in the primary outcomes of recurrent stroke or death. The study also demonstrated a low risk of recurrent stroke in this population, which was 2% at 3-month follow-up.

Most patients with cervical artery dissection, therefore, are now treated with antiplatelet therapy. That said, situations may still arise in which anticoagulation can be considered, and consultation with a neurologist for guidance on choice of therapy is recommended.

Is an anticoagulant in order? Which agent, when

The most common cause of cardioembolic stroke is AF, which accounts for at least 15% of ischemic strokes, a number that rises in those over the age of 80.^20,30,31 A meta-analysis of more than 28,000 patients with non-valvular AF demonstrated that warfarin reduced the risk of stroke by 64%.³²

All ischemic stroke patients who do not have an indication for oral anticoagulation should be placed on long-term daily aspirin.

The rate of intracerebral hemorrhages during oral anticoagulation ranges from 0.3% to 0.6% per year.³³ The risk of bleeding complications can be mitigated by keeping international normalized ratios ≤3.0, maintaining good BP control, and avoiding concurrent use of antiplatelets in the absence of a clear indication for them.³³

Several risk assessment scores, such as the HAS-BLED,³⁴ can help with estimating the risk of hemorrhagic complications, although these scores have their limitations.^35,36 Even in an older population (mean age 83 years) with a high risk for falls, warfarin provided a net benefit in a composite endpoint of out-of-hospital death or hospitalization for stroke, MI, or hemorrhage in a retrospective study of over 1200 Medicare beneficiaries.³⁷

AF is not the only cause of cardioembolic stroke to consider. Additional high-risk factors warranting anticoagulation include rheumatic mitral valve disease, the presence of mechanical aortic or mitral valves, known mural thrombus, and acute anterior ST segment elevation myocardial infarctions (STEMIs) with resulting anterior apical dyskinesis/akinesis and concurrent ischemic stroke/TIA.³ (The specific management of each of these situations is beyond the scope of this paper.)

The choice of anticoagulation agent is based on multiple factors, including cost, risk of non-reversible bleeding, drug interactions, renal function, and patient preference. Approved options currently include warfarin/­vitamin K antagonist therapy, apixaban, rivaroxaban, dabigatran and edoxaban.³ Choice of therapy will continue to evolve as reversal agents, such as idarucizumab, are developed. Idarucizumab, a reversal agent for dabigatran, received approval from the US Food and Drug Administration in October 2015.³⁸

When to start anticoagulation. There are limited data regarding the optimal timing of initiation of anticoagulation following a stroke; however, a recent multicenter prospective study supported the common practice of initiating anticoagulation therapy within 4 to 14 days of the event.³⁹ Individual patient factors must be taken into consideration, including the size of the stroke (the larger the stroke, the higher the risk for hemorrhagic transformation), BP control, any additional risk factors for bleeding, and the estimated risk of early recurrent stroke.

Bridging patients onto anticoagulation with unfractionated or low-molecular-weight heparin in the setting of acute stroke is not recommended.⁴⁰ Results from randomized controlled trials involving unfractionated heparin, heparinoids, and low-molecular-weight heparin have not reported any benefit to these agents over aspirin at preventing early stroke recurrence.^27,41,42

For immobile or hospitalized patients. Subcutaneous heparin for the prevention of deep vein thrombosis (DVT) during immobility and hospitalization is recommended.⁴³ Patients who cannot tolerate anticoagulation should be maintained on low-dose antiplatelet therapy. Experts do not recommend dual treatment with aspirin and anticoagulation in most cases. However, recent coronary artery stent placement does require temporary dual treatment, with duration dependent on the type of stent placed.

A role for glycemic control? Still to be determined

The specific role of diabetic management in secondary stroke prevention remains unclear. The 2008 ACCORD trial,⁴⁴ a randomized study involving over 10,000 patients with a median glycated hemoglobin level of 8.1%, investigated intensive hyperglycemic control (targeting a glycated hemoglobin level <6.0% vs <7.9%) as a means of decreasing cardiovascular risk. However, the trial ended 17 months early because of an increase in all-cause mortality in the intensive treatment arm compared with the standard management group. The same trial was also unable to demonstrate a decrease in stroke risk with a decrease in A1c.⁴⁴

More recently, the IRIS (Insulin Resistance Intervention after Stroke) trial⁴⁵ (2016) found a 2.8% absolute risk reduction in stroke or MI among participants who had a stroke or TIA in the previous 6 months who were treated with pioglitazone vs placebo over 4.8 years (NNT=36). Participants were required to have insulin resistance, but were excluded if they had diabetes. The authors did, however, report a notable increase in the risk of bone fractures requiring surgery or hospitalization in the pioglitazone arm (5.1% vs 3.2%; number needed to harm [NNH]=53).

Treat patients with stroke or TIA presumed to be of atherosclerotic origin with high-intensity statin therapy, regardless of low-density lipoprotein level.

The impact this single study should have on standard secondary prevention is not yet clear. The authors concluded, “It seems reasonable to consider individual treatment preference and risk of drug-related adverse events in addition to potential benefits when making patient-specific decisions regarding therapy.”⁴⁵

Determining whether mechanical interventions are needed

Almost all conditions leading to stroke warrant active medical management, but a few benefit from procedural intervention, as well.

Extracranial carotid atherosclerosis. Carotid endarterectomy or carotid artery stenting is recommended as secondary prevention for patients with a history of stroke or TIA who have ipsilateral high-grade extracranial carotid stenosis of 70% to 99% and, in some cases, 50% to 69%.^3,9,20 In patients with mild non-disabling stroke, the optimal timing for these procedures is within 2 weeks of the ischemic event. A delay of 6 weeks is generally preferred for moderate or larger strokes to allow for some healing of the injured brain.

The choice of procedure is based on risk profile, with the most important factor being age. For patients >70 years, endarterectomy is preferred because stenting is associated with an increased risk of stroke.^3,9,10 Experts do not recommend either procedure for patients who have had a severe disabling stroke. Generally speaking, these procedures have higher rates of success when they are performed in centers that perform a higher number of these procedures.¹⁰

Vertebrobasilar atherosclerosis. Due to generally good compensatory blood flow of the contralateral vertebral artery in the setting of vertebral artery stenosis, and an unacceptably high complication rate of angioplasty and stenting in the basilar artery, medical management is typically the first-line approach. If a patient has recurrent symptoms in the setting of optimal medical management and a focal lesion that is amenable to an endovascular intervention (most commonly a vertebral artery origin high-grade stenosis), angioplasty and stenting may be considered.¹⁰

Intracranial atherosclerosis. Similarly, medical management is the preferred strategy for intracranial atherosclerosis. Angioplasty and/or stenting are reserved for complex cases or recurrence despite adherence to secondary stroke prevention measures. Ideally, these patients should be managed with long-term aspirin 81 mg/d, adjunctive clopidogrel 75 mg/d for 90 days post stroke, a high-intensity statin, BP optimization, and any relevant lifestyle interventions.¹³

Patent foramen ovale. Research to date has not shown that closure of a patent foramen ovale (PFO) is superior to medical therapy for secondary stroke prevention in patients <60 years with cryptogenic stroke.^12,46,47 The decision to anticoagulate these patients should be based on the presence or absence of a DVT and not on a PFO alone. In patients with an identified DVT and a contraindication to oral anticoagulation, inferior vena cava filter placement should be considered. For patients with ongoing prothrombotic risk thought to increase the chances of future paradoxical embolism, closure of the PFO may be considered.

CORRESPONDENCE
Stephen A. Martin, MD, EdM, Barre Family Health Center, 151 Worcester Road, Barre, MA 01005; [email protected].

Patients who suffer a stroke rarely have just one vascular risk factor. Therefore, the approach to secondary stroke prevention must be multifactorial. In fact, it has been estimated that 80% of recurrent strokes could be prevented through the application of a comprehensive, multifactorial approach that includes lifestyle modification and optimal medical management.¹ Such an achievement would save millions of people from disability and functional decline, as well as millions of dollars in related medical costs.

The initial approach to patients with stroke is focused on stabilization and a rapid work-up to identify the most likely etiology. Common causes of stroke include large artery atherosclerosis, cardiac emboli, and small vessel disease; less common causes include dissection, aortic emboli, and non-atherosclerotic vascular disease. If a complete diagnostic work-up is unrevealing, the stroke is said to be cryptogenic. Determining the correct etiology of a stroke is paramount to preventing secondary stroke (FIGURE^2-13).

Effective secondary prevention strategies designed to prevent a stroke or transient ischemic attack (TIA) in a patient with a known history of either event include lifestyle modifications, medications, and when appropriate, mechanical interventions. As a primary care physician (PCP), you are uniquely positioned to spearhead the prevention of secondary strokes: Not only are you at the forefront of prevention and the use of techniques such as motivational interviewing, but you also have longstanding relationships with many of your patients. In fact, the success of many interventions is improved by the informed, enduring, and trusting nature of relationships between patients and their PCPs.

In the first part of this 2-part series, we focused on subacute stroke management and outlined the recommended work-up for subacute stroke/TIA (see “Stroke: A road map to subacute management,” 2017;66:366-374). In this part, we focus on secondary prevention. The more common modifiable conditions encountered in primary care are discussed here, while many of the more rare etiologies (hypercoagulable states, sickle cell disease, and vasculitis) are outside the scope of this article.

Lifestyle interventions: Target tobacco use, obesity, alcohol intake

Lifestyle modifications can have a positive impact on many of America’s most prevalent diseases, and stroke is no exception.¹⁴ Many of the disease states identified as risk factors for stroke (type 2 diabetes, hypertension, dyslipidemia) are exacerbated by tobacco use, obesity, and excessive alcohol intake.

Does your patient smoke? Up to 25% of all strokes are directly attributable to cigarette smoking.¹⁵ Smoking raises an individual’s risk for stroke in a dose-dependent fashion.^15,16 One study demonstrated that, compared to never-smokers, women ages 15 to 49 years who smoked a half-pack per day had an odds ratio for ischemic stroke of 2.2; those who smoked 2 packs per day had an odds ratio of 9.1.¹⁷ After cessation, stroke risk generally returns to baseline within 5 years.¹⁶ Thus, smoking cessation is among the most significant steps a patient can take to reduce the risk of both primary and secondary stroke.

Is your patient overweight? While obesity in and of itself is a risk factor for stroke, a focus on nutrition and physical activity as mechanisms for weight loss is far superior to focusing on either element alone. Physical activity—consisting of at least 40 minutes of moderate intensity aerobic exercise 3 to 4 times per week—and a diet that emphasizes fruits and vegetables, whole grains, and healthy fats, have both independently demonstrated benefits in secondary stroke prevention and are important parts of American College of Cardiology (ACC)/American Heart Association (AHA) guidelines.^2,3

It’s estimated that 80% of recurrent strokes could be prevented through the application of a comprehensive, multifactorial approach that includes optimal medical management.

The Mediterranean Diet, which emphasizes consumption of fruits and vegetables, legumes, tree nuts, olive oil, and lean protein, has long been associated with cardiovascular benefit.¹⁸ One prospective, randomized, single-blinded trial involving approximately 600 patients that looked at secondary prevention of coronary heart disease found that following the diet significantly reduced mortality compared with a usual prudent post-infarct diet (number needed to treat [NNT]=30 over 4 years).¹⁹

Is alcohol consumption an issue? Chronic heavy alcohol intake contributes to the development of hemorrhagic and ischemic stroke through multiple mechanisms, including alcohol-induced hypertension, alcoholic cardiomyopathy, and atrial fibrillation (AF). Light or moderate alcohol consumption has a paradoxical mild protective effect on ischemic stroke, thought to possibly be mediated by an increase in high-density lipoprotein (HDL) level and mild antiplatelet effect.³

AHA/American Stroke Association (ASA) guidelines indicate that no more than one standard drink per day for women and 2 drinks per day for men is reasonable.³ Counsel patients who drink in excess of this about the benefits of decreasing alcohol intake or abstaining altogether.

Choosing medications to manage BP, cholesterol, and clotting

Optimize blood pressure control. Blood pressure (BP) plays a critical role in both the management and prevention of stroke and is considered to be the most important modifiable risk factor in both primary and secondary stroke prevention.²⁰ In the first 24 to 48 hours following a cerebral ischemic event that is not eligible for thrombolysis, permissive hypertension (treating BP only if it exceeds 220/120 mm Hg unless there is a concurrent medical illness that requires you do so) is appropriate, as hypotension or rapid fluctuations in BP can be harmful.²¹

This flexibility does not continue into the subacute phase of management (at a minimum, after the initial 48 hours) or into secondary prevention. Initiation and titration of oral agents to gradually achieve a BP <140/90 mm Hg or a reduction of 10/5 mm Hg for patients already within optimal range are the most widely recognized goals.^3,20 Patients with stroke secondary to small vessel disease may benefit from an even lower goal of <130/<80 mm Hg.¹¹ Encourage patients to monitor their BP at home for added accuracy and consistency.²²

Pharmacologic BP management is appropriate for patients who are consistently above optimal range despite attempting recommended lifestyle modifications. The data are relatively consistent with respect to the effects of different drug classes after a stroke: beta-blockers have no effect on any outcome; thiazide diuretics significantly reduce stroke and total vascular events; angiotensin-converting enzyme (ACE) inhibitors significantly reduce myocardial infarction (MI); and the combination of an ACE inhibitor and thiazide diuretic reduces stroke, MI, and combined vascular events.⁴

This has led many stroke specialists to recommend the combination of an ACE inhibitor or angiotensin II receptor blocker (ARB) and a thiazide diuretic as a first-line approach to secondary stroke prevention rather than a beta-blocker (assuming there is no additional indication for a beta-blocker). Similarly, there is ample evidence to show that the magnitude of BP reduction is proportional to the reduction in recurrent vascular events.³

Make use of statin therapy—regardless of LDL. The SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial⁵ explored the potential role of statin medication for secondary stroke prevention. Researchers randomly assigned almost 5000 participants who’d had a stroke or TIA one to 6 months before study entry (but had no known history of coronary artery disease) to placebo or a high-intensity statin (80 mg/d atorvastatin). The statin group demonstrated a 4.9-year absolute risk reduction in fatal or nonfatal recurrent stroke of 1.9% (NNT=53).

Given these findings and those from other studies, the AHA and ASA recommend treating patients with stroke or TIA presumed to be of atherosclerotic origin with high-intensity statin therapy, regardless of low-density lipoprotein (LDL) level.³ Of note, statins are not indicated for the secondary prevention of hemorrhagic stroke.

Select antiplatelet therapy based on ischemic stroke subtype. Investigators are still trying to determine the optimal antiplatelet for secondary stroke prevention; it is likely that the ideal choice depends largely on the etiology of the stroke. Trials that did not select patients based on subtype of ischemic stroke have not shown a long-term benefit from dual antiplatelet therapy (clopidogrel and aspirin),^23,24 and one double-blind, multicenter trial involving more than 3000 patients with recent stroke secondary to small vessel disease demonstrated harm from such therapy in terms of a significantly increased risk of bleeding and death.⁶

Smoking cessation is among the most significant steps a patient can take to reduce the risk of both primary and secondary stroke.

However, a 2011 study compared aggressive medical management (aspirin 325 mg/d plus clopidogrel 75 mg/d for 90 days) alone to aggressive medical management plus percutaneous transluminal angioplasty and stenting (PTAS). The study involved almost 500 patients who'd had a recent TIA or stroke attributed to intracranial atherosclerotic stenosis. The authors found that the 30-day rate of stroke or death was 14.7% in the PTAS group vs 5.8% in the medical management group.²⁵

Similarly, a randomized double-blind, placebo-controlled trial published in 2013 involving over 5000 patients in China found that short-term use of dual antiplatelets (clopidogrel and aspirin for the first 21 days after an ischemic event, followed by aspirin monotherapy for 90 days) had an absolute risk reduction of 3.5% without increasing the risk of major bleeding in patients with high-risk TIA or minor stroke.²⁶

All stroke patients who do not have an indication for oral anticoagulation should be placed on long-term daily aspirin (75-325 mg); research has shown that lower doses are as effective as higher doses but with a lower risk of adverse gastrointestinal effects, including bleeding.^3,20 Aspirin 81 mg/d is a common effective dose.

For patients who cannot tolerate aspirin due to allergy, clopidogrel 75 mg/d is a reasonable alternative. Long-term studies of aspirin vs clopidogrel⁷ and clopidogrel vs extended-release dipyridamole⁸ showed no difference in secondary stroke prevention. The International Stroke Trial²⁷ and Chinese Acute Stroke Trial²⁸ both indicate that aspirin should be started as soon as possible after the onset of an acute stroke.

This special population should probably get antiplatelets, too. One recent study explored the use of an antiplatelet vs anticoagulation therapy for stroke patients with carotid artery dissection. The CADISS (Cervical Artery Dissection in Stroke Study) trial²⁹ randomized 250 patients with extracranial carotid and vertebral artery dissection with onset of symptoms within the previous 7 days to either antiplatelet or anticoagulation therapy and found no difference in the primary outcomes of recurrent stroke or death. The study also demonstrated a low risk of recurrent stroke in this population, which was 2% at 3-month follow-up.

Most patients with cervical artery dissection, therefore, are now treated with antiplatelet therapy. That said, situations may still arise in which anticoagulation can be considered, and consultation with a neurologist for guidance on choice of therapy is recommended.

Is an anticoagulant in order? Which agent, when

The most common cause of cardioembolic stroke is AF, which accounts for at least 15% of ischemic strokes, a number that rises in those over the age of 80.^20,30,31 A meta-analysis of more than 28,000 patients with non-valvular AF demonstrated that warfarin reduced the risk of stroke by 64%.³²

All ischemic stroke patients who do not have an indication for oral anticoagulation should be placed on long-term daily aspirin.

The rate of intracerebral hemorrhages during oral anticoagulation ranges from 0.3% to 0.6% per year.³³ The risk of bleeding complications can be mitigated by keeping international normalized ratios ≤3.0, maintaining good BP control, and avoiding concurrent use of antiplatelets in the absence of a clear indication for them.³³

Several risk assessment scores, such as the HAS-BLED,³⁴ can help with estimating the risk of hemorrhagic complications, although these scores have their limitations.^35,36 Even in an older population (mean age 83 years) with a high risk for falls, warfarin provided a net benefit in a composite endpoint of out-of-hospital death or hospitalization for stroke, MI, or hemorrhage in a retrospective study of over 1200 Medicare beneficiaries.³⁷

AF is not the only cause of cardioembolic stroke to consider. Additional high-risk factors warranting anticoagulation include rheumatic mitral valve disease, the presence of mechanical aortic or mitral valves, known mural thrombus, and acute anterior ST segment elevation myocardial infarctions (STEMIs) with resulting anterior apical dyskinesis/akinesis and concurrent ischemic stroke/TIA.³ (The specific management of each of these situations is beyond the scope of this paper.)

The choice of anticoagulation agent is based on multiple factors, including cost, risk of non-reversible bleeding, drug interactions, renal function, and patient preference. Approved options currently include warfarin/­vitamin K antagonist therapy, apixaban, rivaroxaban, dabigatran and edoxaban.³ Choice of therapy will continue to evolve as reversal agents, such as idarucizumab, are developed. Idarucizumab, a reversal agent for dabigatran, received approval from the US Food and Drug Administration in October 2015.³⁸

When to start anticoagulation. There are limited data regarding the optimal timing of initiation of anticoagulation following a stroke; however, a recent multicenter prospective study supported the common practice of initiating anticoagulation therapy within 4 to 14 days of the event.³⁹ Individual patient factors must be taken into consideration, including the size of the stroke (the larger the stroke, the higher the risk for hemorrhagic transformation), BP control, any additional risk factors for bleeding, and the estimated risk of early recurrent stroke.

Bridging patients onto anticoagulation with unfractionated or low-molecular-weight heparin in the setting of acute stroke is not recommended.⁴⁰ Results from randomized controlled trials involving unfractionated heparin, heparinoids, and low-molecular-weight heparin have not reported any benefit to these agents over aspirin at preventing early stroke recurrence.^27,41,42

For immobile or hospitalized patients. Subcutaneous heparin for the prevention of deep vein thrombosis (DVT) during immobility and hospitalization is recommended.⁴³ Patients who cannot tolerate anticoagulation should be maintained on low-dose antiplatelet therapy. Experts do not recommend dual treatment with aspirin and anticoagulation in most cases. However, recent coronary artery stent placement does require temporary dual treatment, with duration dependent on the type of stent placed.

A role for glycemic control? Still to be determined

The specific role of diabetic management in secondary stroke prevention remains unclear. The 2008 ACCORD trial,⁴⁴ a randomized study involving over 10,000 patients with a median glycated hemoglobin level of 8.1%, investigated intensive hyperglycemic control (targeting a glycated hemoglobin level <6.0% vs <7.9%) as a means of decreasing cardiovascular risk. However, the trial ended 17 months early because of an increase in all-cause mortality in the intensive treatment arm compared with the standard management group. The same trial was also unable to demonstrate a decrease in stroke risk with a decrease in A1c.⁴⁴

More recently, the IRIS (Insulin Resistance Intervention after Stroke) trial⁴⁵ (2016) found a 2.8% absolute risk reduction in stroke or MI among participants who had a stroke or TIA in the previous 6 months who were treated with pioglitazone vs placebo over 4.8 years (NNT=36). Participants were required to have insulin resistance, but were excluded if they had diabetes. The authors did, however, report a notable increase in the risk of bone fractures requiring surgery or hospitalization in the pioglitazone arm (5.1% vs 3.2%; number needed to harm [NNH]=53).

Treat patients with stroke or TIA presumed to be of atherosclerotic origin with high-intensity statin therapy, regardless of low-density lipoprotein level.

The impact this single study should have on standard secondary prevention is not yet clear. The authors concluded, “It seems reasonable to consider individual treatment preference and risk of drug-related adverse events in addition to potential benefits when making patient-specific decisions regarding therapy.”⁴⁵

Determining whether mechanical interventions are needed

Almost all conditions leading to stroke warrant active medical management, but a few benefit from procedural intervention, as well.

Extracranial carotid atherosclerosis. Carotid endarterectomy or carotid artery stenting is recommended as secondary prevention for patients with a history of stroke or TIA who have ipsilateral high-grade extracranial carotid stenosis of 70% to 99% and, in some cases, 50% to 69%.^3,9,20 In patients with mild non-disabling stroke, the optimal timing for these procedures is within 2 weeks of the ischemic event. A delay of 6 weeks is generally preferred for moderate or larger strokes to allow for some healing of the injured brain.

The choice of procedure is based on risk profile, with the most important factor being age. For patients >70 years, endarterectomy is preferred because stenting is associated with an increased risk of stroke.^3,9,10 Experts do not recommend either procedure for patients who have had a severe disabling stroke. Generally speaking, these procedures have higher rates of success when they are performed in centers that perform a higher number of these procedures.¹⁰

Vertebrobasilar atherosclerosis. Due to generally good compensatory blood flow of the contralateral vertebral artery in the setting of vertebral artery stenosis, and an unacceptably high complication rate of angioplasty and stenting in the basilar artery, medical management is typically the first-line approach. If a patient has recurrent symptoms in the setting of optimal medical management and a focal lesion that is amenable to an endovascular intervention (most commonly a vertebral artery origin high-grade stenosis), angioplasty and stenting may be considered.¹⁰

Intracranial atherosclerosis. Similarly, medical management is the preferred strategy for intracranial atherosclerosis. Angioplasty and/or stenting are reserved for complex cases or recurrence despite adherence to secondary stroke prevention measures. Ideally, these patients should be managed with long-term aspirin 81 mg/d, adjunctive clopidogrel 75 mg/d for 90 days post stroke, a high-intensity statin, BP optimization, and any relevant lifestyle interventions.¹³

Patent foramen ovale. Research to date has not shown that closure of a patent foramen ovale (PFO) is superior to medical therapy for secondary stroke prevention in patients <60 years with cryptogenic stroke.^12,46,47 The decision to anticoagulate these patients should be based on the presence or absence of a DVT and not on a PFO alone. In patients with an identified DVT and a contraindication to oral anticoagulation, inferior vena cava filter placement should be considered. For patients with ongoing prothrombotic risk thought to increase the chances of future paradoxical embolism, closure of the PFO may be considered.

CORRESPONDENCE
Stephen A. Martin, MD, EdM, Barre Family Health Center, 151 Worcester Road, Barre, MA 01005; [email protected].

CASE › A 68-year-old woman with hypertension and hyperlipidemia comes into your office for evaluation of a 30-minute episode of sudden-onset right-hand weakness and difficulty speaking that occurred 4 days earlier. The patient, who is also a smoker, has come in at the insistence of her daughter. On examination, her blood pressure (BP) is 145/88 mm Hg and her heart rate is 76 beats/minute and regular. She appears well and her language function is normal. The rest of her examination is normal. How would you proceed?

Stroke—the death of nerve cells due to a lack of blood supply from either infarction or hemorrhage—strikes nearly 800,000 people in the United States every year.^1,2 Of these events, 130,000 are fatal, making stroke the fifth leading cause of death.³ Effective, early evaluation and cause-specific treatment are crucial parts of stroke care.

Data indicate that evaluation of symptoms suggestive of stroke within 24 hours of an event confers substantial benefit.

Research has helped to clarify the critical role primary care physicians play in recognizing, triaging, and managing stroke and transient ischemic attacks (TIA). This article reviews what we know about the different ways that a stroke and a TIA can present, the appropriate diagnostic work-up for patients presenting with symptoms of either event, and management strategies for subacute care (24 hours to up to 14 days after a stroke has occurred).^4,5 Unless otherwise specified, this review will focus on ischemic stroke because 87% of strokes are attributable to ischemia.¹

A follow-up to this article on secondary stroke prevention will appear in the journal next month.

IMAGE: © 2017 ALEX NUBAUM C/O THE ISPOT

Look to onset more than type of symptoms for clues

Stroke presents as a sudden onset of neurologic deficits (language, motor, sensory, cerebellar, or brainstem functions) (TABLE 1⁴). Because presenting symptoms can vary widely, sudden onset, rather than particular symptoms, should raise a red flag for potential stroke.

The differential diagnosis includes: seizure, complex migraine, medication effect (eg, slurred speech or confusion after taking a central nervous system [CNS] depressant), toxin exposure, electrolyte abnormalities (especially hypoglycemia), concussion/trauma, infection of the CNS, peripheral vertigo, demyelination, intracranial mass, Bell’s palsy, and psychogenic disorders. The history and physical, along with laboratory findings and brain imaging (detailed later in this article), will guide the FP toward (or away from) these various etiologies.

Optimal triage is a subject of ongoing interest and research

If stroke or TIA remains a possibility after an initial assessment, it’s time to stratify patients by risk.

One of the most widely accepted tools is the ABCD² score (see TABLE 2⁶). Clinicians can employ the ABCD² risk stratification tool when trying to determine whether it is reasonable to pursue an expedited work-up (ie, <1 day) in the outpatient setting or recommend that the patient be evaluated in an emergency department (ED). The 90-day stroke rate following a TIA ranges from 3% with an ABCD² score of 0 to 3 to 18% with a score of 6 or 7. A score of 0 to 3 is considered relatively low risk; in the absence of other compelling factors, rapid outpatient evaluation is appropriate. For patients with an ABCD² score ≥4, referral to the ED or direct admission to the hospital is advised.

The validity of the ABCD² score for risk stratification has been studied extensively with conflicting results.^7-10 As with any assessment tool, it should be used as a guide, and should not supplant a full assessment of the patient or the judgment of the examining physician. In making the decision regarding inpatient or outpatient evaluation, it’s also important to consider available resources, access to specialists, and patient preference.

In a 2016 population-based study, the 30-day recurrent stroke/TIA rate for patients hospitalized for TIA was 3% compared with 10.7% for those discharged from the ED with referral to a stroke clinic and 10.6% for those discharged from the ED without a referral to a stroke clinic.¹¹ These data suggest that only patients for whom you have a low clinical suspicion of stroke/TIA should be worked up as outpatients, and that hospital admission is advised in moderate- and high-risk cases. The findings also highlight the critical role that primary care physicians can play in triaging and managing these patients for secondary prevention.

CASE › This patient’s recent history of sudden-onset right-sided weakness and expressive language dysfunction is suspicious for left hemispheric ischemia. She has several risk factors for stroke, and her ABCD² score is 5 (hypertension, age ≥60 years, unilateral weakness, and duration 10-59 min), which places her at moderate risk. Thus, the recommendation would be to have her go directly to an ED for rapid evaluation.

The diagnostic work-up

Even when a patient is sent to the ED, the FP plays a critical role in his or her continuing care. FPs will often coordinate with inpatient care and manage transition of care to the outpatient setting. (And in many communities, the ED or hospital physicians may themselves be family practitioners.)

In terms of care, not even an aspirin should be administered in a case like this because the patient has not yet had any neuroimaging, and differentiation of ischemic from hemorrhagic stroke cannot be made on clinical grounds alone. Once an ischemic stroke is confirmed, determining the etiology is critical given the significant management differences between the different types of stroke (atherosclerotic, cardioembolic, lacunar, or other).

Which imaging method, and when?

While a computerized tomography (CT) scan is the preferred initial imaging strategy for acute stroke to discern the ischemic type from the hemorrhagic, MRI is preferred for the evaluation of acute ischemic stroke because the method has a higher sensitivity for infarction and a greater ability to identify findings (such as demyelination) that would suggest an alternative diagnosis.

Because presenting symptoms can vary widely, sudden onset, rather than particular symptoms, should raise the red flag for potential stroke.

In addition to evaluating the brain parenchyma, physicians must also assess the cerebral vasculature. CT angiography (CTA) or MR angiography (MRA) of the head and neck are preferred over carotid ultrasound because they are capable of evaluating the entire cerebrovascular system^12,13 and can be instrumental in identifying potential causes of stroke, as well as guiding therapeutic decisions. Carotid ultrasound is a reasonable alternative for patients presenting with symptoms indicative of anterior circulation involvement when CTA and MRA are unavailable or contraindicated, but it will not identify intracranial vascular disease, proximal common carotid disease, or vertebrobasilar disease.

Getting to the cause of suspected stroke: Labs and other diagnostic tests

A routine work-up includes BP checks, routine labs (complete blood count, complete metabolic panel, coagulation profile, and troponin), an electrocardiogram (EKG), a transthoracic echocardiogram (TTE) with bubble study if possible, and a minimum of 24 to 48 hours of cardiac rhythm monitoring. Cardiac rhythm monitoring should be extended in the setting of clinical concern for unidentified paroxysmal atrial fibrillation, such as an embolism without a proximal vascular source, multiple embolic infarcts in different vascular territories, a dilated left atrium, or other risk factors for atrial fibrillation that include smoking, systolic hypertension, diabetes, and heart failure (see TABLE 3^12,13,17,18).^14-16 This standard diagnostic work-up will identify the cause of stroke in 70% to 80% of patients.¹⁹

Additional investigations to consider if the etiology is not yet elucidated include a transesophageal echocardiogram (TEE), cerebral angiography, a coagulopathy evaluation, a lumbar puncture, and a vasculitis work-up. If available, consultation with a neurologist is appropriate for any patient who has had a stroke or TIA. Patients with unclear etiologies or for whom there are questions concerning strategies for preventing secondary stroke should be referred to Neurology and preferably a stroke specialist.

Timing matters, even when symptoms have resolved (ie, TIA).^11,20 The EXPRESS trial¹⁷ (the Early use of eXisting PREventive Strategies for Stroke) looked at the effect of urgent assessment and treatment (≤1 day) of patients presenting with a TIA or minor stroke on the risk of recurrent stroke within 90 days. The diagnostic work-up included brain and vascular imaging together with an EKG. This intensive approach led to an absolute risk reduction of 8.2% (from 10.3% to 2.1%) in the risk of recurrent stroke at 90 days (number needed to treat [NNT]=12).¹⁷

Expedited work-up and treatment was also recently evaluated in a non-trial, real-world setting and was associated with reducing recurrent stroke by more than half the rate reported in older studies.²⁰ Overall, the data suggest that evaluation within 24 hours confers substantial benefit, and that this evaluation can happen in an outpatient setting.^21-23

Acute management: Use of tPA

Once imaging rules out intracranial hemorrhage, patients should be treated with tissue plasminogen activator (tPA) or an endovascular intervention as per guidelines.²⁴ For patients with ischemic stroke ineligible for tPA or endovascular treatments, the initial focus is to determine the etiology of the symptoms so that the best strategies for prevention of secondary stroke may be employed.

Aspirin should be provided within 24 to 48 hours to all patients after intracranial hemorrhage is ruled out. Aspirin should be delayed for 24 hours in those given thrombolytics. The initial recommended dose of aspirin is 325 mg with continued low-dose (81 mg) aspirin daily.¹³ The addition of clopidogrel to aspirin within 24 hours of an event and continued for 21 days, followed by aspirin alone, was shown to be beneficial in a Chinese population with high-risk TIA (ABCD² score ≥4) or minor stroke (National Institutes of Health Stroke Scale [NIHSS] ≤3).²⁵ Anticoagulation with heparin, warfarin, or a novel oral anticoagulant is generally not indicated in the acute setting due to the risk of hemorrhagic transformation.

Acute BP management depends upon the type of stroke (ischemic or hemorrhagic), eligibility for thrombolytics, timing of presentation, and possible comorbidities such as myocardial infarction or aortic dissection (see TABLE 4^13,26). In the absence of contraindications, high-intensity statins should be initiated in all patients able to take oral medications.

CASE › You appropriately referred your patient to the local ED. A head CT with head and neck CTA was performed. While the head CT did not show any abnormalities, the CTA demonstrated high-grade left internal carotid artery stenosis. The patient was given an initial dose of aspirin 325 mg and a high-intensity statin and admitted for further management. An MRI revealed a small shower of emboli in the left hemisphere, confirming the diagnosis of stroke over TIA. Labs were marginally remarkable with a low-density lipoprotein level of 115 mg/dL and an HbA1c of 6.2. Telemetry monitoring did not reveal any arrhythmias, and TTE was normal. BP remained in the high-normal to low-hypertensive range.

Timing matters, even when symptoms have resolved, such as with a TIA.

A Vascular Surgery consultation was obtained and the patient underwent a left carotid endarterectomy the following day. She did well without surgical complications. Her BP medications were adjusted; a combination of an angiotensin-converting enzyme inhibitor and a thiazide diuretic achieved a goal BP <140/90 mm Hg.

Permissive hypertension was not indicated due to her presentation >48 hours beyond the acute event. Low-dose aspirin and a high-intensity statin were continued, for secondary stroke prevention in the setting of atherosclerotic disease. She received smoking cessation counseling, which will continue.

CORRESPONDENCE
Stephen A. Martin, MD, EdM, Barre Family Health Center, 151 Worcester Road, Barre, MA 01005; [email protected].

CASE › A 68-year-old woman with hypertension and hyperlipidemia comes into your office for evaluation of a 30-minute episode of sudden-onset right-hand weakness and difficulty speaking that occurred 4 days earlier. The patient, who is also a smoker, has come in at the insistence of her daughter. On examination, her blood pressure (BP) is 145/88 mm Hg and her heart rate is 76 beats/minute and regular. She appears well and her language function is normal. The rest of her examination is normal. How would you proceed?

Stroke—the death of nerve cells due to a lack of blood supply from either infarction or hemorrhage—strikes nearly 800,000 people in the United States every year.^1,2 Of these events, 130,000 are fatal, making stroke the fifth leading cause of death.³ Effective, early evaluation and cause-specific treatment are crucial parts of stroke care.

Data indicate that evaluation of symptoms suggestive of stroke within 24 hours of an event confers substantial benefit.

Research has helped to clarify the critical role primary care physicians play in recognizing, triaging, and managing stroke and transient ischemic attacks (TIA). This article reviews what we know about the different ways that a stroke and a TIA can present, the appropriate diagnostic work-up for patients presenting with symptoms of either event, and management strategies for subacute care (24 hours to up to 14 days after a stroke has occurred).^4,5 Unless otherwise specified, this review will focus on ischemic stroke because 87% of strokes are attributable to ischemia.¹

A follow-up to this article on secondary stroke prevention will appear in the journal next month.

IMAGE: © 2017 ALEX NUBAUM C/O THE ISPOT

Look to onset more than type of symptoms for clues

Stroke presents as a sudden onset of neurologic deficits (language, motor, sensory, cerebellar, or brainstem functions) (TABLE 1⁴). Because presenting symptoms can vary widely, sudden onset, rather than particular symptoms, should raise a red flag for potential stroke.

The differential diagnosis includes: seizure, complex migraine, medication effect (eg, slurred speech or confusion after taking a central nervous system [CNS] depressant), toxin exposure, electrolyte abnormalities (especially hypoglycemia), concussion/trauma, infection of the CNS, peripheral vertigo, demyelination, intracranial mass, Bell’s palsy, and psychogenic disorders. The history and physical, along with laboratory findings and brain imaging (detailed later in this article), will guide the FP toward (or away from) these various etiologies.

Optimal triage is a subject of ongoing interest and research

If stroke or TIA remains a possibility after an initial assessment, it’s time to stratify patients by risk.

One of the most widely accepted tools is the ABCD² score (see TABLE 2⁶). Clinicians can employ the ABCD² risk stratification tool when trying to determine whether it is reasonable to pursue an expedited work-up (ie, <1 day) in the outpatient setting or recommend that the patient be evaluated in an emergency department (ED). The 90-day stroke rate following a TIA ranges from 3% with an ABCD² score of 0 to 3 to 18% with a score of 6 or 7. A score of 0 to 3 is considered relatively low risk; in the absence of other compelling factors, rapid outpatient evaluation is appropriate. For patients with an ABCD² score ≥4, referral to the ED or direct admission to the hospital is advised.

The validity of the ABCD² score for risk stratification has been studied extensively with conflicting results.^7-10 As with any assessment tool, it should be used as a guide, and should not supplant a full assessment of the patient or the judgment of the examining physician. In making the decision regarding inpatient or outpatient evaluation, it’s also important to consider available resources, access to specialists, and patient preference.

In a 2016 population-based study, the 30-day recurrent stroke/TIA rate for patients hospitalized for TIA was 3% compared with 10.7% for those discharged from the ED with referral to a stroke clinic and 10.6% for those discharged from the ED without a referral to a stroke clinic.¹¹ These data suggest that only patients for whom you have a low clinical suspicion of stroke/TIA should be worked up as outpatients, and that hospital admission is advised in moderate- and high-risk cases. The findings also highlight the critical role that primary care physicians can play in triaging and managing these patients for secondary prevention.

CASE › This patient’s recent history of sudden-onset right-sided weakness and expressive language dysfunction is suspicious for left hemispheric ischemia. She has several risk factors for stroke, and her ABCD² score is 5 (hypertension, age ≥60 years, unilateral weakness, and duration 10-59 min), which places her at moderate risk. Thus, the recommendation would be to have her go directly to an ED for rapid evaluation.

The diagnostic work-up

Even when a patient is sent to the ED, the FP plays a critical role in his or her continuing care. FPs will often coordinate with inpatient care and manage transition of care to the outpatient setting. (And in many communities, the ED or hospital physicians may themselves be family practitioners.)

In terms of care, not even an aspirin should be administered in a case like this because the patient has not yet had any neuroimaging, and differentiation of ischemic from hemorrhagic stroke cannot be made on clinical grounds alone. Once an ischemic stroke is confirmed, determining the etiology is critical given the significant management differences between the different types of stroke (atherosclerotic, cardioembolic, lacunar, or other).

Which imaging method, and when?

While a computerized tomography (CT) scan is the preferred initial imaging strategy for acute stroke to discern the ischemic type from the hemorrhagic, MRI is preferred for the evaluation of acute ischemic stroke because the method has a higher sensitivity for infarction and a greater ability to identify findings (such as demyelination) that would suggest an alternative diagnosis.

Because presenting symptoms can vary widely, sudden onset, rather than particular symptoms, should raise the red flag for potential stroke.

In addition to evaluating the brain parenchyma, physicians must also assess the cerebral vasculature. CT angiography (CTA) or MR angiography (MRA) of the head and neck are preferred over carotid ultrasound because they are capable of evaluating the entire cerebrovascular system^12,13 and can be instrumental in identifying potential causes of stroke, as well as guiding therapeutic decisions. Carotid ultrasound is a reasonable alternative for patients presenting with symptoms indicative of anterior circulation involvement when CTA and MRA are unavailable or contraindicated, but it will not identify intracranial vascular disease, proximal common carotid disease, or vertebrobasilar disease.

Getting to the cause of suspected stroke: Labs and other diagnostic tests

A routine work-up includes BP checks, routine labs (complete blood count, complete metabolic panel, coagulation profile, and troponin), an electrocardiogram (EKG), a transthoracic echocardiogram (TTE) with bubble study if possible, and a minimum of 24 to 48 hours of cardiac rhythm monitoring. Cardiac rhythm monitoring should be extended in the setting of clinical concern for unidentified paroxysmal atrial fibrillation, such as an embolism without a proximal vascular source, multiple embolic infarcts in different vascular territories, a dilated left atrium, or other risk factors for atrial fibrillation that include smoking, systolic hypertension, diabetes, and heart failure (see TABLE 3^12,13,17,18).^14-16 This standard diagnostic work-up will identify the cause of stroke in 70% to 80% of patients.¹⁹

Additional investigations to consider if the etiology is not yet elucidated include a transesophageal echocardiogram (TEE), cerebral angiography, a coagulopathy evaluation, a lumbar puncture, and a vasculitis work-up. If available, consultation with a neurologist is appropriate for any patient who has had a stroke or TIA. Patients with unclear etiologies or for whom there are questions concerning strategies for preventing secondary stroke should be referred to Neurology and preferably a stroke specialist.

Timing matters, even when symptoms have resolved (ie, TIA).^11,20 The EXPRESS trial¹⁷ (the Early use of eXisting PREventive Strategies for Stroke) looked at the effect of urgent assessment and treatment (≤1 day) of patients presenting with a TIA or minor stroke on the risk of recurrent stroke within 90 days. The diagnostic work-up included brain and vascular imaging together with an EKG. This intensive approach led to an absolute risk reduction of 8.2% (from 10.3% to 2.1%) in the risk of recurrent stroke at 90 days (number needed to treat [NNT]=12).¹⁷

Expedited work-up and treatment was also recently evaluated in a non-trial, real-world setting and was associated with reducing recurrent stroke by more than half the rate reported in older studies.²⁰ Overall, the data suggest that evaluation within 24 hours confers substantial benefit, and that this evaluation can happen in an outpatient setting.^21-23

Acute management: Use of tPA

Once imaging rules out intracranial hemorrhage, patients should be treated with tissue plasminogen activator (tPA) or an endovascular intervention as per guidelines.²⁴ For patients with ischemic stroke ineligible for tPA or endovascular treatments, the initial focus is to determine the etiology of the symptoms so that the best strategies for prevention of secondary stroke may be employed.

Aspirin should be provided within 24 to 48 hours to all patients after intracranial hemorrhage is ruled out. Aspirin should be delayed for 24 hours in those given thrombolytics. The initial recommended dose of aspirin is 325 mg with continued low-dose (81 mg) aspirin daily.¹³ The addition of clopidogrel to aspirin within 24 hours of an event and continued for 21 days, followed by aspirin alone, was shown to be beneficial in a Chinese population with high-risk TIA (ABCD² score ≥4) or minor stroke (National Institutes of Health Stroke Scale [NIHSS] ≤3).²⁵ Anticoagulation with heparin, warfarin, or a novel oral anticoagulant is generally not indicated in the acute setting due to the risk of hemorrhagic transformation.

Acute BP management depends upon the type of stroke (ischemic or hemorrhagic), eligibility for thrombolytics, timing of presentation, and possible comorbidities such as myocardial infarction or aortic dissection (see TABLE 4^13,26). In the absence of contraindications, high-intensity statins should be initiated in all patients able to take oral medications.

CASE › You appropriately referred your patient to the local ED. A head CT with head and neck CTA was performed. While the head CT did not show any abnormalities, the CTA demonstrated high-grade left internal carotid artery stenosis. The patient was given an initial dose of aspirin 325 mg and a high-intensity statin and admitted for further management. An MRI revealed a small shower of emboli in the left hemisphere, confirming the diagnosis of stroke over TIA. Labs were marginally remarkable with a low-density lipoprotein level of 115 mg/dL and an HbA1c of 6.2. Telemetry monitoring did not reveal any arrhythmias, and TTE was normal. BP remained in the high-normal to low-hypertensive range.

Timing matters, even when symptoms have resolved, such as with a TIA.

A Vascular Surgery consultation was obtained and the patient underwent a left carotid endarterectomy the following day. She did well without surgical complications. Her BP medications were adjusted; a combination of an angiotensin-converting enzyme inhibitor and a thiazide diuretic achieved a goal BP <140/90 mm Hg.

Permissive hypertension was not indicated due to her presentation >48 hours beyond the acute event. Low-dose aspirin and a high-intensity statin were continued, for secondary stroke prevention in the setting of atherosclerotic disease. She received smoking cessation counseling, which will continue.

CORRESPONDENCE
Stephen A. Martin, MD, EdM, Barre Family Health Center, 151 Worcester Road, Barre, MA 01005; [email protected].

CASE › A 68-year-old woman with hypertension and hyperlipidemia comes into your office for evaluation of a 30-minute episode of sudden-onset right-hand weakness and difficulty speaking that occurred 4 days earlier. The patient, who is also a smoker, has come in at the insistence of her daughter. On examination, her blood pressure (BP) is 145/88 mm Hg and her heart rate is 76 beats/minute and regular. She appears well and her language function is normal. The rest of her examination is normal. How would you proceed?

Stroke—the death of nerve cells due to a lack of blood supply from either infarction or hemorrhage—strikes nearly 800,000 people in the United States every year.^1,2 Of these events, 130,000 are fatal, making stroke the fifth leading cause of death.³ Effective, early evaluation and cause-specific treatment are crucial parts of stroke care.

Data indicate that evaluation of symptoms suggestive of stroke within 24 hours of an event confers substantial benefit.

Research has helped to clarify the critical role primary care physicians play in recognizing, triaging, and managing stroke and transient ischemic attacks (TIA). This article reviews what we know about the different ways that a stroke and a TIA can present, the appropriate diagnostic work-up for patients presenting with symptoms of either event, and management strategies for subacute care (24 hours to up to 14 days after a stroke has occurred).^4,5 Unless otherwise specified, this review will focus on ischemic stroke because 87% of strokes are attributable to ischemia.¹

A follow-up to this article on secondary stroke prevention will appear in the journal next month.

IMAGE: © 2017 ALEX NUBAUM C/O THE ISPOT

Look to onset more than type of symptoms for clues

Stroke presents as a sudden onset of neurologic deficits (language, motor, sensory, cerebellar, or brainstem functions) (TABLE 1⁴). Because presenting symptoms can vary widely, sudden onset, rather than particular symptoms, should raise a red flag for potential stroke.

The differential diagnosis includes: seizure, complex migraine, medication effect (eg, slurred speech or confusion after taking a central nervous system [CNS] depressant), toxin exposure, electrolyte abnormalities (especially hypoglycemia), concussion/trauma, infection of the CNS, peripheral vertigo, demyelination, intracranial mass, Bell’s palsy, and psychogenic disorders. The history and physical, along with laboratory findings and brain imaging (detailed later in this article), will guide the FP toward (or away from) these various etiologies.

Optimal triage is a subject of ongoing interest and research

If stroke or TIA remains a possibility after an initial assessment, it’s time to stratify patients by risk.

One of the most widely accepted tools is the ABCD² score (see TABLE 2⁶). Clinicians can employ the ABCD² risk stratification tool when trying to determine whether it is reasonable to pursue an expedited work-up (ie, <1 day) in the outpatient setting or recommend that the patient be evaluated in an emergency department (ED). The 90-day stroke rate following a TIA ranges from 3% with an ABCD² score of 0 to 3 to 18% with a score of 6 or 7. A score of 0 to 3 is considered relatively low risk; in the absence of other compelling factors, rapid outpatient evaluation is appropriate. For patients with an ABCD² score ≥4, referral to the ED or direct admission to the hospital is advised.

The validity of the ABCD² score for risk stratification has been studied extensively with conflicting results.^7-10 As with any assessment tool, it should be used as a guide, and should not supplant a full assessment of the patient or the judgment of the examining physician. In making the decision regarding inpatient or outpatient evaluation, it’s also important to consider available resources, access to specialists, and patient preference.

In a 2016 population-based study, the 30-day recurrent stroke/TIA rate for patients hospitalized for TIA was 3% compared with 10.7% for those discharged from the ED with referral to a stroke clinic and 10.6% for those discharged from the ED without a referral to a stroke clinic.¹¹ These data suggest that only patients for whom you have a low clinical suspicion of stroke/TIA should be worked up as outpatients, and that hospital admission is advised in moderate- and high-risk cases. The findings also highlight the critical role that primary care physicians can play in triaging and managing these patients for secondary prevention.

CASE › This patient’s recent history of sudden-onset right-sided weakness and expressive language dysfunction is suspicious for left hemispheric ischemia. She has several risk factors for stroke, and her ABCD² score is 5 (hypertension, age ≥60 years, unilateral weakness, and duration 10-59 min), which places her at moderate risk. Thus, the recommendation would be to have her go directly to an ED for rapid evaluation.

The diagnostic work-up

Even when a patient is sent to the ED, the FP plays a critical role in his or her continuing care. FPs will often coordinate with inpatient care and manage transition of care to the outpatient setting. (And in many communities, the ED or hospital physicians may themselves be family practitioners.)

In terms of care, not even an aspirin should be administered in a case like this because the patient has not yet had any neuroimaging, and differentiation of ischemic from hemorrhagic stroke cannot be made on clinical grounds alone. Once an ischemic stroke is confirmed, determining the etiology is critical given the significant management differences between the different types of stroke (atherosclerotic, cardioembolic, lacunar, or other).

Which imaging method, and when?

While a computerized tomography (CT) scan is the preferred initial imaging strategy for acute stroke to discern the ischemic type from the hemorrhagic, MRI is preferred for the evaluation of acute ischemic stroke because the method has a higher sensitivity for infarction and a greater ability to identify findings (such as demyelination) that would suggest an alternative diagnosis.

Because presenting symptoms can vary widely, sudden onset, rather than particular symptoms, should raise the red flag for potential stroke.

In addition to evaluating the brain parenchyma, physicians must also assess the cerebral vasculature. CT angiography (CTA) or MR angiography (MRA) of the head and neck are preferred over carotid ultrasound because they are capable of evaluating the entire cerebrovascular system^12,13 and can be instrumental in identifying potential causes of stroke, as well as guiding therapeutic decisions. Carotid ultrasound is a reasonable alternative for patients presenting with symptoms indicative of anterior circulation involvement when CTA and MRA are unavailable or contraindicated, but it will not identify intracranial vascular disease, proximal common carotid disease, or vertebrobasilar disease.

Getting to the cause of suspected stroke: Labs and other diagnostic tests

A routine work-up includes BP checks, routine labs (complete blood count, complete metabolic panel, coagulation profile, and troponin), an electrocardiogram (EKG), a transthoracic echocardiogram (TTE) with bubble study if possible, and a minimum of 24 to 48 hours of cardiac rhythm monitoring. Cardiac rhythm monitoring should be extended in the setting of clinical concern for unidentified paroxysmal atrial fibrillation, such as an embolism without a proximal vascular source, multiple embolic infarcts in different vascular territories, a dilated left atrium, or other risk factors for atrial fibrillation that include smoking, systolic hypertension, diabetes, and heart failure (see TABLE 3^12,13,17,18).^14-16 This standard diagnostic work-up will identify the cause of stroke in 70% to 80% of patients.¹⁹

Additional investigations to consider if the etiology is not yet elucidated include a transesophageal echocardiogram (TEE), cerebral angiography, a coagulopathy evaluation, a lumbar puncture, and a vasculitis work-up. If available, consultation with a neurologist is appropriate for any patient who has had a stroke or TIA. Patients with unclear etiologies or for whom there are questions concerning strategies for preventing secondary stroke should be referred to Neurology and preferably a stroke specialist.

Timing matters, even when symptoms have resolved (ie, TIA).^11,20 The EXPRESS trial¹⁷ (the Early use of eXisting PREventive Strategies for Stroke) looked at the effect of urgent assessment and treatment (≤1 day) of patients presenting with a TIA or minor stroke on the risk of recurrent stroke within 90 days. The diagnostic work-up included brain and vascular imaging together with an EKG. This intensive approach led to an absolute risk reduction of 8.2% (from 10.3% to 2.1%) in the risk of recurrent stroke at 90 days (number needed to treat [NNT]=12).¹⁷

Expedited work-up and treatment was also recently evaluated in a non-trial, real-world setting and was associated with reducing recurrent stroke by more than half the rate reported in older studies.²⁰ Overall, the data suggest that evaluation within 24 hours confers substantial benefit, and that this evaluation can happen in an outpatient setting.^21-23

Acute management: Use of tPA

Once imaging rules out intracranial hemorrhage, patients should be treated with tissue plasminogen activator (tPA) or an endovascular intervention as per guidelines.²⁴ For patients with ischemic stroke ineligible for tPA or endovascular treatments, the initial focus is to determine the etiology of the symptoms so that the best strategies for prevention of secondary stroke may be employed.

Aspirin should be provided within 24 to 48 hours to all patients after intracranial hemorrhage is ruled out. Aspirin should be delayed for 24 hours in those given thrombolytics. The initial recommended dose of aspirin is 325 mg with continued low-dose (81 mg) aspirin daily.¹³ The addition of clopidogrel to aspirin within 24 hours of an event and continued for 21 days, followed by aspirin alone, was shown to be beneficial in a Chinese population with high-risk TIA (ABCD² score ≥4) or minor stroke (National Institutes of Health Stroke Scale [NIHSS] ≤3).²⁵ Anticoagulation with heparin, warfarin, or a novel oral anticoagulant is generally not indicated in the acute setting due to the risk of hemorrhagic transformation.

Acute BP management depends upon the type of stroke (ischemic or hemorrhagic), eligibility for thrombolytics, timing of presentation, and possible comorbidities such as myocardial infarction or aortic dissection (see TABLE 4^13,26). In the absence of contraindications, high-intensity statins should be initiated in all patients able to take oral medications.

CASE › You appropriately referred your patient to the local ED. A head CT with head and neck CTA was performed. While the head CT did not show any abnormalities, the CTA demonstrated high-grade left internal carotid artery stenosis. The patient was given an initial dose of aspirin 325 mg and a high-intensity statin and admitted for further management. An MRI revealed a small shower of emboli in the left hemisphere, confirming the diagnosis of stroke over TIA. Labs were marginally remarkable with a low-density lipoprotein level of 115 mg/dL and an HbA1c of 6.2. Telemetry monitoring did not reveal any arrhythmias, and TTE was normal. BP remained in the high-normal to low-hypertensive range.

Timing matters, even when symptoms have resolved, such as with a TIA.

A Vascular Surgery consultation was obtained and the patient underwent a left carotid endarterectomy the following day. She did well without surgical complications. Her BP medications were adjusted; a combination of an angiotensin-converting enzyme inhibitor and a thiazide diuretic achieved a goal BP <140/90 mm Hg.

Permissive hypertension was not indicated due to her presentation >48 hours beyond the acute event. Low-dose aspirin and a high-intensity statin were continued, for secondary stroke prevention in the setting of atherosclerotic disease. She received smoking cessation counseling, which will continue.

CORRESPONDENCE
Stephen A. Martin, MD, EdM, Barre Family Health Center, 151 Worcester Road, Barre, MA 01005; [email protected].

It is friday afternoon on a sunny July day. The last patient of the day, Ms. Connecticut, is an active hiker who has had Lyme disease previously. She found a tick on her ankle yesterday. She successfully removed the tick but has not brought the tick with her to the appointment. She had been hiking several times over the last week and is not certain when the tick bite occurred. Her question for you centers on the role of antibiotic prophylaxis and Lyme disease prevention.

TECHNOLOGY: PROBLEM AND SOLUTION

Physicians need to keep up with an ever-increasing stream of information—new guidelines, new medications, and updates in medical literature.¹ They have to do this while seeing more patients with more chronic problems in less time and while meeting reporting requirements for meaningful use or quality measures for accountable care organizations.

Though some of these challenges are due to technology, one solution is to use technology to our advantage. While researching information in textbooks won’t drain a phone battery, carrying a textbook around is not feasible, and many textbooks (including their electronic versions) contain information that is outdated before they go to print or that is quickly outdated thereafter.² Further, even online textbooks are currently more dense than the online resources that we review here.  

Different types of resources can help task-saturated healthcare providers stay aware of new information while delivering evidence-based care. These tools—online textbooks, decision guides embedded within electronic health record systems, or even a Google search—are termed “point-of-care” resources when used at the time of patient care for decision-making in the moment.

Not all of these resources are of high quality, with reliable factual information. Researchers estimate that up to 70% of clinicians may use Wikipedia to research medical questions, and a comparison of 10 Wikipedia articles vs peer-reviewed sources on the 10 most costly diseases found that 9 of the 10 Wikipedia articles had errors.^3,4

In an earlier article,⁵ we advocated a proactive approach to managing information, highlighting ways to scan for new information and to develop habits of extracting useful information that can then be stored and easily recovered. To complement this strategy and weed out erroneous information, physicians need reliable sources of unbiased information to efficiently answer clinical questions at the point of care.^1,6

Here, to help busy clinicians choose which point-of-care resources to use, we review several of the most popular ones, examining their ease of use, key elements, strengths, and weaknesses.

WHAT MAKES A RESOURCE GOOD?

Key features that make point-of-care tools effective include:

Ease of use, with standard formats, a summary for each topic, or both

Links to original articles and concise, capsular summaries and syntheses of the data

Continuing medical education (CME) credit. Tip: when searching, add “CME” to the search string on the browser to access resources that provide this.

Institutional and individual accounts. For clinicians who work for large organizations, point-of-care products may be paid for already, or reimbursement may be available for your subscription. If unsure, ask your director of information technology or library services.

Freedom from advertisements. Many Internet sources have advertisements that either run alongside the information you want to see or, more annoyingly, pop up and require an action to move forward. There is also continuing concern about the effect of industry support on content.⁷ While not all of the resources that we use regularly and that we review here are ad-free, avoiding programs with high ad content helps limit the possibility of bias and the time it takes to access information. Although advertisements do bring up a risk of bias, resources with a low-level ad content can limit bias while providing free or low-cost access.

Evidence, not expert opinion. Many resources have an “about” page that explains their philosophy and the source of their information. It is vital to be sure that point-of-care databases are providing facts based on evidence.⁸ This page also typically addresses how authors and editors are selected and whether expert opinion is used when randomized trials are lacking.

Ease of access. Many tools can be accessed not only on computers but also through apps for smartphones and tablets. Some electronic medical records have clinical decision tools embedded in them, with varying capabilities.

Disclosure of conflict of interest. As conflicts of interest can shade recommendations, information sources should clearly disclose financial relationships that could be perceived as conflicts of interest—for example, authors writing about medications sold by companies with whom they have a financial relationship.

NO SINGLE RESOURCE DOES EVERYTHING

There are many types of tools for finding evidence-based medical information. Different tools serve different purposes. Table 1 lists “toolbox essentials” for clinicians needing to answer clinical questions during patient care.

For example, when a question about the need for a bone mineral density measurement comes up, it is useful to be able to quickly compare guidelines from different professional societies on the National Guideline Clearing House. For another example, if a patient brings in a medication in an unlabeled bottle, a pill identifier app can tell you what it is.  Clinicians who can use these resources appropriately will be at an advantage in being able to use information to provide better care to their patients.

To date, no point-of-care summary source has been shown to be superior in all categories, and use may be driven by ease of navigation, clinician preference, clinical question, or past success.^9,10

Reviewed below are several applications that can be used as point-of-care resources (Table 2).

CLINICAL EVIDENCE

Clinical Evidence provides systematic reviews on medical topics. Founded in 1999 by the British Medical Journal, it is available in print as the Clinical Evidence Handbook and in online desktop and smartphone formats.

More than any other source we reviewed, Clinical Evidence addresses not only the evidence that exists, but also the data that do not exist to guide decisions. Compared with 9 other point-of-care resources, Clinical Evidence was found to have the highest quality of evidence.¹¹

Strengths of Clinical Evidence

• Uncommonly transparent in terms of source of evidence or disclosing when there is a lack of evidence.
• Clearly lists the strength and relevance of the evidence.
• Personalization. Users can add notes to articles, save personal searches, and bookmark pages for easy access later.
• Navigability. Users can easily access systematic reviews, key points, retracted papers, or guidelines.
• Intuitive organization, with information categorized as research, education, news, or campaigns.
• New content daily:  podcasts, articles, videos.

Weaknesses of Clinical Evidence

• Limited topics (eg, Lyme disease was not available)
• The limited content is a challenge when needing quick information at the point of care and may cause most clinicians to use another source unless looking for comparisons of interventions.
• Cost. Subscribing to the service “on demand,” ie, to look up a single specific topic, costs $36 for 48 hours of access; monthly access or a “season ticket” allows 30 days of viewing of all content for $53. At over $600/year, this is one of the most costly of the sources we reviewed.
• Marketing of Clinical Evidence to academic institutions that support the service for faculty may limit its appeal to other clinicians.

DYNAMED

Dynamed, a clinical reference created by a group of physicians, was previously owned by the American College of Physicians and known as Smart Medicine; it is now owned by EBSCO.¹² Reviewers investigate the literature for a given topic and create pithy summaries for busy clinicians. A top feature in Dynamed is its links to full articles cited for best practices or evidence-based guidelines. The company describes their content as free of expert opinion, while being unbiased and evidence-based.

Dynamed uses a 7-step algorithm for searched topics that identifies articles, assesses clinical relevance, evaluates validity of outcomes, compiles the evidence from multiple articles, and then updates the final recommendations daily.

Dynamed Plus, the new upgraded version, updates searched topics several times a day. Dynamed may be the most frequently updated point-of-care resource, with the least risk of conflict of interest, but it offers limited topics drawn from evidence-based findings.^11,13–15

With the rapid doubling of the medical literature, frequent updates allow clinicians to be most current with practice guidelines. This potentially affects quality of care for antibiotic use, vaccination, health promotion, and screening as well as newly approved medications.

Strengths of Dynamed                                                               

• Large collection of topics, critically appraised, written for primary care physicians, presented in bulleted format
• The most frequently updated database^11,14,15
• Can integrate with major electronic health records (eg, Epic, Allscripts, NextGen, Cerner)
• Has an area devoted to new information that changes current practice
• Chosen topic grouped with related topics in the differential diagnosis after the initial search
• Easy-to-read outline for quick access to information such as billing, diagnosis, and references
• Medical calculators
• No advertisements
• Helpful embedded tools
• Icons to print or email the article
• An icon to create a “perma-link” to topics, searches, and browse categories
• Graded evidence with a link to the grading model used
• Links to primary articles
• Patient information handouts
• Alerts for updated information
• CME credit
• Special consideration and features for medical education
• The upgraded version Dynamed Plus contains Micromedex for a medication database, expanded graphics, semantic search, concise overview for each topic, and expanded content.

Weaknesses of Dynamed

• Although the topic list is large, it is only about one-third the size of UpToDate.
• A subscription for a physician costs $395 a year. Residents can sign up for about $150, and students for just under $100.
• CME is obtainable but cumbersome; one submits the CME credits through Tufts Healthcare, which requires a second sign-on to access and track.
• Drug and nondrug treatments for diseases cannot be separated.
• Useful calculators include decision trees for clinical decision-making, but there is no way to search them—one must waste time scrolling  through the topics and specialties looking for desired information.
• Major shortcoming: there is no medication reference tool unless you upgrade to Dynamed Plus.
• The expanded graphics of Dynamed Plus are difficult to view on mobile applications within the articles (they are brought up more reliably when searching just for the image).
• The use of strict evidence-based methodology without expert opinion is a strength, but limits the collection of topics without randomized controlled trials, for which turning to expert opinion may be the only option.

EVIDENCE ESSENTIALS

Evidence Essentials is a point-of-care resource from Wiley that offers a variety of content types. The website lists 13,000 medical topics; however, they are not all summary reviews as discussed in the other products above. Subject matter is reviewed 3 times a year. Comprehensive reviews number just under 800 individual topics, with the remaining content consisting of Cochrane reviews, calculators, decision support tools, POEMs (Patient-Oriented Evidence that Matters), evidence-based medical guidelines, and dermatology images (1,000).

Evidence Essentials provides some unique content including a quick evaluation and management (E/M) code-finder and calculators not only for the typical medical equations, but also for history and physical examination likelihood ratios and pretest probabilities, which are practical and an excellent teaching aid. It also offers CME along with POEMs, e-mail alerts, and a listing of upcoming topics.

Strengths of Evidence Essentials

• Relatively inexpensive at $85 a year.
• High-functioning filter system to choose to search one or multiple databases.
• Related results are listed for aid in differential diagnosis, similar to Dynamed.
• Authors, editors, and date of last review are highly visible. As in UpToDate, relevant medical calculators appear on the page.
• The likelihood and odds ratio calculators are a huge plus for clinical decision-making and putting guidelines into practice.
• “Overall bottom line” highlights key points
• Grading of evidence per topic.
• Bulleted and tabbed information for quick access.
• Tabs for information on background, prevention, diagnosis, treatment, references, guidelines, and special populations.

Weaknesses of Evidence Essentials

• Limited number of topics with comprehensive reviews.
• While you can click on any drug name and link to a choice of two drug databases, this is not included in the subscription and requires a second account.
• The resources tabs had some broken links. In our clinical example, the tab contained several videos at the top that were not related, followed by a map and tables that were relevant to Lyme disease.
• Likewise, some of the guideline references were disappointing. For example, the guideline link for Lyme disease is for the US Department of Labor Occupational Safety and Health Administration rather than a professional society.
• For the provider wanting a narrative, this is more of a bare-bones text.

FIRST CONSULT

First Consult is Elsevier’s point-of-care clinical decision product contained within ClinicalKey.

Unlike UpToDate and Dynamed, in which authors and editors read original articles and summarize or synthesize information for the learner, First Consult is a “smart” search engine that will research a question, together with associated terms and key words. Filters such as full-text availability, journal articles, and patient education can be applied.

You may need to read about your topic in a textbook first, and then, if you are looking for treatment information, find an original article through First Consult. It is available in mobile and desktop formats, and the point-of-care product, First Consult, has an app that can be downloaded and used for free for the first 60 days.

Importantly, the First Consult portion of ClinicalKey with the summary topics was rated by Shurtz and Foster¹³ as least current of the products we are discussing in this article. On the other hand, it was the only product that had an embedded program to assist the user in making presentations by allowing drag and drop of images and automatic citing of sources. Kim et al report that First Consult is one of the resources providers prefer.⁹

Strengths of First Consult

• Lengthy free trial
• Ability to access original articles from a list vs lengthy narrative
• Access to journals and books published by Elsevier
• Powerful search engine that applies associated terms automatically
• Patient education is available in different languages and font size with the ability to add instructions and even a local branding
• Can integrate with electronic health record
• Can filter results by guideline, patient education, topic overviews
• Presentation assistance.

Weaknesses of First Consult

• Time-intensive. A provider needing quick advice on treatment for a medical condition has to guess if an article or textbook will have the most up-to-date and digestible information, whereas this has already been summarized in other products. For the busy clinician, this may be prohibitive.
• Search results are limited to Elsevier products, and major journals such as the New England Journal of Medicine are not available.
• Inconsistent platform functionality. The app version was somewhat “sticky” to use, as pages did not always load efficiently, and the menu bar navigation is not ideal.
• Expensive, especially given cheaper alternatives. For example, subscribing to the specialty of internal medicine or family medicine costs $499 and provides access to 8 journals and 11 books. Extended access costs $998 and offers full-text access to 23 books and 45 journals. The complete service has a total of 400 journals, 700 books, and 2,500 procedural videos.

MEDSCAPE

Medscape, owned by parent company WebMD, has long been a popular resource. The most recent versions are available for both for Android and iOS mobile platforms. The desktop and mobile apps claim to be designed for point-of-care use, and can be downloaded at no cost after registering as a Medscape user.

Medscape has some interesting features, including a handy pill identifier tool that is new to Medscape and perfect for the “I take one blue pill for my cholesterol” moments. The drug information tools and other features work well offline.

Medscape contains a well-presented drug database and interaction checker, as well as a growing collection of evidence-based articles and videos with links to references in Medline. From the point-of-care standpoint, Medscape also offers a number of decision-making algorithms and a continuously updated medical literature and health-related newsfeed. It contains in-app medical calculators, searchable directories for providers, hospitals, and pharmacies, and CME that can be earned on the website or from the application.

The main Medscape website contains pop-up advertisements, but the mobile app has fewer. Among the occasional frustrations, updates are relatively infrequent,  the content is slow to load, and the phone app can be cumbersome. Of note, in one review,¹¹ Medscape was found to have the lowest quality of evidence.

Strengths of Medscape

• Free with registration
• Medical calculator
• Drug interaction checker
• Pill identifier
• Evidence-based information covering about 4,000 conditions with links to references in Medline
• Ability to e-mail articles for sharing or future reference
• CME
• Unique database of hospitals, providers, and pharmacies to aid in referrals or locating other healthcare professionals
• Algorithms for decision-making
• Images and videos for procedural review and learning
• Option for downloading certain databases for offline use
• Medical news helps you keep up with what patients are watching and reading.

Weaknesses of Medscape

• Advertisements (many of them pop-up)
• The content is updated less frequently than other products listed in this article
• The smartphone app can run slowly
• Quality of reviews may be a concern.

UpToDate

UpToDate (Wolters Kluwer) is used widely by medical students, residents, and fellows as well as practicing providers. It contains narrative reviews of topics written by respected experts directed at both clinicians and clinical staff. In hopes of appealing to many markets, it offers different subscription types so you can customize your choices with add-on features (UpToDate Desktop and UpToDate MobileComplete allow downloading of all content to be accessed offline), different service packages (1-, 2-, and 3-year subscriptions), and the traditional base product that provides online access.

Of the products we reviewed, UpToDate has the largest selection of medical topics, approaching 10,000.¹⁴ In some studies,^10,15 it also had the fastest retrieval time for searches. It uses evidence-based graded recommendations that are updated regularly.

Some have lamented that there is too much information per topic.⁹ In response to early reviews, Wolters Kluwer has made significant changes in the platform and greatly improved the search engine. UpToDate has expanded to include CME and patient information, trying to become that Holy Grail of websites—a one-stop experience. For the lucky few, UpToDate integrates into some electronic health records and provides a relatively seamless experience at the point of care.

Strengths of UpToDate

• One-stop shopping for information, resources, and CME
• Patient information is easy to read and accessible from the same screen
• The largest repository of medical subject matter
• Ability to cull out only pediatric or adult topics
• Searching available within a medical topic
• Tabs for quick access
• The What’s New feature allows access to practice-changing medical updates
• Medical calculators
• Drug interactions
• CME is is tracked in the system, allowing for CME credit information for hospital privileges and board certification
• Flexibility of access: can use online or download content to mobile/desktop device (the online version is easy to use, although robust wireless reception is needed; offices with slow Internet benefit from the offline feature)
• Electronic health record integration is possible with the most popular systems, such as Epic, eClinicalWorks, NextGen, and Allscripts
• Patient education and medication interaction features embedded in the electronic health record; produced in collaboration with Lexicomp
• Integrated drug database
• Alerts for updates
• References have links to full-text articles
• The date of last update is easily found for verifying information accuracy
• May be provided free for clinicians who are a part of a university or large health system.

Weaknesses of UpToDate

• Articles can be lengthy, which is both a strength and a weakness. Searches can retrieve too much information.⁹ High volume of text can frustrate the user trying to find bulleted, easy-to-read facts. However, for the person looking for a narrative summary, the content is organized as narrative paragraphs with appropriate headers in the left margin, and the search function is robust and powerful.
• Each topic has a “Summary of Recommendations,” but answers here often require linking back to the main text.
• Patient information is sometimes at a high literacy level.
• Costs more than Dynamed. A 1-year subscription is $499 for a physician, but you have the option of paying $53 for a 30-day recurring subscription. Residents, fellows, and students can pay $199 for 1 year or $19 for a 30-day recurring subscription.
• The requirement to download means that users need to keep their version updated on all of their computers—in each of their examination rooms, for example.
• Concerns about conflict of interest arise because authors and editors may maintain financial relationships with companies that produce medications discussed in the articles they have written.

BUILDING YOUR OWN PERSONAL ONLINE REPOSITORY

Our previous article⁵ reviewed how to store information using tools such as Evernote and Diigo that allow information viewed on a web page to be exported to any online repository. This can be done using extensions for a web browser or by sending the information to a custom e-mail account for these services.

For information that a provider knows he or she will need repeatedly, storage in one system is actually the easiest method. Such a system can then incorporate key information from the summary tools we have reviewed here. The ideal “electronic filing cabinet” should have several features such as a the capability to label articles by topic, to separate or sort as you see fit, and a search function to find information quickly—making it a personalized and effective point-of-care resource.

STAYING AFLOAT

Clinicians make many decisions every day. In fact, the release of How Doctors Think (both publications) has led to increased research into how clinical decisions and diagnoses are formed.^16,17

With the medical literature expected to double every 73 days by 2020,¹⁸ there is an ever-widening ocean of information to sift through. With this onslaught, clinicians can no longer remain fully current. Instead, refining skills in accessing, sorting, and interpreting accurate scientific evidence efficiently is crucial to time spent actually caring for patients and coordinating their care.

Guidelines, algorithms, and comprehensive databases can aid clinicians in all aspects of care, from generating more complete differential diagnoses to managing disease-specific treatment. Individuals can first think about and list the qualities of a tool that are most important to them (eg, breadth of topics, frequency of updates, integration within their electronic health record, and cost) before focusing on a few applications or websites that meet those goals. With practice, point-of-care knowledge can become part of the everyday visit.

Effective integration into electronic health records will require design input from front-line clinicians. Otherwise, systems are prone to add too much “support” and overly rely on orthodox metrics and guidelines, resulting in alarm fatigue and frustration rather than facilitation.^19–23

OUR CONCLUSIONS

Comprehensive point-of-care resources can play a significant role in helping busy clinicians provide best evidence-based care to their patients. Embedded clinical decision guides within an electronic health record are ideal, but low topic coverage has limited the usefulness of these systems.²⁴ Here are our conclusions:

Medscape, ePocrates, and Wikipedia are probably the most popular free resources. Dynamed has offered free subscriptions to Wikipedia’s top health editors with the hopes of correcting factual errors. Medscape has excellent features but is supported by sponsored content, which raises a concern about bias and potential time-consuming distractions.

Dynamed and UpToDate have both been reported to answer more questions than other sources.¹²

UpToDate has the largest repository, with each topic curated by an expert or experts in that subject. This content can be dense and difficult to scan quickly at the point of care, but this is balanced by the ability to search within a medical topic, which  has given it the fastest retrieval time.¹⁵ It does, however, allow authors and editors to maintain financial relationships with companies that produce medications discussed in the article.²²

Dynamed has the advantage in frequency of updates, clearest conflict-of-interest policy, and the least amount of conflict of interest. Its topic list is not as extensive as UpToDate’s due to the limitation of using only evidence-based medicine without expert opinion.

First Consult has high user satisfaction, but as a point-of-care resource it can be time-consuming to find the best source for the clinical question at hand, and its expanded access is costly.⁹

ART AND SCIENCE

Point-of-care resources do not solve all the complicated problems of patient care, and no single resource is ideal for all situations. A busy clinician has limited time to process the evolving literature to practice the best evidence-based medicine. Effective information access, quality of care provided, and the marginal time cost required create a complex calculus. Clinical decision-making remains an art and a science,²⁵ but these technologies help define a new era in its pursuit.

Ultimately, a clinician’s choice needs to correlate with a provider’s resources and style. This article has detailed several options available on the market today. This is a quickly evolving area of products and services. Longer term, users might consider a tool’s preferred key features when evaluating any current or future resource in order to choose the right ones for their practice.

CASE REVISITED

Before we leave for the weekend, we need a plan for Ms. Connecticut. To find appropriate recommendations for our patient, we search several of our point-of-care resources: UpToDate and Dynamed. Both resources have correct information according to the Infectious Disease Society of America (IDSA) guidelines.

UpToDate has a monograph of approximately 2,000 words on Lyme disease, which is lengthy but adds to clinical-decision making skills for a learner thinking through the decision. This service also has a patient handout highlighting the recommendations. The topic was last updated in 2016, but states that it is current with literature through January 2017. 

Dynamed has bulleted information that is quicker to digest, but essentially highlights the IDSA recommendations without the thought process behind them. It too, has patient resources with links to a variety of handouts from professional organizations such as the US Centers for Disease Control and Prevention. They last updated the topic January 31, 2017. 

When searching for the topic on both sites, a clinician can see the breadth of information in each program. However, this is also a detractor. Searching for Lyme disease prophylaxis on Dynamed brought up related data (that doxycycline is not FDA-approved for prophylaxis), but not the primary information. Likewise, the search under UpToDate first brought us to the patient information. Both articles have helpful tables and links to associated topics.

My partner chose the UpToDate article, in part to review the topic with a medical student. However, I used Dynamed for its quick bulleted information, as I was on call that evening and needed to return to the hospital.  We both came to the same conclusion, and Ms. Connecticut chose no prophylaxis even though her home is in an endemic area. She has done well.

It is friday afternoon on a sunny July day. The last patient of the day, Ms. Connecticut, is an active hiker who has had Lyme disease previously. She found a tick on her ankle yesterday. She successfully removed the tick but has not brought the tick with her to the appointment. She had been hiking several times over the last week and is not certain when the tick bite occurred. Her question for you centers on the role of antibiotic prophylaxis and Lyme disease prevention.

TECHNOLOGY: PROBLEM AND SOLUTION

Physicians need to keep up with an ever-increasing stream of information—new guidelines, new medications, and updates in medical literature.¹ They have to do this while seeing more patients with more chronic problems in less time and while meeting reporting requirements for meaningful use or quality measures for accountable care organizations.

Though some of these challenges are due to technology, one solution is to use technology to our advantage. While researching information in textbooks won’t drain a phone battery, carrying a textbook around is not feasible, and many textbooks (including their electronic versions) contain information that is outdated before they go to print or that is quickly outdated thereafter.² Further, even online textbooks are currently more dense than the online resources that we review here.  

Different types of resources can help task-saturated healthcare providers stay aware of new information while delivering evidence-based care. These tools—online textbooks, decision guides embedded within electronic health record systems, or even a Google search—are termed “point-of-care” resources when used at the time of patient care for decision-making in the moment.

Not all of these resources are of high quality, with reliable factual information. Researchers estimate that up to 70% of clinicians may use Wikipedia to research medical questions, and a comparison of 10 Wikipedia articles vs peer-reviewed sources on the 10 most costly diseases found that 9 of the 10 Wikipedia articles had errors.^3,4

In an earlier article,⁵ we advocated a proactive approach to managing information, highlighting ways to scan for new information and to develop habits of extracting useful information that can then be stored and easily recovered. To complement this strategy and weed out erroneous information, physicians need reliable sources of unbiased information to efficiently answer clinical questions at the point of care.^1,6

Here, to help busy clinicians choose which point-of-care resources to use, we review several of the most popular ones, examining their ease of use, key elements, strengths, and weaknesses.

WHAT MAKES A RESOURCE GOOD?

Key features that make point-of-care tools effective include:

Ease of use, with standard formats, a summary for each topic, or both

Links to original articles and concise, capsular summaries and syntheses of the data

Continuing medical education (CME) credit. Tip: when searching, add “CME” to the search string on the browser to access resources that provide this.

Institutional and individual accounts. For clinicians who work for large organizations, point-of-care products may be paid for already, or reimbursement may be available for your subscription. If unsure, ask your director of information technology or library services.

Freedom from advertisements. Many Internet sources have advertisements that either run alongside the information you want to see or, more annoyingly, pop up and require an action to move forward. There is also continuing concern about the effect of industry support on content.⁷ While not all of the resources that we use regularly and that we review here are ad-free, avoiding programs with high ad content helps limit the possibility of bias and the time it takes to access information. Although advertisements do bring up a risk of bias, resources with a low-level ad content can limit bias while providing free or low-cost access.

Evidence, not expert opinion. Many resources have an “about” page that explains their philosophy and the source of their information. It is vital to be sure that point-of-care databases are providing facts based on evidence.⁸ This page also typically addresses how authors and editors are selected and whether expert opinion is used when randomized trials are lacking.

Ease of access. Many tools can be accessed not only on computers but also through apps for smartphones and tablets. Some electronic medical records have clinical decision tools embedded in them, with varying capabilities.

Disclosure of conflict of interest. As conflicts of interest can shade recommendations, information sources should clearly disclose financial relationships that could be perceived as conflicts of interest—for example, authors writing about medications sold by companies with whom they have a financial relationship.

NO SINGLE RESOURCE DOES EVERYTHING

There are many types of tools for finding evidence-based medical information. Different tools serve different purposes. Table 1 lists “toolbox essentials” for clinicians needing to answer clinical questions during patient care.

For example, when a question about the need for a bone mineral density measurement comes up, it is useful to be able to quickly compare guidelines from different professional societies on the National Guideline Clearing House. For another example, if a patient brings in a medication in an unlabeled bottle, a pill identifier app can tell you what it is.  Clinicians who can use these resources appropriately will be at an advantage in being able to use information to provide better care to their patients.

To date, no point-of-care summary source has been shown to be superior in all categories, and use may be driven by ease of navigation, clinician preference, clinical question, or past success.^9,10

Reviewed below are several applications that can be used as point-of-care resources (Table 2).

CLINICAL EVIDENCE

Clinical Evidence provides systematic reviews on medical topics. Founded in 1999 by the British Medical Journal, it is available in print as the Clinical Evidence Handbook and in online desktop and smartphone formats.

More than any other source we reviewed, Clinical Evidence addresses not only the evidence that exists, but also the data that do not exist to guide decisions. Compared with 9 other point-of-care resources, Clinical Evidence was found to have the highest quality of evidence.¹¹

Strengths of Clinical Evidence

• Uncommonly transparent in terms of source of evidence or disclosing when there is a lack of evidence.
• Clearly lists the strength and relevance of the evidence.
• Personalization. Users can add notes to articles, save personal searches, and bookmark pages for easy access later.
• Navigability. Users can easily access systematic reviews, key points, retracted papers, or guidelines.
• Intuitive organization, with information categorized as research, education, news, or campaigns.
• New content daily:  podcasts, articles, videos.

Weaknesses of Clinical Evidence

• Limited topics (eg, Lyme disease was not available)
• The limited content is a challenge when needing quick information at the point of care and may cause most clinicians to use another source unless looking for comparisons of interventions.
• Cost. Subscribing to the service “on demand,” ie, to look up a single specific topic, costs $36 for 48 hours of access; monthly access or a “season ticket” allows 30 days of viewing of all content for $53. At over $600/year, this is one of the most costly of the sources we reviewed.
• Marketing of Clinical Evidence to academic institutions that support the service for faculty may limit its appeal to other clinicians.

DYNAMED

Dynamed, a clinical reference created by a group of physicians, was previously owned by the American College of Physicians and known as Smart Medicine; it is now owned by EBSCO.¹² Reviewers investigate the literature for a given topic and create pithy summaries for busy clinicians. A top feature in Dynamed is its links to full articles cited for best practices or evidence-based guidelines. The company describes their content as free of expert opinion, while being unbiased and evidence-based.

Dynamed uses a 7-step algorithm for searched topics that identifies articles, assesses clinical relevance, evaluates validity of outcomes, compiles the evidence from multiple articles, and then updates the final recommendations daily.

Dynamed Plus, the new upgraded version, updates searched topics several times a day. Dynamed may be the most frequently updated point-of-care resource, with the least risk of conflict of interest, but it offers limited topics drawn from evidence-based findings.^11,13–15

With the rapid doubling of the medical literature, frequent updates allow clinicians to be most current with practice guidelines. This potentially affects quality of care for antibiotic use, vaccination, health promotion, and screening as well as newly approved medications.

Strengths of Dynamed                                                               

• Large collection of topics, critically appraised, written for primary care physicians, presented in bulleted format
• The most frequently updated database^11,14,15
• Can integrate with major electronic health records (eg, Epic, Allscripts, NextGen, Cerner)
• Has an area devoted to new information that changes current practice
• Chosen topic grouped with related topics in the differential diagnosis after the initial search
• Easy-to-read outline for quick access to information such as billing, diagnosis, and references
• Medical calculators
• No advertisements
• Helpful embedded tools
• Icons to print or email the article
• An icon to create a “perma-link” to topics, searches, and browse categories
• Graded evidence with a link to the grading model used
• Links to primary articles
• Patient information handouts
• Alerts for updated information
• CME credit
• Special consideration and features for medical education
• The upgraded version Dynamed Plus contains Micromedex for a medication database, expanded graphics, semantic search, concise overview for each topic, and expanded content.

Weaknesses of Dynamed

• Although the topic list is large, it is only about one-third the size of UpToDate.
• A subscription for a physician costs $395 a year. Residents can sign up for about $150, and students for just under $100.
• CME is obtainable but cumbersome; one submits the CME credits through Tufts Healthcare, which requires a second sign-on to access and track.
• Drug and nondrug treatments for diseases cannot be separated.
• Useful calculators include decision trees for clinical decision-making, but there is no way to search them—one must waste time scrolling  through the topics and specialties looking for desired information.
• Major shortcoming: there is no medication reference tool unless you upgrade to Dynamed Plus.
• The expanded graphics of Dynamed Plus are difficult to view on mobile applications within the articles (they are brought up more reliably when searching just for the image).
• The use of strict evidence-based methodology without expert opinion is a strength, but limits the collection of topics without randomized controlled trials, for which turning to expert opinion may be the only option.

EVIDENCE ESSENTIALS

Evidence Essentials is a point-of-care resource from Wiley that offers a variety of content types. The website lists 13,000 medical topics; however, they are not all summary reviews as discussed in the other products above. Subject matter is reviewed 3 times a year. Comprehensive reviews number just under 800 individual topics, with the remaining content consisting of Cochrane reviews, calculators, decision support tools, POEMs (Patient-Oriented Evidence that Matters), evidence-based medical guidelines, and dermatology images (1,000).

Evidence Essentials provides some unique content including a quick evaluation and management (E/M) code-finder and calculators not only for the typical medical equations, but also for history and physical examination likelihood ratios and pretest probabilities, which are practical and an excellent teaching aid. It also offers CME along with POEMs, e-mail alerts, and a listing of upcoming topics.

Strengths of Evidence Essentials

• Relatively inexpensive at $85 a year.
• High-functioning filter system to choose to search one or multiple databases.
• Related results are listed for aid in differential diagnosis, similar to Dynamed.
• Authors, editors, and date of last review are highly visible. As in UpToDate, relevant medical calculators appear on the page.
• The likelihood and odds ratio calculators are a huge plus for clinical decision-making and putting guidelines into practice.
• “Overall bottom line” highlights key points
• Grading of evidence per topic.
• Bulleted and tabbed information for quick access.
• Tabs for information on background, prevention, diagnosis, treatment, references, guidelines, and special populations.

Weaknesses of Evidence Essentials

• Limited number of topics with comprehensive reviews.
• While you can click on any drug name and link to a choice of two drug databases, this is not included in the subscription and requires a second account.
• The resources tabs had some broken links. In our clinical example, the tab contained several videos at the top that were not related, followed by a map and tables that were relevant to Lyme disease.
• Likewise, some of the guideline references were disappointing. For example, the guideline link for Lyme disease is for the US Department of Labor Occupational Safety and Health Administration rather than a professional society.
• For the provider wanting a narrative, this is more of a bare-bones text.

FIRST CONSULT

First Consult is Elsevier’s point-of-care clinical decision product contained within ClinicalKey.

Unlike UpToDate and Dynamed, in which authors and editors read original articles and summarize or synthesize information for the learner, First Consult is a “smart” search engine that will research a question, together with associated terms and key words. Filters such as full-text availability, journal articles, and patient education can be applied.

You may need to read about your topic in a textbook first, and then, if you are looking for treatment information, find an original article through First Consult. It is available in mobile and desktop formats, and the point-of-care product, First Consult, has an app that can be downloaded and used for free for the first 60 days.

Importantly, the First Consult portion of ClinicalKey with the summary topics was rated by Shurtz and Foster¹³ as least current of the products we are discussing in this article. On the other hand, it was the only product that had an embedded program to assist the user in making presentations by allowing drag and drop of images and automatic citing of sources. Kim et al report that First Consult is one of the resources providers prefer.⁹

Strengths of First Consult

• Lengthy free trial
• Ability to access original articles from a list vs lengthy narrative
• Access to journals and books published by Elsevier
• Powerful search engine that applies associated terms automatically
• Patient education is available in different languages and font size with the ability to add instructions and even a local branding
• Can integrate with electronic health record
• Can filter results by guideline, patient education, topic overviews
• Presentation assistance.

Weaknesses of First Consult

• Time-intensive. A provider needing quick advice on treatment for a medical condition has to guess if an article or textbook will have the most up-to-date and digestible information, whereas this has already been summarized in other products. For the busy clinician, this may be prohibitive.
• Search results are limited to Elsevier products, and major journals such as the New England Journal of Medicine are not available.
• Inconsistent platform functionality. The app version was somewhat “sticky” to use, as pages did not always load efficiently, and the menu bar navigation is not ideal.
• Expensive, especially given cheaper alternatives. For example, subscribing to the specialty of internal medicine or family medicine costs $499 and provides access to 8 journals and 11 books. Extended access costs $998 and offers full-text access to 23 books and 45 journals. The complete service has a total of 400 journals, 700 books, and 2,500 procedural videos.

MEDSCAPE

Medscape, owned by parent company WebMD, has long been a popular resource. The most recent versions are available for both for Android and iOS mobile platforms. The desktop and mobile apps claim to be designed for point-of-care use, and can be downloaded at no cost after registering as a Medscape user.

Medscape has some interesting features, including a handy pill identifier tool that is new to Medscape and perfect for the “I take one blue pill for my cholesterol” moments. The drug information tools and other features work well offline.

Medscape contains a well-presented drug database and interaction checker, as well as a growing collection of evidence-based articles and videos with links to references in Medline. From the point-of-care standpoint, Medscape also offers a number of decision-making algorithms and a continuously updated medical literature and health-related newsfeed. It contains in-app medical calculators, searchable directories for providers, hospitals, and pharmacies, and CME that can be earned on the website or from the application.

The main Medscape website contains pop-up advertisements, but the mobile app has fewer. Among the occasional frustrations, updates are relatively infrequent,  the content is slow to load, and the phone app can be cumbersome. Of note, in one review,¹¹ Medscape was found to have the lowest quality of evidence.

Strengths of Medscape

• Free with registration
• Medical calculator
• Drug interaction checker
• Pill identifier
• Evidence-based information covering about 4,000 conditions with links to references in Medline
• Ability to e-mail articles for sharing or future reference
• CME
• Unique database of hospitals, providers, and pharmacies to aid in referrals or locating other healthcare professionals
• Algorithms for decision-making
• Images and videos for procedural review and learning
• Option for downloading certain databases for offline use
• Medical news helps you keep up with what patients are watching and reading.

Weaknesses of Medscape

• Advertisements (many of them pop-up)
• The content is updated less frequently than other products listed in this article
• The smartphone app can run slowly
• Quality of reviews may be a concern.

UpToDate

UpToDate (Wolters Kluwer) is used widely by medical students, residents, and fellows as well as practicing providers. It contains narrative reviews of topics written by respected experts directed at both clinicians and clinical staff. In hopes of appealing to many markets, it offers different subscription types so you can customize your choices with add-on features (UpToDate Desktop and UpToDate MobileComplete allow downloading of all content to be accessed offline), different service packages (1-, 2-, and 3-year subscriptions), and the traditional base product that provides online access.

Of the products we reviewed, UpToDate has the largest selection of medical topics, approaching 10,000.¹⁴ In some studies,^10,15 it also had the fastest retrieval time for searches. It uses evidence-based graded recommendations that are updated regularly.

Some have lamented that there is too much information per topic.⁹ In response to early reviews, Wolters Kluwer has made significant changes in the platform and greatly improved the search engine. UpToDate has expanded to include CME and patient information, trying to become that Holy Grail of websites—a one-stop experience. For the lucky few, UpToDate integrates into some electronic health records and provides a relatively seamless experience at the point of care.

Strengths of UpToDate

• One-stop shopping for information, resources, and CME
• Patient information is easy to read and accessible from the same screen
• The largest repository of medical subject matter
• Ability to cull out only pediatric or adult topics
• Searching available within a medical topic
• Tabs for quick access
• The What’s New feature allows access to practice-changing medical updates
• Medical calculators
• Drug interactions
• CME is is tracked in the system, allowing for CME credit information for hospital privileges and board certification
• Flexibility of access: can use online or download content to mobile/desktop device (the online version is easy to use, although robust wireless reception is needed; offices with slow Internet benefit from the offline feature)
• Electronic health record integration is possible with the most popular systems, such as Epic, eClinicalWorks, NextGen, and Allscripts
• Patient education and medication interaction features embedded in the electronic health record; produced in collaboration with Lexicomp
• Integrated drug database
• Alerts for updates
• References have links to full-text articles
• The date of last update is easily found for verifying information accuracy
• May be provided free for clinicians who are a part of a university or large health system.

Weaknesses of UpToDate

• Articles can be lengthy, which is both a strength and a weakness. Searches can retrieve too much information.⁹ High volume of text can frustrate the user trying to find bulleted, easy-to-read facts. However, for the person looking for a narrative summary, the content is organized as narrative paragraphs with appropriate headers in the left margin, and the search function is robust and powerful.
• Each topic has a “Summary of Recommendations,” but answers here often require linking back to the main text.
• Patient information is sometimes at a high literacy level.
• Costs more than Dynamed. A 1-year subscription is $499 for a physician, but you have the option of paying $53 for a 30-day recurring subscription. Residents, fellows, and students can pay $199 for 1 year or $19 for a 30-day recurring subscription.
• The requirement to download means that users need to keep their version updated on all of their computers—in each of their examination rooms, for example.
• Concerns about conflict of interest arise because authors and editors may maintain financial relationships with companies that produce medications discussed in the articles they have written.

BUILDING YOUR OWN PERSONAL ONLINE REPOSITORY

Our previous article⁵ reviewed how to store information using tools such as Evernote and Diigo that allow information viewed on a web page to be exported to any online repository. This can be done using extensions for a web browser or by sending the information to a custom e-mail account for these services.

For information that a provider knows he or she will need repeatedly, storage in one system is actually the easiest method. Such a system can then incorporate key information from the summary tools we have reviewed here. The ideal “electronic filing cabinet” should have several features such as a the capability to label articles by topic, to separate or sort as you see fit, and a search function to find information quickly—making it a personalized and effective point-of-care resource.

STAYING AFLOAT

Clinicians make many decisions every day. In fact, the release of How Doctors Think (both publications) has led to increased research into how clinical decisions and diagnoses are formed.^16,17

With the medical literature expected to double every 73 days by 2020,¹⁸ there is an ever-widening ocean of information to sift through. With this onslaught, clinicians can no longer remain fully current. Instead, refining skills in accessing, sorting, and interpreting accurate scientific evidence efficiently is crucial to time spent actually caring for patients and coordinating their care.

Guidelines, algorithms, and comprehensive databases can aid clinicians in all aspects of care, from generating more complete differential diagnoses to managing disease-specific treatment. Individuals can first think about and list the qualities of a tool that are most important to them (eg, breadth of topics, frequency of updates, integration within their electronic health record, and cost) before focusing on a few applications or websites that meet those goals. With practice, point-of-care knowledge can become part of the everyday visit.

Effective integration into electronic health records will require design input from front-line clinicians. Otherwise, systems are prone to add too much “support” and overly rely on orthodox metrics and guidelines, resulting in alarm fatigue and frustration rather than facilitation.^19–23

OUR CONCLUSIONS

Comprehensive point-of-care resources can play a significant role in helping busy clinicians provide best evidence-based care to their patients. Embedded clinical decision guides within an electronic health record are ideal, but low topic coverage has limited the usefulness of these systems.²⁴ Here are our conclusions:

Medscape, ePocrates, and Wikipedia are probably the most popular free resources. Dynamed has offered free subscriptions to Wikipedia’s top health editors with the hopes of correcting factual errors. Medscape has excellent features but is supported by sponsored content, which raises a concern about bias and potential time-consuming distractions.

Dynamed and UpToDate have both been reported to answer more questions than other sources.¹²

UpToDate has the largest repository, with each topic curated by an expert or experts in that subject. This content can be dense and difficult to scan quickly at the point of care, but this is balanced by the ability to search within a medical topic, which  has given it the fastest retrieval time.¹⁵ It does, however, allow authors and editors to maintain financial relationships with companies that produce medications discussed in the article.²²

Dynamed has the advantage in frequency of updates, clearest conflict-of-interest policy, and the least amount of conflict of interest. Its topic list is not as extensive as UpToDate’s due to the limitation of using only evidence-based medicine without expert opinion.

First Consult has high user satisfaction, but as a point-of-care resource it can be time-consuming to find the best source for the clinical question at hand, and its expanded access is costly.⁹

ART AND SCIENCE

Point-of-care resources do not solve all the complicated problems of patient care, and no single resource is ideal for all situations. A busy clinician has limited time to process the evolving literature to practice the best evidence-based medicine. Effective information access, quality of care provided, and the marginal time cost required create a complex calculus. Clinical decision-making remains an art and a science,²⁵ but these technologies help define a new era in its pursuit.

Ultimately, a clinician’s choice needs to correlate with a provider’s resources and style. This article has detailed several options available on the market today. This is a quickly evolving area of products and services. Longer term, users might consider a tool’s preferred key features when evaluating any current or future resource in order to choose the right ones for their practice.

CASE REVISITED

Before we leave for the weekend, we need a plan for Ms. Connecticut. To find appropriate recommendations for our patient, we search several of our point-of-care resources: UpToDate and Dynamed. Both resources have correct information according to the Infectious Disease Society of America (IDSA) guidelines.

UpToDate has a monograph of approximately 2,000 words on Lyme disease, which is lengthy but adds to clinical-decision making skills for a learner thinking through the decision. This service also has a patient handout highlighting the recommendations. The topic was last updated in 2016, but states that it is current with literature through January 2017. 

Dynamed has bulleted information that is quicker to digest, but essentially highlights the IDSA recommendations without the thought process behind them. It too, has patient resources with links to a variety of handouts from professional organizations such as the US Centers for Disease Control and Prevention. They last updated the topic January 31, 2017. 

When searching for the topic on both sites, a clinician can see the breadth of information in each program. However, this is also a detractor. Searching for Lyme disease prophylaxis on Dynamed brought up related data (that doxycycline is not FDA-approved for prophylaxis), but not the primary information. Likewise, the search under UpToDate first brought us to the patient information. Both articles have helpful tables and links to associated topics.

My partner chose the UpToDate article, in part to review the topic with a medical student. However, I used Dynamed for its quick bulleted information, as I was on call that evening and needed to return to the hospital.  We both came to the same conclusion, and Ms. Connecticut chose no prophylaxis even though her home is in an endemic area. She has done well.

It is friday afternoon on a sunny July day. The last patient of the day, Ms. Connecticut, is an active hiker who has had Lyme disease previously. She found a tick on her ankle yesterday. She successfully removed the tick but has not brought the tick with her to the appointment. She had been hiking several times over the last week and is not certain when the tick bite occurred. Her question for you centers on the role of antibiotic prophylaxis and Lyme disease prevention.

TECHNOLOGY: PROBLEM AND SOLUTION

Physicians need to keep up with an ever-increasing stream of information—new guidelines, new medications, and updates in medical literature.¹ They have to do this while seeing more patients with more chronic problems in less time and while meeting reporting requirements for meaningful use or quality measures for accountable care organizations.

Though some of these challenges are due to technology, one solution is to use technology to our advantage. While researching information in textbooks won’t drain a phone battery, carrying a textbook around is not feasible, and many textbooks (including their electronic versions) contain information that is outdated before they go to print or that is quickly outdated thereafter.² Further, even online textbooks are currently more dense than the online resources that we review here.  

Different types of resources can help task-saturated healthcare providers stay aware of new information while delivering evidence-based care. These tools—online textbooks, decision guides embedded within electronic health record systems, or even a Google search—are termed “point-of-care” resources when used at the time of patient care for decision-making in the moment.

Not all of these resources are of high quality, with reliable factual information. Researchers estimate that up to 70% of clinicians may use Wikipedia to research medical questions, and a comparison of 10 Wikipedia articles vs peer-reviewed sources on the 10 most costly diseases found that 9 of the 10 Wikipedia articles had errors.^3,4

In an earlier article,⁵ we advocated a proactive approach to managing information, highlighting ways to scan for new information and to develop habits of extracting useful information that can then be stored and easily recovered. To complement this strategy and weed out erroneous information, physicians need reliable sources of unbiased information to efficiently answer clinical questions at the point of care.^1,6

Here, to help busy clinicians choose which point-of-care resources to use, we review several of the most popular ones, examining their ease of use, key elements, strengths, and weaknesses.

WHAT MAKES A RESOURCE GOOD?

Key features that make point-of-care tools effective include:

Ease of use, with standard formats, a summary for each topic, or both

Links to original articles and concise, capsular summaries and syntheses of the data

Continuing medical education (CME) credit. Tip: when searching, add “CME” to the search string on the browser to access resources that provide this.

Institutional and individual accounts. For clinicians who work for large organizations, point-of-care products may be paid for already, or reimbursement may be available for your subscription. If unsure, ask your director of information technology or library services.

Freedom from advertisements. Many Internet sources have advertisements that either run alongside the information you want to see or, more annoyingly, pop up and require an action to move forward. There is also continuing concern about the effect of industry support on content.⁷ While not all of the resources that we use regularly and that we review here are ad-free, avoiding programs with high ad content helps limit the possibility of bias and the time it takes to access information. Although advertisements do bring up a risk of bias, resources with a low-level ad content can limit bias while providing free or low-cost access.

Evidence, not expert opinion. Many resources have an “about” page that explains their philosophy and the source of their information. It is vital to be sure that point-of-care databases are providing facts based on evidence.⁸ This page also typically addresses how authors and editors are selected and whether expert opinion is used when randomized trials are lacking.

Ease of access. Many tools can be accessed not only on computers but also through apps for smartphones and tablets. Some electronic medical records have clinical decision tools embedded in them, with varying capabilities.

Disclosure of conflict of interest. As conflicts of interest can shade recommendations, information sources should clearly disclose financial relationships that could be perceived as conflicts of interest—for example, authors writing about medications sold by companies with whom they have a financial relationship.

NO SINGLE RESOURCE DOES EVERYTHING

There are many types of tools for finding evidence-based medical information. Different tools serve different purposes. Table 1 lists “toolbox essentials” for clinicians needing to answer clinical questions during patient care.

For example, when a question about the need for a bone mineral density measurement comes up, it is useful to be able to quickly compare guidelines from different professional societies on the National Guideline Clearing House. For another example, if a patient brings in a medication in an unlabeled bottle, a pill identifier app can tell you what it is.  Clinicians who can use these resources appropriately will be at an advantage in being able to use information to provide better care to their patients.

To date, no point-of-care summary source has been shown to be superior in all categories, and use may be driven by ease of navigation, clinician preference, clinical question, or past success.^9,10

Reviewed below are several applications that can be used as point-of-care resources (Table 2).

CLINICAL EVIDENCE

Clinical Evidence provides systematic reviews on medical topics. Founded in 1999 by the British Medical Journal, it is available in print as the Clinical Evidence Handbook and in online desktop and smartphone formats.

More than any other source we reviewed, Clinical Evidence addresses not only the evidence that exists, but also the data that do not exist to guide decisions. Compared with 9 other point-of-care resources, Clinical Evidence was found to have the highest quality of evidence.¹¹

Strengths of Clinical Evidence

• Uncommonly transparent in terms of source of evidence or disclosing when there is a lack of evidence.
• Clearly lists the strength and relevance of the evidence.
• Personalization. Users can add notes to articles, save personal searches, and bookmark pages for easy access later.
• Navigability. Users can easily access systematic reviews, key points, retracted papers, or guidelines.
• Intuitive organization, with information categorized as research, education, news, or campaigns.
• New content daily:  podcasts, articles, videos.

Weaknesses of Clinical Evidence

• Limited topics (eg, Lyme disease was not available)
• The limited content is a challenge when needing quick information at the point of care and may cause most clinicians to use another source unless looking for comparisons of interventions.
• Cost. Subscribing to the service “on demand,” ie, to look up a single specific topic, costs $36 for 48 hours of access; monthly access or a “season ticket” allows 30 days of viewing of all content for $53. At over $600/year, this is one of the most costly of the sources we reviewed.
• Marketing of Clinical Evidence to academic institutions that support the service for faculty may limit its appeal to other clinicians.

DYNAMED

Dynamed, a clinical reference created by a group of physicians, was previously owned by the American College of Physicians and known as Smart Medicine; it is now owned by EBSCO.¹² Reviewers investigate the literature for a given topic and create pithy summaries for busy clinicians. A top feature in Dynamed is its links to full articles cited for best practices or evidence-based guidelines. The company describes their content as free of expert opinion, while being unbiased and evidence-based.

Dynamed uses a 7-step algorithm for searched topics that identifies articles, assesses clinical relevance, evaluates validity of outcomes, compiles the evidence from multiple articles, and then updates the final recommendations daily.

Dynamed Plus, the new upgraded version, updates searched topics several times a day. Dynamed may be the most frequently updated point-of-care resource, with the least risk of conflict of interest, but it offers limited topics drawn from evidence-based findings.^11,13–15

With the rapid doubling of the medical literature, frequent updates allow clinicians to be most current with practice guidelines. This potentially affects quality of care for antibiotic use, vaccination, health promotion, and screening as well as newly approved medications.

Strengths of Dynamed                                                               

• Large collection of topics, critically appraised, written for primary care physicians, presented in bulleted format
• The most frequently updated database^11,14,15
• Can integrate with major electronic health records (eg, Epic, Allscripts, NextGen, Cerner)
• Has an area devoted to new information that changes current practice
• Chosen topic grouped with related topics in the differential diagnosis after the initial search
• Easy-to-read outline for quick access to information such as billing, diagnosis, and references
• Medical calculators
• No advertisements
• Helpful embedded tools
• Icons to print or email the article
• An icon to create a “perma-link” to topics, searches, and browse categories
• Graded evidence with a link to the grading model used
• Links to primary articles
• Patient information handouts
• Alerts for updated information
• CME credit
• Special consideration and features for medical education
• The upgraded version Dynamed Plus contains Micromedex for a medication database, expanded graphics, semantic search, concise overview for each topic, and expanded content.

Weaknesses of Dynamed

• Although the topic list is large, it is only about one-third the size of UpToDate.
• A subscription for a physician costs $395 a year. Residents can sign up for about $150, and students for just under $100.
• CME is obtainable but cumbersome; one submits the CME credits through Tufts Healthcare, which requires a second sign-on to access and track.
• Drug and nondrug treatments for diseases cannot be separated.
• Useful calculators include decision trees for clinical decision-making, but there is no way to search them—one must waste time scrolling  through the topics and specialties looking for desired information.
• Major shortcoming: there is no medication reference tool unless you upgrade to Dynamed Plus.
• The expanded graphics of Dynamed Plus are difficult to view on mobile applications within the articles (they are brought up more reliably when searching just for the image).
• The use of strict evidence-based methodology without expert opinion is a strength, but limits the collection of topics without randomized controlled trials, for which turning to expert opinion may be the only option.

EVIDENCE ESSENTIALS

Evidence Essentials is a point-of-care resource from Wiley that offers a variety of content types. The website lists 13,000 medical topics; however, they are not all summary reviews as discussed in the other products above. Subject matter is reviewed 3 times a year. Comprehensive reviews number just under 800 individual topics, with the remaining content consisting of Cochrane reviews, calculators, decision support tools, POEMs (Patient-Oriented Evidence that Matters), evidence-based medical guidelines, and dermatology images (1,000).

Evidence Essentials provides some unique content including a quick evaluation and management (E/M) code-finder and calculators not only for the typical medical equations, but also for history and physical examination likelihood ratios and pretest probabilities, which are practical and an excellent teaching aid. It also offers CME along with POEMs, e-mail alerts, and a listing of upcoming topics.

Strengths of Evidence Essentials

• Relatively inexpensive at $85 a year.
• High-functioning filter system to choose to search one or multiple databases.
• Related results are listed for aid in differential diagnosis, similar to Dynamed.
• Authors, editors, and date of last review are highly visible. As in UpToDate, relevant medical calculators appear on the page.
• The likelihood and odds ratio calculators are a huge plus for clinical decision-making and putting guidelines into practice.
• “Overall bottom line” highlights key points
• Grading of evidence per topic.
• Bulleted and tabbed information for quick access.
• Tabs for information on background, prevention, diagnosis, treatment, references, guidelines, and special populations.

Weaknesses of Evidence Essentials

• Limited number of topics with comprehensive reviews.
• While you can click on any drug name and link to a choice of two drug databases, this is not included in the subscription and requires a second account.
• The resources tabs had some broken links. In our clinical example, the tab contained several videos at the top that were not related, followed by a map and tables that were relevant to Lyme disease.
• Likewise, some of the guideline references were disappointing. For example, the guideline link for Lyme disease is for the US Department of Labor Occupational Safety and Health Administration rather than a professional society.
• For the provider wanting a narrative, this is more of a bare-bones text.

FIRST CONSULT

First Consult is Elsevier’s point-of-care clinical decision product contained within ClinicalKey.

Unlike UpToDate and Dynamed, in which authors and editors read original articles and summarize or synthesize information for the learner, First Consult is a “smart” search engine that will research a question, together with associated terms and key words. Filters such as full-text availability, journal articles, and patient education can be applied.

You may need to read about your topic in a textbook first, and then, if you are looking for treatment information, find an original article through First Consult. It is available in mobile and desktop formats, and the point-of-care product, First Consult, has an app that can be downloaded and used for free for the first 60 days.

Importantly, the First Consult portion of ClinicalKey with the summary topics was rated by Shurtz and Foster¹³ as least current of the products we are discussing in this article. On the other hand, it was the only product that had an embedded program to assist the user in making presentations by allowing drag and drop of images and automatic citing of sources. Kim et al report that First Consult is one of the resources providers prefer.⁹

Strengths of First Consult

• Lengthy free trial
• Ability to access original articles from a list vs lengthy narrative
• Access to journals and books published by Elsevier
• Powerful search engine that applies associated terms automatically
• Patient education is available in different languages and font size with the ability to add instructions and even a local branding
• Can integrate with electronic health record
• Can filter results by guideline, patient education, topic overviews
• Presentation assistance.

Weaknesses of First Consult

• Time-intensive. A provider needing quick advice on treatment for a medical condition has to guess if an article or textbook will have the most up-to-date and digestible information, whereas this has already been summarized in other products. For the busy clinician, this may be prohibitive.
• Search results are limited to Elsevier products, and major journals such as the New England Journal of Medicine are not available.
• Inconsistent platform functionality. The app version was somewhat “sticky” to use, as pages did not always load efficiently, and the menu bar navigation is not ideal.
• Expensive, especially given cheaper alternatives. For example, subscribing to the specialty of internal medicine or family medicine costs $499 and provides access to 8 journals and 11 books. Extended access costs $998 and offers full-text access to 23 books and 45 journals. The complete service has a total of 400 journals, 700 books, and 2,500 procedural videos.

MEDSCAPE

Medscape, owned by parent company WebMD, has long been a popular resource. The most recent versions are available for both for Android and iOS mobile platforms. The desktop and mobile apps claim to be designed for point-of-care use, and can be downloaded at no cost after registering as a Medscape user.

Medscape has some interesting features, including a handy pill identifier tool that is new to Medscape and perfect for the “I take one blue pill for my cholesterol” moments. The drug information tools and other features work well offline.

Medscape contains a well-presented drug database and interaction checker, as well as a growing collection of evidence-based articles and videos with links to references in Medline. From the point-of-care standpoint, Medscape also offers a number of decision-making algorithms and a continuously updated medical literature and health-related newsfeed. It contains in-app medical calculators, searchable directories for providers, hospitals, and pharmacies, and CME that can be earned on the website or from the application.

The main Medscape website contains pop-up advertisements, but the mobile app has fewer. Among the occasional frustrations, updates are relatively infrequent,  the content is slow to load, and the phone app can be cumbersome. Of note, in one review,¹¹ Medscape was found to have the lowest quality of evidence.

Strengths of Medscape

• Free with registration
• Medical calculator
• Drug interaction checker
• Pill identifier
• Evidence-based information covering about 4,000 conditions with links to references in Medline
• Ability to e-mail articles for sharing or future reference
• CME
• Unique database of hospitals, providers, and pharmacies to aid in referrals or locating other healthcare professionals
• Algorithms for decision-making
• Images and videos for procedural review and learning
• Option for downloading certain databases for offline use
• Medical news helps you keep up with what patients are watching and reading.

Weaknesses of Medscape

• Advertisements (many of them pop-up)
• The content is updated less frequently than other products listed in this article
• The smartphone app can run slowly
• Quality of reviews may be a concern.

UpToDate

UpToDate (Wolters Kluwer) is used widely by medical students, residents, and fellows as well as practicing providers. It contains narrative reviews of topics written by respected experts directed at both clinicians and clinical staff. In hopes of appealing to many markets, it offers different subscription types so you can customize your choices with add-on features (UpToDate Desktop and UpToDate MobileComplete allow downloading of all content to be accessed offline), different service packages (1-, 2-, and 3-year subscriptions), and the traditional base product that provides online access.

Of the products we reviewed, UpToDate has the largest selection of medical topics, approaching 10,000.¹⁴ In some studies,^10,15 it also had the fastest retrieval time for searches. It uses evidence-based graded recommendations that are updated regularly.

Some have lamented that there is too much information per topic.⁹ In response to early reviews, Wolters Kluwer has made significant changes in the platform and greatly improved the search engine. UpToDate has expanded to include CME and patient information, trying to become that Holy Grail of websites—a one-stop experience. For the lucky few, UpToDate integrates into some electronic health records and provides a relatively seamless experience at the point of care.

Strengths of UpToDate

• One-stop shopping for information, resources, and CME
• Patient information is easy to read and accessible from the same screen
• The largest repository of medical subject matter
• Ability to cull out only pediatric or adult topics
• Searching available within a medical topic
• Tabs for quick access
• The What’s New feature allows access to practice-changing medical updates
• Medical calculators
• Drug interactions
• CME is is tracked in the system, allowing for CME credit information for hospital privileges and board certification
• Flexibility of access: can use online or download content to mobile/desktop device (the online version is easy to use, although robust wireless reception is needed; offices with slow Internet benefit from the offline feature)
• Electronic health record integration is possible with the most popular systems, such as Epic, eClinicalWorks, NextGen, and Allscripts
• Patient education and medication interaction features embedded in the electronic health record; produced in collaboration with Lexicomp
• Integrated drug database
• Alerts for updates
• References have links to full-text articles
• The date of last update is easily found for verifying information accuracy
• May be provided free for clinicians who are a part of a university or large health system.

Weaknesses of UpToDate

• Articles can be lengthy, which is both a strength and a weakness. Searches can retrieve too much information.⁹ High volume of text can frustrate the user trying to find bulleted, easy-to-read facts. However, for the person looking for a narrative summary, the content is organized as narrative paragraphs with appropriate headers in the left margin, and the search function is robust and powerful.
• Each topic has a “Summary of Recommendations,” but answers here often require linking back to the main text.
• Patient information is sometimes at a high literacy level.
• Costs more than Dynamed. A 1-year subscription is $499 for a physician, but you have the option of paying $53 for a 30-day recurring subscription. Residents, fellows, and students can pay $199 for 1 year or $19 for a 30-day recurring subscription.
• The requirement to download means that users need to keep their version updated on all of their computers—in each of their examination rooms, for example.
• Concerns about conflict of interest arise because authors and editors may maintain financial relationships with companies that produce medications discussed in the articles they have written.

BUILDING YOUR OWN PERSONAL ONLINE REPOSITORY

Our previous article⁵ reviewed how to store information using tools such as Evernote and Diigo that allow information viewed on a web page to be exported to any online repository. This can be done using extensions for a web browser or by sending the information to a custom e-mail account for these services.

For information that a provider knows he or she will need repeatedly, storage in one system is actually the easiest method. Such a system can then incorporate key information from the summary tools we have reviewed here. The ideal “electronic filing cabinet” should have several features such as a the capability to label articles by topic, to separate or sort as you see fit, and a search function to find information quickly—making it a personalized and effective point-of-care resource.

STAYING AFLOAT

Clinicians make many decisions every day. In fact, the release of How Doctors Think (both publications) has led to increased research into how clinical decisions and diagnoses are formed.^16,17

With the medical literature expected to double every 73 days by 2020,¹⁸ there is an ever-widening ocean of information to sift through. With this onslaught, clinicians can no longer remain fully current. Instead, refining skills in accessing, sorting, and interpreting accurate scientific evidence efficiently is crucial to time spent actually caring for patients and coordinating their care.

Guidelines, algorithms, and comprehensive databases can aid clinicians in all aspects of care, from generating more complete differential diagnoses to managing disease-specific treatment. Individuals can first think about and list the qualities of a tool that are most important to them (eg, breadth of topics, frequency of updates, integration within their electronic health record, and cost) before focusing on a few applications or websites that meet those goals. With practice, point-of-care knowledge can become part of the everyday visit.

Effective integration into electronic health records will require design input from front-line clinicians. Otherwise, systems are prone to add too much “support” and overly rely on orthodox metrics and guidelines, resulting in alarm fatigue and frustration rather than facilitation.^19–23

OUR CONCLUSIONS

Comprehensive point-of-care resources can play a significant role in helping busy clinicians provide best evidence-based care to their patients. Embedded clinical decision guides within an electronic health record are ideal, but low topic coverage has limited the usefulness of these systems.²⁴ Here are our conclusions:

Medscape, ePocrates, and Wikipedia are probably the most popular free resources. Dynamed has offered free subscriptions to Wikipedia’s top health editors with the hopes of correcting factual errors. Medscape has excellent features but is supported by sponsored content, which raises a concern about bias and potential time-consuming distractions.

Dynamed and UpToDate have both been reported to answer more questions than other sources.¹²

UpToDate has the largest repository, with each topic curated by an expert or experts in that subject. This content can be dense and difficult to scan quickly at the point of care, but this is balanced by the ability to search within a medical topic, which  has given it the fastest retrieval time.¹⁵ It does, however, allow authors and editors to maintain financial relationships with companies that produce medications discussed in the article.²²

Dynamed has the advantage in frequency of updates, clearest conflict-of-interest policy, and the least amount of conflict of interest. Its topic list is not as extensive as UpToDate’s due to the limitation of using only evidence-based medicine without expert opinion.

First Consult has high user satisfaction, but as a point-of-care resource it can be time-consuming to find the best source for the clinical question at hand, and its expanded access is costly.⁹

ART AND SCIENCE

Point-of-care resources do not solve all the complicated problems of patient care, and no single resource is ideal for all situations. A busy clinician has limited time to process the evolving literature to practice the best evidence-based medicine. Effective information access, quality of care provided, and the marginal time cost required create a complex calculus. Clinical decision-making remains an art and a science,²⁵ but these technologies help define a new era in its pursuit.

Ultimately, a clinician’s choice needs to correlate with a provider’s resources and style. This article has detailed several options available on the market today. This is a quickly evolving area of products and services. Longer term, users might consider a tool’s preferred key features when evaluating any current or future resource in order to choose the right ones for their practice.

CASE REVISITED

Before we leave for the weekend, we need a plan for Ms. Connecticut. To find appropriate recommendations for our patient, we search several of our point-of-care resources: UpToDate and Dynamed. Both resources have correct information according to the Infectious Disease Society of America (IDSA) guidelines.

UpToDate has a monograph of approximately 2,000 words on Lyme disease, which is lengthy but adds to clinical-decision making skills for a learner thinking through the decision. This service also has a patient handout highlighting the recommendations. The topic was last updated in 2016, but states that it is current with literature through January 2017. 

Dynamed has bulleted information that is quicker to digest, but essentially highlights the IDSA recommendations without the thought process behind them. It too, has patient resources with links to a variety of handouts from professional organizations such as the US Centers for Disease Control and Prevention. They last updated the topic January 31, 2017. 

When searching for the topic on both sites, a clinician can see the breadth of information in each program. However, this is also a detractor. Searching for Lyme disease prophylaxis on Dynamed brought up related data (that doxycycline is not FDA-approved for prophylaxis), but not the primary information. Likewise, the search under UpToDate first brought us to the patient information. Both articles have helpful tables and links to associated topics.

My partner chose the UpToDate article, in part to review the topic with a medical student. However, I used Dynamed for its quick bulleted information, as I was on call that evening and needed to return to the hospital.  We both came to the same conclusion, and Ms. Connecticut chose no prophylaxis even though her home is in an endemic area. She has done well.

Accessing, absorbing, organizing, storing, and retrieving potentially useful medical information is a challenge. Physicians used to try meet this challenge with personal libraries of journal articles in their file cabinet. Today, that is inadequate to combat the deluge of digital information. In 2013, the Institute of Medicine acknowledged this problem, stating, “The ever-increasing volume of evidence makes it difficult for clinicians to maintain a working knowledge of new clinical information.”¹

The sheer volume of data has meant that, rather than try to maintain a regular diet of professional reading (proactive scanning²), many of us now seek information only when we need answers to specific clinical questions (reactive searching). This approach promotes lifelong problem-based learning but assumes that we are consciously aware of this need and are aware of the need to search for new information.

We need to constantly scan for new evidence in our area of practice to avoid becoming falsely assured of our knowledge. We also need to be able to find information we have seen before we need to use it. The following are examples of how using this approach could dramatically empower a busy clinician.

On a recent clinic day, a colleague pokes his head into your office and asks, “Have you heard anything about niacin in the news? I have a patient who is asking me if we should discontinue it.” You respond: “Yes, there was something that just came out. I am not sure where I read it or heard about it. Give me a couple of seconds and I can find it.” True to your word, a few seconds later you find and share the latest article on the HPS2-THRIVE trial and a commentary on the results.

Later, your first patient of the day asks you, “When we switched to dabigatran, you mentioned that, unlike warfarin, there was no specific reversal agent. I heard that there is one now?” Instead of being taken aback, you nod your head. “Yes, I saw that recent article showing that the medication rapidly and completely reverses the effect of dabigatran in the majority of patients. While I hope we don’t need it, this is good news, particularly as there did not seem to be any major adverse events.”

Sounds too good to be true? Can this really be you? In this article, we outline an information management strategy (Figure 1) and tools to help busy clinicians stay up to date with new medical evidence in their areas of interest or expertise. In addition, we provide a strategy for leveraging technology to easily retrieve previously viewed information. A future article will specifically show how to best access information at the point of patient care.

THE NEED TO MANAGE INFORMATION

Physicians are expected to practice evidence-based medicine. When faced with a clinical question, we should search for evidence using focused queries of primary and secondary sources such as PubMed or the Cochrane Library. This is an important skill and is appropriate when we take time to look for an evidence-based answer to a specific question. In many cases, it is appropriate to continue with a current practice until newer information has been reviewed and validated.

Unfortunately, indexing and adding new recommendations to these information sources takes time. We may also be unaware that new information is available and may continue to practice as usual until faced with a situation like those outlined above or until we attend a continuing medical education activity, often quite by chance.

Today we can proactively update ourselves in a manner tailored to our own interests and focus and retrieve important information easily when we need it.

A STRATEGY FOR INFORMATION MANAGEMENT

In general, we come across new information in one of three ways:

• Proactive scanning of personalized sources of information—as discussed above, a habit of regular scanning is critical to information management
• Reactive searching for information to answer clinical problems or when doing research
• Incidentally—an e-mail from a colleague, information shared on a social network or encountered while surfing the Internet.

In each case, we may find information that is potentially useful, something we may need to find again in the future. But unless we use this information often, we will not remember the details or may even forget we had seen it. Thus, we need a strategy to store this information so we can retrieve it easily at any time with any device; neuroscientists call this the “externalization” of memory.³ Ideally, even if we forget that we ever saw this information or where we stored it, a search would retrieve the location and details of this formerly viewed information.

In the following sections, we outline steps and tools of a strategy for managing clinical information relevant to your practice.

STEP 1: SETTING UP INFORMATION FEEDS

The first step in this information management strategy is to become aware of relevant new information in your area of practice or research. To do this, you proactively set up feeds of information from reliable and authentic sources. These feeds can be browsed on any computer or smart mobile device.

There are several possibilities for creating these feeds. One option is to subscribe to the table of contents (TOC) of relevant journals via e-mail.

A more versatile and full-featured option is a research site summary (RSS) feed-reader. RSS is a standard for publishing summaries (feeds) of frequently updated content on the World Wide Web, such as journal TOCs and items from medical journal news sites (Table 1 shows what this looks like on screen), as well as aggregators like the American College of Physicians Journal Club. You can subscribe to these using feed-reader software from Feedly (www.feedly.com) or Inoreader (www.inoreader.com), which can be used with any browser on a desktop or laptop. They are also available as apps for mobile devices such as smartphones and tablets. The feed-reader periodically checks for new content and automatically downloads it to the device. Thus, you do not need to check multiple websites for updates or have e-mail inboxes fill with content; the content is delivered to your device for perusal at your convenience. (See online supplement “Information Management for Clinicians” for step-by-step instructions on creating a free Inoreader account and subscribing to feeds.)

RSS feed-readers have several advantages over e-mailed TOCs:

• RSS feeds create a centralized searchable repository of all subscribed information.
• The software keeps track of what you have read and displays only unread items; after a journal TOC e-mail is opened, the entire TOC is marked as having been read.
• You can organize news items into folders by tagging key words.
• Most journals and medical news sites like Medscape and the health section of the New York Times provide RSS feeds at no cost.
• An unlimited number of feed items, or articles, are stored in the cloud and do not affect e-mail storage capacity.
• The feed is automatically updated multiple times a day instead of once a week or once a month.
• In addition, one can create RSS feeds on PubMed for custom searches. Thus, a physician can get automatic regular updates of new articles indexed in MEDLINE in their area of interest.

Users can thus build their own personalized magazine of constantly updated information for access and can search from any web-enabled device. (Note: It is advisable to turn off notifications generated by these apps on mobile devices to reduce distraction.)

STEP 2: BOOKMARKING EVIDENCE

When you find something useful or interesting, bookmarks help you find the information again quickly when you need it. But while the browsers Firefox, Chrome, Internet Explorer, and Safari allow bookmarking, they have significant limitations. Bookmarks may be available only on the device they were created on, and because people use more than one device to go online, they may not remember which device they used to bookmark or view the web page.

Browser bookmarks generally store the address (URL) of the web page and a label that you create, but they do not do much else. Sharing bookmarks with others is also difficult or impossible.

Social bookmarking

Social bookmarking lets you create bookmarks you can share across other devices and with other people. Diigo (www.diigo.com) and Delicious (www.delicious.com) are two social bookmarking services that let you integrate with all popular browsers through a button or toolbar. They allow you to save displayed web pages with labels, descriptions, and tags.

Diigo offers two additional features. It allows web pages to be annotated with highlights and notes. And during a Google search, relevant results from the Diigo library are simultaneously displayed.

If you forget you bookmarked something and saved it in your Diigo library, when you search for the information again on Google, Diigo will automatically display any results from your Diigo library next to the Google search results. This is very helpful as it is much easier to review information you have already read, marked up, and saved than it is to start over.

Bookmarks and annotations are stored in the cloud and can be accessed by any device. (See “Information Management for Clinicians” to learn how to sign up for a free Diigo account, and how to use it.)

STEP 3: STORING YOUR INFORMATION

You may want the option to store full-text information in your personal library. This information was once stored in file cabinets and, more recently, on hard drives and USB flash drives. But information stored with these methods is not available or searchable on multiple devices from any location.

Cloud storage

Cloud storage services meet the need for access to stored information at any time and with any device. Options include Dropbox (www.dropbox.com), Box (www.box.com), Google Drive (drive.google.com), OneDrive (onedrive.live.com), and Evernote (www.evernote.com). Each provides different amounts of free storage and has apps available for most platforms and devices. They provide search tools and the ability to share articles or “folders” with other users. The information on these online drives is “synced” between all devices so that the most up-to-date version is always available to the user regardless of location and device.

Evernote offers multiple folders called notebooks to store and segregate data. The open notebook shown in Figure 2 is named “reference articles.” It has the HPS2-Thrive article from the New England Journal of Medicine (N Engl J Med) tagged with the terms “niacin” and “lipid” to facilitate retrieval. The article was saved from that journal’s website using an Evernote browser extension that allows entire web pages or selections to be saved to Evernote with a single click. Evernote also has a powerful search feature that can find text in images or in PDF documents. In addition, it allows easy sharing of a note or an entire notebook. Once a note or notebook is shared, all parties can add to it. In The Evernote app also allows tablet and smartphone access to the shareable content.

From Landray MJ, et al. Effects of extended-release niacin with laropiprant in high-risk patients. HPS2-THRIVE Collaborative Group. N Engl J Med 2014; 371:203-212. Copyright 2014, Massachusetts Medical Society (MMS). Reprinted with permission from MMS.

The other services listed here have similar feature sets. Dropbox is perhaps the easiest to adopt, but it offers the least amount of free storage. If you use Microsoft Office software, OneDrive lets you edit documents online, and an Office 365 subscription includes 1 terabyte of storage. Google Drive is probably the best solution for online collaboration, such as coauthoring a paper. Box is one of the few online storage solutions that complies with the Health Insurance Portability and Accountability privacy rules.

PUTTING IT ALL INTO PRACTICE

Once you have become familiar with Inoreader and Diigo (see Information Management for Clinicians for step-by-step instructions), the following scenario shows how to adapt them into an efficient workflow.

Dr. Smith has a smartphone, a tablet, a laptop at home, and a desktop at work. She signs onto Google Chrome as her preferred browser on all devices. This seamlessly loads her Diigo extension when she is using a laptop or desktop. She has set her RSS feeds for her preferred journal TOCs and medical news sites to be downloaded to Inoreader. (For details on how to add a medical journals feed bundle and a medical news feed bundle, visit Information Management for Clinicians.)

Instead of reading paper journals, Dr. Smith browses her customized up-to-date “magazine” on Inoreader. When she comes across a relevant article, she marks it as “favorite.” If she has more time, she visits the web page, reviews the information, and saves it to her Diigo library with annotations if appropriate.

When searching for information on the web, she uses Google—without having to remember if she bookmarked information related to the search term. The Diigo extension in her browser automatically searches and displays information from her Diigo library next to her Google search results, and she can instantly see her notes from the last time she read the article.

Relating this workflow to the example of the dabigatran story above, Dr. Smith sees an article about dabigatran reversal while viewing her N Engl J Med medical news feed on her feed-reader. She marks it as a favorite and tags it with the key terms “cardiology” and “vascular” (Figure 3).

Dr. Smith later returns to look at her favorite feed items and visits the article on the N Engl J Med website. She annotates the article and saves it to her Diigo library (Figure 4).

Since this information is highly relevant to her practice, she also visits the N Engl J Med website to read the full article and the accompanying editorial (Figure 5). She annotates these and also saves them to her Diigo library.

From Landray MJ, et al. Effects of extended-release niacin with laropiprant in high-risk patients. HPS2-THRIVE Collaborative Group. N Engl J Med 2014; 371:203-212. Copyright 2014, Massachusetts Medical Society (MMS). Reprinted with permission from MMS.

Later, if she searches Google for dabigatran (using her default Google Chrome browser with Diigo extension), she will see the usual Google search results and twinned Diigo bookmarks (Figure 6).

If she clicks on one of the links, the browser will load the web page with all the annotations that she made when she first visited.

CONCLUSION

The strategies and tools we describe here let you create a personalized and constantly updated medical news “magazine,” accessible from any of your web-enabled devices. They can transform the Internet into a searchable notebook of personally selected, annotated information, helping you to more easily stay up to date with advances in your field of practice, and to more easily manage the modern information overload.

Accessing, absorbing, organizing, storing, and retrieving potentially useful medical information is a challenge. Physicians used to try meet this challenge with personal libraries of journal articles in their file cabinet. Today, that is inadequate to combat the deluge of digital information. In 2013, the Institute of Medicine acknowledged this problem, stating, “The ever-increasing volume of evidence makes it difficult for clinicians to maintain a working knowledge of new clinical information.”¹

The sheer volume of data has meant that, rather than try to maintain a regular diet of professional reading (proactive scanning²), many of us now seek information only when we need answers to specific clinical questions (reactive searching). This approach promotes lifelong problem-based learning but assumes that we are consciously aware of this need and are aware of the need to search for new information.

We need to constantly scan for new evidence in our area of practice to avoid becoming falsely assured of our knowledge. We also need to be able to find information we have seen before we need to use it. The following are examples of how using this approach could dramatically empower a busy clinician.

On a recent clinic day, a colleague pokes his head into your office and asks, “Have you heard anything about niacin in the news? I have a patient who is asking me if we should discontinue it.” You respond: “Yes, there was something that just came out. I am not sure where I read it or heard about it. Give me a couple of seconds and I can find it.” True to your word, a few seconds later you find and share the latest article on the HPS2-THRIVE trial and a commentary on the results.

Later, your first patient of the day asks you, “When we switched to dabigatran, you mentioned that, unlike warfarin, there was no specific reversal agent. I heard that there is one now?” Instead of being taken aback, you nod your head. “Yes, I saw that recent article showing that the medication rapidly and completely reverses the effect of dabigatran in the majority of patients. While I hope we don’t need it, this is good news, particularly as there did not seem to be any major adverse events.”

Sounds too good to be true? Can this really be you? In this article, we outline an information management strategy (Figure 1) and tools to help busy clinicians stay up to date with new medical evidence in their areas of interest or expertise. In addition, we provide a strategy for leveraging technology to easily retrieve previously viewed information. A future article will specifically show how to best access information at the point of patient care.

THE NEED TO MANAGE INFORMATION

Physicians are expected to practice evidence-based medicine. When faced with a clinical question, we should search for evidence using focused queries of primary and secondary sources such as PubMed or the Cochrane Library. This is an important skill and is appropriate when we take time to look for an evidence-based answer to a specific question. In many cases, it is appropriate to continue with a current practice until newer information has been reviewed and validated.

Unfortunately, indexing and adding new recommendations to these information sources takes time. We may also be unaware that new information is available and may continue to practice as usual until faced with a situation like those outlined above or until we attend a continuing medical education activity, often quite by chance.

Today we can proactively update ourselves in a manner tailored to our own interests and focus and retrieve important information easily when we need it.

A STRATEGY FOR INFORMATION MANAGEMENT

In general, we come across new information in one of three ways:

• Proactive scanning of personalized sources of information—as discussed above, a habit of regular scanning is critical to information management
• Reactive searching for information to answer clinical problems or when doing research
• Incidentally—an e-mail from a colleague, information shared on a social network or encountered while surfing the Internet.

In each case, we may find information that is potentially useful, something we may need to find again in the future. But unless we use this information often, we will not remember the details or may even forget we had seen it. Thus, we need a strategy to store this information so we can retrieve it easily at any time with any device; neuroscientists call this the “externalization” of memory.³ Ideally, even if we forget that we ever saw this information or where we stored it, a search would retrieve the location and details of this formerly viewed information.

In the following sections, we outline steps and tools of a strategy for managing clinical information relevant to your practice.

STEP 1: SETTING UP INFORMATION FEEDS

The first step in this information management strategy is to become aware of relevant new information in your area of practice or research. To do this, you proactively set up feeds of information from reliable and authentic sources. These feeds can be browsed on any computer or smart mobile device.

There are several possibilities for creating these feeds. One option is to subscribe to the table of contents (TOC) of relevant journals via e-mail.

A more versatile and full-featured option is a research site summary (RSS) feed-reader. RSS is a standard for publishing summaries (feeds) of frequently updated content on the World Wide Web, such as journal TOCs and items from medical journal news sites (Table 1 shows what this looks like on screen), as well as aggregators like the American College of Physicians Journal Club. You can subscribe to these using feed-reader software from Feedly (www.feedly.com) or Inoreader (www.inoreader.com), which can be used with any browser on a desktop or laptop. They are also available as apps for mobile devices such as smartphones and tablets. The feed-reader periodically checks for new content and automatically downloads it to the device. Thus, you do not need to check multiple websites for updates or have e-mail inboxes fill with content; the content is delivered to your device for perusal at your convenience. (See online supplement “Information Management for Clinicians” for step-by-step instructions on creating a free Inoreader account and subscribing to feeds.)

RSS feed-readers have several advantages over e-mailed TOCs:

• RSS feeds create a centralized searchable repository of all subscribed information.
• The software keeps track of what you have read and displays only unread items; after a journal TOC e-mail is opened, the entire TOC is marked as having been read.
• You can organize news items into folders by tagging key words.
• Most journals and medical news sites like Medscape and the health section of the New York Times provide RSS feeds at no cost.
• An unlimited number of feed items, or articles, are stored in the cloud and do not affect e-mail storage capacity.
• The feed is automatically updated multiple times a day instead of once a week or once a month.
• In addition, one can create RSS feeds on PubMed for custom searches. Thus, a physician can get automatic regular updates of new articles indexed in MEDLINE in their area of interest.

Users can thus build their own personalized magazine of constantly updated information for access and can search from any web-enabled device. (Note: It is advisable to turn off notifications generated by these apps on mobile devices to reduce distraction.)

STEP 2: BOOKMARKING EVIDENCE

When you find something useful or interesting, bookmarks help you find the information again quickly when you need it. But while the browsers Firefox, Chrome, Internet Explorer, and Safari allow bookmarking, they have significant limitations. Bookmarks may be available only on the device they were created on, and because people use more than one device to go online, they may not remember which device they used to bookmark or view the web page.

Browser bookmarks generally store the address (URL) of the web page and a label that you create, but they do not do much else. Sharing bookmarks with others is also difficult or impossible.

Social bookmarking

Social bookmarking lets you create bookmarks you can share across other devices and with other people. Diigo (www.diigo.com) and Delicious (www.delicious.com) are two social bookmarking services that let you integrate with all popular browsers through a button or toolbar. They allow you to save displayed web pages with labels, descriptions, and tags.

Diigo offers two additional features. It allows web pages to be annotated with highlights and notes. And during a Google search, relevant results from the Diigo library are simultaneously displayed.

If you forget you bookmarked something and saved it in your Diigo library, when you search for the information again on Google, Diigo will automatically display any results from your Diigo library next to the Google search results. This is very helpful as it is much easier to review information you have already read, marked up, and saved than it is to start over.

Bookmarks and annotations are stored in the cloud and can be accessed by any device. (See “Information Management for Clinicians” to learn how to sign up for a free Diigo account, and how to use it.)

STEP 3: STORING YOUR INFORMATION

You may want the option to store full-text information in your personal library. This information was once stored in file cabinets and, more recently, on hard drives and USB flash drives. But information stored with these methods is not available or searchable on multiple devices from any location.

Cloud storage

Cloud storage services meet the need for access to stored information at any time and with any device. Options include Dropbox (www.dropbox.com), Box (www.box.com), Google Drive (drive.google.com), OneDrive (onedrive.live.com), and Evernote (www.evernote.com). Each provides different amounts of free storage and has apps available for most platforms and devices. They provide search tools and the ability to share articles or “folders” with other users. The information on these online drives is “synced” between all devices so that the most up-to-date version is always available to the user regardless of location and device.

Evernote offers multiple folders called notebooks to store and segregate data. The open notebook shown in Figure 2 is named “reference articles.” It has the HPS2-Thrive article from the New England Journal of Medicine (N Engl J Med) tagged with the terms “niacin” and “lipid” to facilitate retrieval. The article was saved from that journal’s website using an Evernote browser extension that allows entire web pages or selections to be saved to Evernote with a single click. Evernote also has a powerful search feature that can find text in images or in PDF documents. In addition, it allows easy sharing of a note or an entire notebook. Once a note or notebook is shared, all parties can add to it. In The Evernote app also allows tablet and smartphone access to the shareable content.

From Landray MJ, et al. Effects of extended-release niacin with laropiprant in high-risk patients. HPS2-THRIVE Collaborative Group. N Engl J Med 2014; 371:203-212. Copyright 2014, Massachusetts Medical Society (MMS). Reprinted with permission from MMS.

The other services listed here have similar feature sets. Dropbox is perhaps the easiest to adopt, but it offers the least amount of free storage. If you use Microsoft Office software, OneDrive lets you edit documents online, and an Office 365 subscription includes 1 terabyte of storage. Google Drive is probably the best solution for online collaboration, such as coauthoring a paper. Box is one of the few online storage solutions that complies with the Health Insurance Portability and Accountability privacy rules.

PUTTING IT ALL INTO PRACTICE

Once you have become familiar with Inoreader and Diigo (see Information Management for Clinicians for step-by-step instructions), the following scenario shows how to adapt them into an efficient workflow.

Dr. Smith has a smartphone, a tablet, a laptop at home, and a desktop at work. She signs onto Google Chrome as her preferred browser on all devices. This seamlessly loads her Diigo extension when she is using a laptop or desktop. She has set her RSS feeds for her preferred journal TOCs and medical news sites to be downloaded to Inoreader. (For details on how to add a medical journals feed bundle and a medical news feed bundle, visit Information Management for Clinicians.)

Instead of reading paper journals, Dr. Smith browses her customized up-to-date “magazine” on Inoreader. When she comes across a relevant article, she marks it as “favorite.” If she has more time, she visits the web page, reviews the information, and saves it to her Diigo library with annotations if appropriate.

When searching for information on the web, she uses Google—without having to remember if she bookmarked information related to the search term. The Diigo extension in her browser automatically searches and displays information from her Diigo library next to her Google search results, and she can instantly see her notes from the last time she read the article.

Relating this workflow to the example of the dabigatran story above, Dr. Smith sees an article about dabigatran reversal while viewing her N Engl J Med medical news feed on her feed-reader. She marks it as a favorite and tags it with the key terms “cardiology” and “vascular” (Figure 3).

Dr. Smith later returns to look at her favorite feed items and visits the article on the N Engl J Med website. She annotates the article and saves it to her Diigo library (Figure 4).

Since this information is highly relevant to her practice, she also visits the N Engl J Med website to read the full article and the accompanying editorial (Figure 5). She annotates these and also saves them to her Diigo library.

From Landray MJ, et al. Effects of extended-release niacin with laropiprant in high-risk patients. HPS2-THRIVE Collaborative Group. N Engl J Med 2014; 371:203-212. Copyright 2014, Massachusetts Medical Society (MMS). Reprinted with permission from MMS.

Later, if she searches Google for dabigatran (using her default Google Chrome browser with Diigo extension), she will see the usual Google search results and twinned Diigo bookmarks (Figure 6).

If she clicks on one of the links, the browser will load the web page with all the annotations that she made when she first visited.

CONCLUSION

The strategies and tools we describe here let you create a personalized and constantly updated medical news “magazine,” accessible from any of your web-enabled devices. They can transform the Internet into a searchable notebook of personally selected, annotated information, helping you to more easily stay up to date with advances in your field of practice, and to more easily manage the modern information overload.

Accessing, absorbing, organizing, storing, and retrieving potentially useful medical information is a challenge. Physicians used to try meet this challenge with personal libraries of journal articles in their file cabinet. Today, that is inadequate to combat the deluge of digital information. In 2013, the Institute of Medicine acknowledged this problem, stating, “The ever-increasing volume of evidence makes it difficult for clinicians to maintain a working knowledge of new clinical information.”¹

The sheer volume of data has meant that, rather than try to maintain a regular diet of professional reading (proactive scanning²), many of us now seek information only when we need answers to specific clinical questions (reactive searching). This approach promotes lifelong problem-based learning but assumes that we are consciously aware of this need and are aware of the need to search for new information.

We need to constantly scan for new evidence in our area of practice to avoid becoming falsely assured of our knowledge. We also need to be able to find information we have seen before we need to use it. The following are examples of how using this approach could dramatically empower a busy clinician.

On a recent clinic day, a colleague pokes his head into your office and asks, “Have you heard anything about niacin in the news? I have a patient who is asking me if we should discontinue it.” You respond: “Yes, there was something that just came out. I am not sure where I read it or heard about it. Give me a couple of seconds and I can find it.” True to your word, a few seconds later you find and share the latest article on the HPS2-THRIVE trial and a commentary on the results.

Later, your first patient of the day asks you, “When we switched to dabigatran, you mentioned that, unlike warfarin, there was no specific reversal agent. I heard that there is one now?” Instead of being taken aback, you nod your head. “Yes, I saw that recent article showing that the medication rapidly and completely reverses the effect of dabigatran in the majority of patients. While I hope we don’t need it, this is good news, particularly as there did not seem to be any major adverse events.”

Sounds too good to be true? Can this really be you? In this article, we outline an information management strategy (Figure 1) and tools to help busy clinicians stay up to date with new medical evidence in their areas of interest or expertise. In addition, we provide a strategy for leveraging technology to easily retrieve previously viewed information. A future article will specifically show how to best access information at the point of patient care.

THE NEED TO MANAGE INFORMATION

Physicians are expected to practice evidence-based medicine. When faced with a clinical question, we should search for evidence using focused queries of primary and secondary sources such as PubMed or the Cochrane Library. This is an important skill and is appropriate when we take time to look for an evidence-based answer to a specific question. In many cases, it is appropriate to continue with a current practice until newer information has been reviewed and validated.

Unfortunately, indexing and adding new recommendations to these information sources takes time. We may also be unaware that new information is available and may continue to practice as usual until faced with a situation like those outlined above or until we attend a continuing medical education activity, often quite by chance.

Today we can proactively update ourselves in a manner tailored to our own interests and focus and retrieve important information easily when we need it.

A STRATEGY FOR INFORMATION MANAGEMENT

In general, we come across new information in one of three ways:

• Proactive scanning of personalized sources of information—as discussed above, a habit of regular scanning is critical to information management
• Reactive searching for information to answer clinical problems or when doing research
• Incidentally—an e-mail from a colleague, information shared on a social network or encountered while surfing the Internet.

In each case, we may find information that is potentially useful, something we may need to find again in the future. But unless we use this information often, we will not remember the details or may even forget we had seen it. Thus, we need a strategy to store this information so we can retrieve it easily at any time with any device; neuroscientists call this the “externalization” of memory.³ Ideally, even if we forget that we ever saw this information or where we stored it, a search would retrieve the location and details of this formerly viewed information.

In the following sections, we outline steps and tools of a strategy for managing clinical information relevant to your practice.

STEP 1: SETTING UP INFORMATION FEEDS

The first step in this information management strategy is to become aware of relevant new information in your area of practice or research. To do this, you proactively set up feeds of information from reliable and authentic sources. These feeds can be browsed on any computer or smart mobile device.

There are several possibilities for creating these feeds. One option is to subscribe to the table of contents (TOC) of relevant journals via e-mail.

A more versatile and full-featured option is a research site summary (RSS) feed-reader. RSS is a standard for publishing summaries (feeds) of frequently updated content on the World Wide Web, such as journal TOCs and items from medical journal news sites (Table 1 shows what this looks like on screen), as well as aggregators like the American College of Physicians Journal Club. You can subscribe to these using feed-reader software from Feedly (www.feedly.com) or Inoreader (www.inoreader.com), which can be used with any browser on a desktop or laptop. They are also available as apps for mobile devices such as smartphones and tablets. The feed-reader periodically checks for new content and automatically downloads it to the device. Thus, you do not need to check multiple websites for updates or have e-mail inboxes fill with content; the content is delivered to your device for perusal at your convenience. (See online supplement “Information Management for Clinicians” for step-by-step instructions on creating a free Inoreader account and subscribing to feeds.)

RSS feed-readers have several advantages over e-mailed TOCs:

• RSS feeds create a centralized searchable repository of all subscribed information.
• The software keeps track of what you have read and displays only unread items; after a journal TOC e-mail is opened, the entire TOC is marked as having been read.
• You can organize news items into folders by tagging key words.
• Most journals and medical news sites like Medscape and the health section of the New York Times provide RSS feeds at no cost.
• An unlimited number of feed items, or articles, are stored in the cloud and do not affect e-mail storage capacity.
• The feed is automatically updated multiple times a day instead of once a week or once a month.
• In addition, one can create RSS feeds on PubMed for custom searches. Thus, a physician can get automatic regular updates of new articles indexed in MEDLINE in their area of interest.

Users can thus build their own personalized magazine of constantly updated information for access and can search from any web-enabled device. (Note: It is advisable to turn off notifications generated by these apps on mobile devices to reduce distraction.)

STEP 2: BOOKMARKING EVIDENCE

When you find something useful or interesting, bookmarks help you find the information again quickly when you need it. But while the browsers Firefox, Chrome, Internet Explorer, and Safari allow bookmarking, they have significant limitations. Bookmarks may be available only on the device they were created on, and because people use more than one device to go online, they may not remember which device they used to bookmark or view the web page.

Browser bookmarks generally store the address (URL) of the web page and a label that you create, but they do not do much else. Sharing bookmarks with others is also difficult or impossible.

Social bookmarking

Social bookmarking lets you create bookmarks you can share across other devices and with other people. Diigo (www.diigo.com) and Delicious (www.delicious.com) are two social bookmarking services that let you integrate with all popular browsers through a button or toolbar. They allow you to save displayed web pages with labels, descriptions, and tags.

Diigo offers two additional features. It allows web pages to be annotated with highlights and notes. And during a Google search, relevant results from the Diigo library are simultaneously displayed.

If you forget you bookmarked something and saved it in your Diigo library, when you search for the information again on Google, Diigo will automatically display any results from your Diigo library next to the Google search results. This is very helpful as it is much easier to review information you have already read, marked up, and saved than it is to start over.

Bookmarks and annotations are stored in the cloud and can be accessed by any device. (See “Information Management for Clinicians” to learn how to sign up for a free Diigo account, and how to use it.)

STEP 3: STORING YOUR INFORMATION

You may want the option to store full-text information in your personal library. This information was once stored in file cabinets and, more recently, on hard drives and USB flash drives. But information stored with these methods is not available or searchable on multiple devices from any location.

Cloud storage

Cloud storage services meet the need for access to stored information at any time and with any device. Options include Dropbox (www.dropbox.com), Box (www.box.com), Google Drive (drive.google.com), OneDrive (onedrive.live.com), and Evernote (www.evernote.com). Each provides different amounts of free storage and has apps available for most platforms and devices. They provide search tools and the ability to share articles or “folders” with other users. The information on these online drives is “synced” between all devices so that the most up-to-date version is always available to the user regardless of location and device.

Evernote offers multiple folders called notebooks to store and segregate data. The open notebook shown in Figure 2 is named “reference articles.” It has the HPS2-Thrive article from the New England Journal of Medicine (N Engl J Med) tagged with the terms “niacin” and “lipid” to facilitate retrieval. The article was saved from that journal’s website using an Evernote browser extension that allows entire web pages or selections to be saved to Evernote with a single click. Evernote also has a powerful search feature that can find text in images or in PDF documents. In addition, it allows easy sharing of a note or an entire notebook. Once a note or notebook is shared, all parties can add to it. In The Evernote app also allows tablet and smartphone access to the shareable content.

From Landray MJ, et al. Effects of extended-release niacin with laropiprant in high-risk patients. HPS2-THRIVE Collaborative Group. N Engl J Med 2014; 371:203-212. Copyright 2014, Massachusetts Medical Society (MMS). Reprinted with permission from MMS.

The other services listed here have similar feature sets. Dropbox is perhaps the easiest to adopt, but it offers the least amount of free storage. If you use Microsoft Office software, OneDrive lets you edit documents online, and an Office 365 subscription includes 1 terabyte of storage. Google Drive is probably the best solution for online collaboration, such as coauthoring a paper. Box is one of the few online storage solutions that complies with the Health Insurance Portability and Accountability privacy rules.

PUTTING IT ALL INTO PRACTICE

Once you have become familiar with Inoreader and Diigo (see Information Management for Clinicians for step-by-step instructions), the following scenario shows how to adapt them into an efficient workflow.

Dr. Smith has a smartphone, a tablet, a laptop at home, and a desktop at work. She signs onto Google Chrome as her preferred browser on all devices. This seamlessly loads her Diigo extension when she is using a laptop or desktop. She has set her RSS feeds for her preferred journal TOCs and medical news sites to be downloaded to Inoreader. (For details on how to add a medical journals feed bundle and a medical news feed bundle, visit Information Management for Clinicians.)

Instead of reading paper journals, Dr. Smith browses her customized up-to-date “magazine” on Inoreader. When she comes across a relevant article, she marks it as “favorite.” If she has more time, she visits the web page, reviews the information, and saves it to her Diigo library with annotations if appropriate.

When searching for information on the web, she uses Google—without having to remember if she bookmarked information related to the search term. The Diigo extension in her browser automatically searches and displays information from her Diigo library next to her Google search results, and she can instantly see her notes from the last time she read the article.

Relating this workflow to the example of the dabigatran story above, Dr. Smith sees an article about dabigatran reversal while viewing her N Engl J Med medical news feed on her feed-reader. She marks it as a favorite and tags it with the key terms “cardiology” and “vascular” (Figure 3).

Dr. Smith later returns to look at her favorite feed items and visits the article on the N Engl J Med website. She annotates the article and saves it to her Diigo library (Figure 4).

Since this information is highly relevant to her practice, she also visits the N Engl J Med website to read the full article and the accompanying editorial (Figure 5). She annotates these and also saves them to her Diigo library.

From Landray MJ, et al. Effects of extended-release niacin with laropiprant in high-risk patients. HPS2-THRIVE Collaborative Group. N Engl J Med 2014; 371:203-212. Copyright 2014, Massachusetts Medical Society (MMS). Reprinted with permission from MMS.

Later, if she searches Google for dabigatran (using her default Google Chrome browser with Diigo extension), she will see the usual Google search results and twinned Diigo bookmarks (Figure 6).

If she clicks on one of the links, the browser will load the web page with all the annotations that she made when she first visited.

CONCLUSION

The strategies and tools we describe here let you create a personalized and constantly updated medical news “magazine,” accessible from any of your web-enabled devices. They can transform the Internet into a searchable notebook of personally selected, annotated information, helping you to more easily stay up to date with advances in your field of practice, and to more easily manage the modern information overload.