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Evidence based health lecture

Evidence based health lecture

arinbasu
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Evidence based health lecture

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  1. Evidence Based Health Care Arindam Basu University of Canterbury Christchurch, New Zealand E-mail: arindam.basu@canterbury.ac.nz

  2. Objective of This Presentation • Explain Evidence Based Health Care (EBHC) • Explain Key Terms and Rationale • This is a Low LevelOverview • Forin-depth Discussion, • Check the Resources Section of these Slides • Email at arin.basu@gmail.com with specific question • Search the Internet Read and Practice More …

  3. What Shall We Cover • What is meant by EBHC • Steps and processes of EBHC • How todo EBHC

  4. What IS EBHC?

  5. Problems in modern health care • High Costs • Inequality or inequity of access to care • Practice Variations

  6. Too Much Information, Too Little Time

  7. What Can a Clinician Do About It? • Select the Best Literature (Read Selectively) • Search Efficiently • Search Keeping the Patient in Focus • Learn to Critically Appraise Literature • Incorporate Best Evidence in Practice

  8. Enter, EBHC • Evidence based medicine or health care • Explicit, judicious use of best information

  9. Purpose of EBHC • Stronger foundation for clinical work • Achieve consistency • Efficiency • Effectiveness • Quality and safety

  10. Popularity of EBM • Organizations devoted to do EBM • Journal Clubs in Hospitals • Care Pathways, and Outcomes Research • EBM curricula in Medical Education

  11. Definition • Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. • (David Sackett, 1995)

  12. What does EBHC involve? • Statistical meta analysis • Promotion ofRCTs • Reporting Styles • Self Evaluation • Use of Clinical Practice Guidelines • Addresses Clinical Practice Variations • (Timmermans, 2010, Health Affairs)

  13. Evidence Based Health Care Practice • Clinical Expertise • External Evidence • Patient Centric Shared Decision

  14. Clinical expertise • Proficiency • Judgment • Clinical Experience and Practice

  15. Signs and Symptoms of Clinical Expertise • Effective Diagnosis • Efficient Diagnosis • Identification and compassion with Patients’ • Predicaments • Rights, • Preferences • (The Clinician is Patient Focused, Saves Money, and Good at Diagnosing and Treating!)

  16. Best available external evidence • Clinically relevant research • Basic sciences of medicine • Patient-centered clinical research

  17. Good External Evidence … • Challenges Previously accepted diagnostic tests • Replaces with new ones • Makes Decision Making More powerful • Makes Decision Making More efficacious • Makes Practice Safer

  18. Different Types of Clinical Evidence Studies • Diagnostic and Screening Studies • Accuracy • Precision • Prognostic Markers • Safety and Efficacy • Therapy • Rehabilitation • Prevention

  19. What Happens with Only Expertise but No Evidence? • Tyrannical • Cannot always apply to single patients • No current evidence • Out of date • Can be dangerous to patients

  20. You Need Both External Evidence and Expertise!

  21. What’s New About EBHC?

  22. Thomas Kuhn and Paradigms

  23. Knowledge Evolves in Paradigms • Biology or Eminence Based Medicine Was Old Paradigm • Evidence Based Medicine is a paradigm shift • EBHC is the NEW Paradigm in health care

  24. Steps and Processes of EBHC

  25. Steps • Frame a Question • Search the Literature • Critically Appraise Studies • Synthesize Information from Studies • Work with Your Patient to Share Decisions

  26. How to Frame Questions? • Foreground Knowledge • Background Knowledge • People • Intervention • Exposure • Comparison Group • Outcomes

  27. Background Knowledge • Established knowledge • Clinical Expertise • Knowledge learned from Textbooks • Usually covered in University Curricula • Basis of Asking Further Questions

  28. Foreground knowledge • Knowledge Gained by Systematic Inquiry • New knowledge

  29. Challenge 1: Alternatives? • Eminence Based Medicine or Health • Experience Based health • Opinion Based health • What are the problems with these?

  30. So, How Do You Learn to Do EBH? • Develop Clinical Expertise • Frame Answerable Questions • Search Literature • Critically Appraise Literature • Do Shared Decision Making with Patients/Clients

  31. Step I: How Do You Frame Answerable Questions?

  32. PICO Approach • People-Interventions-Comparator-Outcomes

  33. People • "Who" aspect of the question • They should match your Target Patient • Age, Sex, Other characteristics

  34. Challenge 2: Low Back Pain in a 40 year old Nurse • A 40 year old nurse approachesuswith low back pain and you have heard that bed rest is good treatment in general for low back pain. How do you know that it is indeed good for this patient? What would you advise? What are the risks and benefits? How do you know? what questions will you frame?

  35. Intervention or Exposure • What treatment is proposed? • What was the patient or the person exposed to? • Example: is exposure to cell phone radiation really bad for health for older people? For pregnant? For a child? How do you know?

  36. Comparison Group • Who are compared with? • What Should Be Parameters of Comparison?

  37. Outcomes • What outcomes are relevant? • Pain? • Are all outcomes measurable • What are the different types of outcomes?

  38. Challenge 3: Ginger Patch • ProfessorX has developed a treatment he calls “Ginger Patch” and claims that it is a great remedy for low back pain among a variety of patients. You have not heard about this treatment before and would like to take an Evidence Based Health Approach. How would you frame your question?

  39. Searching the Scholarly Literature • What is Scholarly Literature? • Why Should one use Specialized Databases? • What Databases are out there?

  40. Some Literature Databases • Google Scholar • Ovid • Medline (Pubmed and Pubmed Central) • Embase • CINAHL • Web of Science • IndMed??

  41. Boolean Logic

  42. And

  43. Or

  44. Not

  45. Use of different terms (specific terms) • Look Up Help Files • Ovid • Medline [MeSH] • Google Scholar • Subject Headings

  46. Fuzzy Logic • Artificial intelligence Based • Nearness • Usually Words or Cluster • Curation of databases is important

  47. Critical Appraisal of Scholarly Literature

  48. What to look for? • Is the research is believable? • What does the literature say? • Can I apply to my patient?

  49. Is the paper valid?

  50. Are there significant biases? • Systematic Errors • Response Bias • Selection Bias • Confirmation Bias

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