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PROCEP Teaching and Research CenterRio de Janeiro, Brazil
PROCEP Teaching and Research CenterRio de Janeiro, Brazil
Scientifically Informed Medical Practice and LEarning (SIMPLE)
The Roadmap for Evidence Based Health Care
Scientifically Informed Medical Practice and LEarning (SIMPLE)
The Roadmap for Evidence Based Health Care
Suzana Alves da Silva, MD, PhD
“The integration of best research evidence with clinical expertise
and patient values and circumstances”
David Sackett, 1992
Evidence-Based MedicineEvidence-Based Medicine
2. Acquire
1. Ask
3. Appraise
4. Apply
0. Problem Delineation
EBM Skills CycleEBM Skills Cycle
Patients rarely knew to whom they had been talking, either by name or designation
Patients knew that something was going wrong but rarely knew what was going wrong. They only knew that it was not a heart attack
“But it is something, you know, there is something going on”
Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008
Patient’s Opinion after a Chest Pain Unit
Experience
Patient’s Opinion after a Chest Pain Unit
ExperienceBased on ESCAPE Trial, Goodacre et al. BMJ 2007.Based on ESCAPE Trial, Goodacre et al. BMJ 2007.
• Low Patient Satisfaction• Overwhelming• $$$$$$
• Low Patient Satisfaction• Overwhelming• $$$$$$
+
=
• Low risk patient
• Follow the algorithm for low risk chest pain in the ER which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram + non-invasive test for stratification before discharge
Chest Pain UnitChest Pain Unit
Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008
The SIMPLE ModelThe SIMPLE Model
ValuesValues
PreferencesPreferences
PrioritiesPrioritiesProblem
delineation
“The process of problematization implies
a critical return to action. It starts from
action and returns to it”
Paulo Freire, 1972
Problem delineation
“The process of problematization implies
a critical return to action. It starts from
action and returns to it”
Paulo Freire, 1972
P
Problem
AAction
CChoices
TTargets
Utility
Performance
Probability
Silva, Charon, Wyer. JECP 2010.
Pati
en
t-Pra
ctit
ion
er
Rela
tion
ship
an
d
Pra
ctic
e C
ircu
mst
an
ces
P
Problem
AAction
CChoices
TTargets
Utility
Performance
Probability
P
Problem
AAction
CChoices
TTargets
Share consideration of the utility
alternatives
Estimate of impact on patient outcomes
Share consideration
of the performance
alternativesEstimate of effect
Share consideration
of the probability
Estimate of likelihood of possible causes
Silva, Charon, Wyer. JECP 2010.
Pati
en
t-Pra
ctit
ion
er
Rela
tion
ship
an
d
Pra
ctic
e C
ircu
mst
an
ces
Clinical ScenarioClinical Scenario
‘‘I woke up with palpitations and chest pressure this I woke up with palpitations and chest pressure this morning. I just want to get it checked out, thatmorning. I just want to get it checked out, that’’s all.s all.’’
This is how a 31-year-old worker, who has come to the emergency department during lunch break, describes his problem. The patient has no significant past medical history but that his father died in his 50’s of a ‘massive heart attack’. The patient lives alone, has an unclear history of similar symptoms. He states that he occasionally takes benzodiazepine ‘for sleep’. However, he stresses that, for now, he just wants his chest symptoms ‘checked out. ’
EKG, vital signs and physical examination and first cardiac enzymes are normal.
PatientPatient PractitionerPractitioner
Am I having a Heart Attack?
Diagnosis likelihood
If I come back to work what is the probability of
something bad happening?
Prognosis likelihood
Will the algorithm for low risk chest pain help me out
excluding ACS for this patient?Diagnosis performance
If this patient in fact has ACS what will be the probability of being sued as a result of a bad
outcome?Prognosis likelihood
Chest Pain UnitChest Pain UnitPrioritiesPriorities
Is it safe to perform an outpatient investigation in this low risk patient? What is the
impact on outcomes?Diagnosis utility
I would like to perform the tests later. Is that
okay?Diagnosis utility
P
Problem
AAction
CChoices
TTargets
UtilityDiagnostic Intervention
Utility of out patient
investigation within few days
To follow the algorithm for low risk chest pain in the ER
Estimate of impact on
cardiovascular events
PerformanceDiagnosis
Performance of negative cardiac
markers 6 hours after symptoms
Criterion Standard
Estimate of accuracy
Probability Differential Dx
Probability of ACS when
chest pain is present
Estimate of likelihood of
possible causes
Silva, Charon, Wyer. JECP 2010.
Pati
en
t-Pra
ctit
ion
er
Rela
tion
ship
an
d
Pra
ctic
e C
ircu
mst
an
ces
< 10%
< 10%
< 1%< 1%
Pre-Test Probability of ACS
Probability of a Bad Outcome if the patient has ACS
< 1 out of1.000
< 1 out of1.000
Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.
Within 1 month
Will have a heart attack
100
% o
f p
ati
en
ts >
40
y/o
3%
wit
h m
ult
iple
ris
k fa
ctors
Low Risk Chest PainLow Risk Chest PainSolving the issues of probabilitySolving the issues of probability
Diagnosis
Prognosis
Goldman. PREDICTION OF THE NEED FOR INTENSIVE CARE IN PATIENTS WHO COME TO EMERGENCY DEPARTMENTS WITH ACUTE CHEST PAIN. NEJM 1996.
PACTPACTAction DomainsAction Domains
Categories of ProblemsCategories of Problems
PACTPACT
THERAPYTHERAPYTHERAPYTHERAPY DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSIS PROGNOSISPROGNOSISPROGNOSISPROGNOSIS HARMHARMHARMHARM
Utility
PerformanceProbability
UtilityPerformanceProbability
Utility
PerformanceProbability
Utility
PerformanceProbability
Action DomainsAction Domains
The Anatomy of the The Anatomy of the QuestionQuestion
The Anatomy of the The Anatomy of the QuestionQuestion
opulation
ntervention
omparison
utcome
Clinical ScenarioYou are seeing new patients in the “major care” area of the ED. You reassess a 45 yo male who had been held in the ED overnight while being treated for renal colic,
in the hope he could be discharged.
Unfortunately, this patient is not doing so well; he is extremely weak, nauseous and suffering extensive
rigors. He has spiked a temp to 39.9 oC and his BP is 90/50, HR 135, and RR 22. His O2 saturation is 98% on
room air.
You initiate a septic work-up and order aggressive hydration and broad-spectrum antibiotics. Based on tests you diagnose septic shock secondary to UTI,
complicated by an obstructing stone.
In patients with septic shock, does Early Goal Directed Therapy affect
mortality?
In patients with septic shock, does Early Goal Directed Therapy affect
mortality?
Utility
Performance
Probability
TherapyTherapyUtilityUtility
TherapyTherapyProbabilityProbability
PP In patients with septic In patients with septic shockshock
IFIF a pt with septic a pt with septic shock shock ISIS submitted to submitted to
EGDTEGDT
II Does EGDTDoes EGDT During the During the hospitalization phasehospitalization phase
CC Compared to the usual Compared to the usual carecare
OO Decrease mortality?What is the expected
mortality?
Acquiring the Best Available Evidence
Acquiring the Best Available Evidence
Utility of a Therapeutic Intervention
Utility of a Therapeutic Intervention
Guidelines
Systematic Reviews
Randomized trials
Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008
The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis*
The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis*
Guidelines
Systematic Reviews
Observational Studies
Likelihood of outcome if submitted to therapy
Likelihood of outcome if submitted to therapy
In-Hospital mortality in In-Hospital mortality in SepsisSepsis
Patients submitted to EGDTPatients submitted to EGDT
In-Hospital mortality in In-Hospital mortality in SepsisSepsis
Patients submitted to EGDTPatients submitted to EGDT
Lagu et al. Incorporating initial treatments improves performance of a mortality prediction model for patients with sepsis. Pharmacoepidemiology and drug safety 2012; 21(S2): 44–52
Silva and Wyer, Where is the wisdom? II, JECP 2009
Clinical ResearchClinical
Research
Basic ScienceBasic Science
Clinical ExpertiseClinical Expertise
Clinical Knowledge“Problematization” - Constructivism
Clinical Knowledge“Problematization” - Constructivism
Scientific KnowledgePos-Positivism - Pragmatism
Scientific KnowledgePos-Positivism - Pragmatism
InformationPositivism
InformationPositivism
Evid
ence
Hiera
rchy
JAMA 1
992
Epist
emol
ogic
al H
iera
rchy
Compl
exityW
isd
om
Wis
dom
Oxford Classification
Guidelines
Integration of Knowledge
Integration of Knowledge
David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.Wyer, Silva. Where is the Wisdom I. JECP 2009.
Sival, Wyer. Where is the Wisdom II. JECP 2009.
TS Eliot. The Rock.Acknowledgement to Peter Wyer
“Where is the wisdom we have lost in knowledge? Where is the
knowledge we have lost in information?”
Where is the Wisdom?
Where is the Wisdom?
Obrigada!
Gracias!
Thank You!
Danke!
Merci!