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

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t-Pra

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Rela

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ship

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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

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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

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Rela

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ship

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Pra

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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!