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The First International Conference for Evidence-based Healthcare
First International Conference on
Evidence-based healthcareThe Inaugural Conference of the
International Society of Evidence-based Health Care
India International Centre, New DelhiWorkshops: 6 October 2012
(Pre-Conference workshops on topics related to EBHC)
Conference: 7-8 October 2012www.isehcon2012.com
Who should attend?
• Physicians, nurses, pharmacists, chiropractors, naturopaths, involved in the implementation of evidence including frontline healthcare professionals
• Educators involved in teaching and training in evidence based healthcare
Speakers
• Kameshwar Prasad, Paul Glasziou, Gordon Guyatt, Luz Letelier, Victor Montori
www.isehcon2012.com
The second principle of evidence-based medicine
changes everythingVictor M. Montori, MD, MSc
Professor of MedicineKER UNIT - Mayo Clinic
[email protected] @vmontori
DisclosuresDisclosures
Relevant Financial RelationshipsRelevant Financial RelationshipsNoneNone
Off Label UsageOff Label UsageNoneNone
Relevant Financial RelationshipsRelevant Financial RelationshipsNoneNone
Off Label UsageOff Label UsageNoneNone
Our confidence in estimates of risk and benefit
from the body of evidence
contributes to
our confidence in making decisions.
Our confidence in estimates of risk and benefit
from the body of evidence
contributes to
our confidence in making decisions.
Confidence in the estimates of risk and benefit
Bias
Imprecision
Inconsistency
Indirectness
Biased reporting
Our confidence in estimates of risk and benefit
from the body of evidence
contributes to
our confidence in making decisions.
body of evidence
Trelle et al. BMJ 2011;342:c7086
Our confidence in estimates of risk and benefit
from the body of evidence
contributes to
our confidence in making decisions.
Appropriate care
Care < Need
Underuse
Appropriate care
Glasziou and Haynes ACP JC 2005
Care > NeedCare < Need
Underuse Overuse
Appropriate care
Geographic variation in overuse
Variation in overuse by procedure (n=172)Preventive services
PSA 16-36%Urinalysis 37%
Follow-up colonoscopy: 61%Pap smear: 58%
Korenstein D, et al. Arch Intern Med 2012: 172: 171-8
Shah ND et al. NEJM 2012
Sources of waste and their projected growth to 2020
Berwick, D. M. et al. JAMA 2012;307:1513-1516
Care > NeedCare < Need
Underuse Overuse
Appropriate care
Guidelines
Every patient with diabetes is a ‘coronary heart disease risk equivalent’
Every patient with diabetes should take a statin and achieve LDL < 100 mg/dL
ATP III, 2004
Minnesota Community Measurement
Weymiller et al. Arch Intern Med 2007
Weymiller et al. Arch Intern Med 2007
Weymiller et al. Arch Intern Med 2007
>90% <20%~50%
% who opted for treatment
% who should take statins based on ATP III
>90% >90%>90%
The evidence alone is never sufficient to make a decision.
Context and patient values, preferences and goals should be considered.
Encounter Research
Care > NeedCare < Need
Underuse Overuse
Appropriate care
Care > WantCare < Want
Undertreatment Overtreatment
Desirablecare
A survey of 627 US primary care clinicians
Sirovich BE et al. Arch Intern Med 2011
50% of my patients get too much care
50% of primary care docs are too aggressive60% of specialists are too aggressive
35% practice much more aggressively than what they would like
Weymiller et al. Arch Intern Med 2007
Statin Choice
Statin Decision Aid
Web-based tool
34
Mullan et al Arch Intern Med 2009
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
Neuropathy
108 kg
Pain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
Exercise
Check his feet
3 2 1Numbers don’t add up
Deadline is nowtake work home
perform!
Daughter back at home2 beautiful girls
Wasted!
mortgagedebt
insurance
Care > NeedCare < Need
Underuse Overuse
Appropriate care
Care > WantCare < Want
Undertreatment Overtreatment
Desirablecare
Care > CanCare < Can
Undertreatment Overtreatment
Feasiblecare
WORKLOAD
CAPACITY
Encounter Research
NEED
WANT
CAN
APPROPRIATE
DESIRABLE
FEASIBLE
http://shareddecisions.mayoclinic.org
http://minimallydisruptivemedicine.org
Needhttp://www.gradeworkinggroup.org
Want
Can
7th International Shared Decision Making Conference
Lima, Perú - June 16-19 2013
www.isdm2013.org
Our confidence in the research contributes to
our confidence in making decisions.The evidence alone is never sufficient
to make a decision.
