The First International Conference for Evidence-based Healthcare

1. The First International Conference for Evidence-based Healthcare

2. First International Conference on Evidence-based healthcare The Inaugural Conference of the International Society of Evidence-based Health Care India International Centre, New Delhi Workshops: 6 October 2012 (Pre-Conference workshops on topics related to EBHC) Conference: 7-8 October 2012 www.isehcon2012.com

3. 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

4. The second principle of evidence-based medicine changes everything Victor M. Montori, MD, MSc Professor of Medicine KER UNIT - Mayo Clinic montori.victor@mayo.edu @vmontori

5. Disclosures • Relevant Financial Relationships • None • Off Label Usage • None

6. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

7. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

8. Confidence in the estimates of risk and benefit Bias Imprecision Inconsistency Indirectness Biased reporting

9. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

10. body of evidence Trelle et al. BMJ 2011;342:c7086

11. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

12. Appropriate care

13. Care < Need Underuse Appropriate care

14. Glasziou and Haynes ACP JC 2005

15. Care < Need Care > Need Overuse Underuse Appropriate care

16. 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% Shah ND et al. NEJM 2012 Korenstein D, et al. Arch Intern Med 2012: 172: 171-8

17. Sources of waste and their projected growth to 2020 Berwick, D. M. et al. JAMA 2012;307:1513-1516

18. Care < Need Care > Need Overuse Underuse Appropriate care

19. 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

20. Minnesota Community Measurement

21. Weymiller et al. Arch Intern Med 2007

22. Weymiller et al. Arch Intern Med 2007

23. Weymiller et al. Arch Intern Med 2007

24. % who opted for treatment >90% ~50% <20% % who should take statins based on ATP III >90% >90% >90%

25. The evidence alone is never sufficient to make a decision. Context and patient values, preferences and goals should be considered.

26. Encounter Research

27. Care < Need Care > Need Overuse Underuse Appropriate care

28. Care < Want Care > Want Overtreatment Undertreatment Desirable care

29. A survey of 627 US primary care clinicians 50% of my patients get too much care 50% of primary care docs are too aggressive 60% of specialists are too aggressive 35% practice much more aggressively than what they would like Sirovich BE et al. Arch Intern Med 2011

30. Statin Choice Weymiller et al. Arch Intern Med 2007

31. Statin Decision Aid

32. Web-based tool

33. Mullan et al Arch Intern Med 2009

35. 55 3 2 1 Get a ride Dietitian Numbers don’t add up Take off work Deadline is now Endocrinologist 108 kg take work home Obese High cholesterol perform! LDL high Avoid salt, fats, carbs insurance Metformin A1c 8.2% Diabetes mortgage Check sugars Glipizide debt Hypertension Dizzy HCTZ Take pills Wasted! Beta-blocker Daughter back at home Depression Can’t sleep Exercise 2 beautiful girls Bad back Neuropathy Pain Podiatrist Check his feet

36. Care < Need Care > Need Overuse Underuse Appropriate care

37. Care < Want Care > Want Overtreatment Undertreatment Desirable care

38. Care < Can Care > Can Overtreatment Undertreatment Feasible care

39. WORKLOAD CAPACITY

40. DESIRABLE Encounter Research WANT CAN NEED FEASIBLE APPROPRIATE

41. Need http://www.gradeworkinggroup.org Want http://shareddecisions.mayoclinic.org Can http://minimallydisruptivemedicine.org

42. 7th International Shared Decision Making Conference Lima, Perú - June 16-19 2013 www.isdm2013.org

43. Our confidence in the research contributes to our confidence in making decisions. The evidence alone is never sufficient to make a decision.