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The Culture of Health Care: Evidence-Based Practice Lecture

This lecture explores the key tenets of evidence-based medicine (EBM) and its role in the culture of health care. It covers constructing answerable clinical questions, critically appraising evidence, applying EBM to intervention studies, diagnosis, harm, and prognosis, summarizing evidence, and using EBM in clinical settings.

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The Culture of Health Care: Evidence-Based Practice Lecture

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  1. The Culture of Health Care Evidence-Based Practice Lecture a This material (Comp 2 Unit 5) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

  2. Evidence-Based PracticeLearning Objectives • Define the key tenets of evidence-based medicine (EBM) and its role in the culture of health care (Lectures a, b). • Construct answerable clinical questions and critically appraise evidence answering them (Lecture b). • Explain how EBM can be applied to intervention studies, including the phrasing of answerable questions, finding evidence to answer them, and applying them to given clinical situations (Lecture c). • Describe how EBM can be applied to key clinical questions of diagnosis, harm, and prognosis (Lectures d, e). • Discuss the benefits and limitations to summarizing evidence (Lecture f). • Describe how EBM is used in clinical settings through clinical practice guidelines and decision analysis (Lecture g).

  3. What Is Evidence-Based Medicine (EBM)? • A set of tools and a disciplined approach to informing clinical decision making • Applies the best evidence available • But remember the caveat: “Absence of evidence is not evidence of absence” (Martin Rees) • Allows clinical experience (art) to be integrated with best clinical science • Makes medical literature more clinically applicable and relevant

  4. Why Are We Not Evidence-Based? • Thomas Kida (2006) lists six ways we arrive at false beliefs: • We prefer stories to statistics. • We seek to confirm, not to question, our ideas. • We rarely appreciate the role of chance and coincidence in shaping events. • We sometimes misperceive the world around us. • We tend to oversimplify our thinking. • Our memories are often inaccurate.

  5. Growing Advocacy for Medicine Being More Evidence-Based • “Effectiveness” was one of six attributes advocated in IOM’s Crossing the Quality Chasm (Source: Institute of Medicine, 2001) • Report advocates in detail the use of informatics for a “learning health care system” (Source: Eden, Wheatley, McNeil, & Sox, 2008) • “Descriptions of Methodological Details and Challenges for EBM,” in Medical Care (Source: Medical Care, 2007) • EBM key points in JAMA (Source: Guyatt & Voelker, 2015)

  6. “Cultural” Pushback on EBM • Not everyone agrees with the experimentally oriented approach of EBM (Source: Luce et al., 2009) • Some criticisms of EBM are valid (Source: Cohen, Stavri, & Hersh, 2004) • Challenges physician-patient autonomy • Focuses on large-scale, randomized controlled trials that homogenize individual differences • Concerns about manipulations of clinical trials data and reports

  7. The New EBM Mantra: Comparative Effectiveness Research (CER) • Achieved prominence when American Recovery and Reinvestment Act (ARRA) allocated $1.1 billion for CER • Required preparation of two reports to inform operational plan: • Federal Coordinating Council for Comparative Effectiveness Research (2009) • Defined CER (next slide) • Called for development not only of research but also of human and scientific capital, data infrastructure, and dissemination • IOM report for prioritizing research (Committee on Comparative Effectiveness Research Prioritization, Board on Health Care Services, & Institute of Medicine, 2009) • Identified top 100 research priorities

  8. CER • Definition of CER from Federal Coordinating Council report • “Research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions” • “Must assess a comprehensive array of health-related outcomes for diverse patient populations” • “Necessitates the development, expansion, and use of a variety of data sources and methods” (informatics!) • Healthcare reform legislation (Affordable Care Act, ACA) allocated funding for Patient-Centered Outcomes Research Institute (PCORI, http://www.pcori.org) • Independent body with multiple stakeholder representation to advance and carry out research in CER (Washington, 2011)

  9. Unit Topics • Definitions and Application of EBM • Intervention • Diagnosis • Harm and Prognosis • Summarizing Evidence • Putting Evidence into Practice

  10. Evidence-Based PracticeSummary – Lecture a • EBM is an approach to informing clinical decision making that applies the best evidence available • Allows clinical experience (art) to be integrated with best clinical science • Makes medical literature more clinically applicable and relevant

  11. Evidence-Based PracticeReferences – Lecture a References Brush, J. E., & Halperin, J. L. (2016). A baby in the bathwater: Preserving evidence-based medicine. Journal of the American College of Cardiology, 68(2), 214-216. Retrieved from http://www.onlinejacc.org/content/68/2/214 Committee on Comparative Effectiveness Research Prioritization, Board on Health Care Services, & Institute of Medicine (2009). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=12648 Cohen, A., Stavri, P., & Hersh, W. (2004). A categorization and analysis of the criticisms of evidence-based medicine. International Journal of Medical Informatics, 73, 35–43. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15036077 Descriptions of methodological details and challenges for EBM. (2007). In Medical Care, 47, Suppl 2(10). Eden, J., Wheatley, B., McNeil, B., & Sox, H. (Eds.). (2008). Knowing what works in health care: A roadmap for the nation. Washington, DC: National Academies Press. Federal Coordinating Council for Comparative Effectiveness Research. (2009). Report to the President and the Congress. Washington, DC: Department of Health and Human Services. Retrieved from http://www.med.upenn.edu/sleepctr/documents/FederalCoordinatingCoucilforCER_2009.pdf Guyatt, G., & Voelker, R. (2015). Everything you ever wanted to know about evidence-based medicine. JAMA, 313(18): 1783–1785. doi:10.1001/jama.2015.2845. Hersch, W. (2009). Information retrieval: A health and biomedical perspective. New York: Springer Verlag.

  12. Evidence-Based PracticeReferences – Lecture a Continued References Hoffmann, T., Montori, V., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. JAMA, 312(13): 1295–1296. doi:10.1001/jama.2014.10186 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Retrieved from http://iom.nationalacademies.org/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx Johnson, L. B., & Warren, B. E. (2011). Evidence-based practice and health advocacy organizations. JAMA, 306(13): 1443–1445. doi:10.1001/jama.2011.1405 Kida, T. (2006). Don’t believe everything you think: The 6 basic mistakes we make in thinking. Amherst, NY: Prometheus Books. Luce, B., Kramer, J., Goodman, S., Connor, J., Tunis, S., Whicher, D., & Schwartz, J. (2009). Rethinking randomized clinical trials for comparative effectiveness research: the need for transformational change. Annals of Internal Medicine, 151, 206–209. Ohman, E., & Califf, R. (2010). When can noninferior be superior: The multidimensional nature of clinical decision-making calls for innovative approaches to clinical trials. Journal of the American College of Cardiology, 55(6): 555–557 Sheridan, D. J., & Julian, D. G. (2016). Achievements and limitations of evidence-based medicine. Journal of the American College of Cardiology, 68(2), 204-213. Retrieved from http://www.onlinejacc.org/content/68/2/204 Washington, A., & Lipstein, S. (2011). The patient-centered outcomes research institute — Promoting better information, decisions, and health. New England Journal of Medicine, 365, e31. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1109407

  13. The Culture of Health CareEvidence-Based PracticeLecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.

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