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Outline of presentation Key messages HFA Thoughtful physicians: Difficult Questions EBM

Outline of presentation Key messages HFA Thoughtful physicians: Difficult Questions EBM Measurement Iterative Loop COPCORD / WHO / ILAR Studies In conclusion ……. The cyclic process of differential diagnosis. Listen Listen Listen. listen & generate hypotheses.

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Outline of presentation Key messages HFA Thoughtful physicians: Difficult Questions EBM

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  1. Outline of presentation • Key messages • HFA • Thoughtful physicians: Difficult Questions • EBM • Measurement Iterative Loop • COPCORD / WHO / ILAR Studies • In conclusion ……

  2. The cyclic process of differential diagnosis • Listen • Listen • Listen listen & generate hypotheses cross examine to gather data for hypothesis testing test hypotheses NO is one of the hypotheses valid? YES TAKE ACTION

  3. How do I select the appropriate diagnostic test? • 1) Diagnostic tests RARELY reveal a patient’s true state with certainty. • 2) Test selection should be restricted to those • diagnostic tests whose results could change • physician’s mind as to what should be done • for a patient. • 3) Physicians often start treatment despite • uncertainty about true state of patient.

  4. Number of diagnostic hypotheses remaining during The steps of evaluating a symptom chief complaint Number of diagnoses to be considered history physical exam tests

  5. Certain not to occur Equal chance of occurring or not occurring Certain to occur 0 0.5 1.0 Probability of disease - 1

  6. Prior Probability Posterior Probability 0 0.5 1.0 Probability of disease - 2

  7. P[disease] = 0.06 0 0.5 1.0 Probability of disease - 3

  8. EBM: Essential Steps & Flowchart • 1) Convert information needs into answerable questions • 2) Track down, with maximum efficiency, the best evidence with which to answer them (from the clinical examination, the diagnostic laboratory, the published literature, or other sources) • 3) Critically appraise that evidence performance for its validity (closeness to the truth) & usefulness (clinical applicability) • 4) Apply the results of this appraisal in clinical practice • 5) Evaluate performance

  9. Clinical knowledge, experience, skills, guts, flair Patient Preferences Best Evidence Diagnosis, Therapy, Prognosis Performance Fig : Flowchart of evidence-based medicine (adapted from Jenicek7)

  10. Clinical aphorisms • 1) If you hear hoofbeats, think of horses, • not zebras • 2) Rare manifestations of common diseases are • often more likely than common manifestations of rare diseases • 3) If a test is unlikely to change the management of the patient, don’t do the test • 4) If a test result surprises you, repeat the test • before taking action • 5) The first priority in differential diagnosis is to • think about the diseases you can’t afford to miss

  11. Outline of presentation • Key messages • HFA • Thoughtful physicians: Difficult Questions • EBM • Measurement Iterative Loop • COPCORD / WHO / ILAR Studies • In conclusion ……

  12. Measurement Iterative Loop Burden of Illness (Assessment) Monitoring & Reassessment Etiology or Causation Diagnosis Prognosis Synthesis & Implementation of Program Community Effectiveness Therapy Policy Process Efficiency

  13. Relevance of population based studies * Prevalence * Incidence * Risk factors * Protective factors * Knowledge, Attitude, Practice & Behavior

  14. Relevance of population based studies - 1 • Prevalence = No. of affected persons present in • the population at a specific time • --------------------------------------------- • No. of persons in the population • at that time • Implication : • - Useful measure of burden of disease • Age/gender prevalence • Valuable for planning health services & • allocating resources (M) • Spectrum of disease seen (mild /moderate /severe)

  15. Relevance of population based studies - 2 Incidence : No. of new cases that occur during a specific period of time ----------------------------------------- population at risk of developing the disease Implication : Helpful in exploring the relationship of an exposure & the risk of disease e.g. sore throat & RF Rheumatic fever – “licks the joint and bites the heart”

  16. Relevance of population based studies - 3 Risk factors : Factors associated with occurrence of disease – most likely to be present prior to the onset of disease Implication : Risk factors – potential causal implications eg. Hypertension & heart disease

  17. Relevance of population based studies - 4 Protective factors : Those which appear to have an inverse association with the presence or development of disease Implication : For potential treatment or even prevention of disorders eg. Low fat diet & atherosclerosis

  18. Relevance of population based studies - 5 Knowledge, Attitude, Practice, & Behavior (KAPB) Studies: Assess the knowledge, attitude, practice & behavior of a particular disease in the population Implication: - Health behavior - Treatment seeking behavior - Compliance of treatment

  19. Outline of presentation • Key messages • HFA • Thoughtful physicians: Difficult Questions • EBM • Measurement Iterative Loop • COPCORD / WHO / ILAR Studies • In conclusion ……

  20. The Bhigwan (India) COPCORD Study: Publications • The Bhigwan (India) COPCORD : Methodology & First Information Report • A Chopra, J Patil, V Billampelly, J Relwani, HS Tandale • APLAR Journal of Rheumatoloty, September 1997 • - Prevalence of Rheumatic diseases in a Rural Population in Western India: A WHO-ILAR COPCORD Study • A Chopra, J Patil, V Billampelly, J Relwani, HS Tandale • J Assoc Physicians India, February 2001 • - Pain & disability, perceptions & beliefs of a Rural Indian Population : A WHO-ILAR COPCORD study • A Chopra, M Saluja, J Patil, HS Tandale • The Journal of Rheumatology, 2002

  21. The Bhigwan (India) COPCORD : Methodology & First Information Report - 1 Study objective : Well stated Study population : Characteristics well defined & compared with national level (generalizability) Study team : COPCORD team & good representation of local resources (manpower) Study design : Cross-sectional community based study Chopra et al. APLAR Journal of Rheumatology September 1997

  22. The Bhigwan (India) COPCORD : Methodology & First Information Report - 2 Study instruments : Standardized COPCORD questionnaires - Questions translated to local language - Validated on 50 referral patients (General population) Chopra et al. APLAR Journal of Rheumatology September 1997

  23. The Bhigwan (India) COPCORD : • Methodology & first information report - 3 • Survey teams : Trained Community Health Workers • COPCORD Medical Team : One rheumatologist, one • orthopedic surgeons, one rural doctor, two • rheumatology research associates • Data collection : • House to house daily visits • Daily operations were supervised • Due care was taken to look at the NON respondents • - Results well presented Chopra et al. APLAR Journal of Rheumatology September 1997

  24. Prevalence of Rheumatic diseases in a Rural Population in Western India: • A WHO-ILAR COPCORD Study - 1 • Prevalence data from 1st rural Indian COPCORD survey in Bhigwan • Cross-sectional survey : n = 6034 • Significant rural spectrum of rheumatic-musculoskeletal symptoms/diseases (RMSD) Chopra et al. JAPI 2001

  25. Prevalence of Rheumatic diseases in a Rural Population in Western India: A WHO-ILAR COPCORD Study - 2 Chopra et al. JAPI 2001

  26. Pain & disability, perceptions & beliefs of • a Rural Indian Population : • A WHO-ILAR COPCORD study • < 25% of patients perceive that they have severe problem which influences their work ability & personal life • 21% did not perceive a need to see a doctor • Implications : • Health seeking behavior • Treatment & Compliance • Cost & quality of life implications Chopra et al. The Journal of Rheumatology 2002

  27. Outline of presentation • Key messages • HFA • Thoughtful physicians: Difficult Questions • EBM • Measurement Iterative Loop • COPCORD / WHO / ILAR Studies • In conclusion ……

  28. Measurement Iterative Loop Burden of Illness (Assessment) Monitoring & Reassessment Etiology or Causation Diagnosis Prognosis Synthesis & Implementation of Program Community Effectiveness Therapy Policy Process Efficiency

  29. Relationship between incidence & prevalence Incidence Prevalence Recovery Death

  30. In conclusion ….. • Key messages • HFA • Thoughtful physicians: Difficult Questions • EBM • Measurement Iterative Loop • COPCORD / WHO / ILAR Studies • In conclusion ……

  31. Inferior doctors treated the patient’s disease, Mediocre doctors treat the patient as a person, Superior doctors treat the community as a whole. - Huang Lee, 2600 BC

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