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Facets of Teaching Evidence Based Health Care

Facets of Teaching Evidence Based Health Care. The OU Family Medicine Experience Dewey Scheid MD, MPH Clinical Decision Making Program Department of Family and Preventive Medicine The University of Oklahoma Health Sciences Center Learning to Practice and Teach Evidence Based Health Care

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Facets of Teaching Evidence Based Health Care

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  1. Facets of Teaching Evidence Based Health Care The OU Family Medicine Experience Dewey Scheid MD, MPH Clinical Decision Making Program Department of Family and Preventive Medicine The University of Oklahoma Health Sciences Center Learning to Practice and Teach Evidence Based Health Care Second Annual Workshop September 21-22, 2007 The University of Oklahoma Health Sciences Center

  2. PRACTICE-BASED LEARNING AND IMPROVEMENT - ACGME • Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: • analyze practice experience and perform practice-based improvement activities using a systematic methodology • locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems • obtain and use information about their own population of patients and the larger population from which their patients are drawn • apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness • use information technology to manage information, access on-line medical information; and support their own education • facilitate the learning of students and other health care professionals

  3. Six Facets of EBM at OU DFPM • Journal Club • CDM Conferences • MS3 Clerkship • MS4 Elective • CLIN-IQ • CQI

  4. Journal ClubA Brief Evolutionary History • Neal Clemenson, beer, and EBM • Laine McCarthy, HRSA EBM grant, 1992 • UVa Information Mastery Program • Users' guides to the medical literature • After dinner articles • Back to Wednesday afternoon • “Just in Time” Journal Club

  5. The Evolution of Journal ClubSurvival of the Fittest - Principles • If they read it, they will come • I just look at the pictures • Noble “cheating” • I like to watch • News! • EBM Nazis • EBuMers • Cassandra syndrome

  6. Archie Cochrane Effectiveness and Efficiency: Random Reflections on Health Services (1972) “Best evidence" methodologies were established by the McMaster University research group led by David Sackett and Gordon Guyatt. “Evidence based" 1990 by David Eddy. “Evidence-based medicine" 1992 by Guyatt et al. Introduction to Medical Decision Making by Lee B. Lusted, 1968 “uncertainty about the correlation of signs, symptoms, and diseases makes medical diagnosis a matter of probability” Society for Medical Decision Making founded in 1979 SG Pauker, and JP Kassirer. The threshold approach to clinical decision making. NEJM 1980. John Paul Alvan Feinstein Annals series 1968 David Sackett EBM, CDM, MDM, Clinical EpiSurvival of the Memes

  7. CDM – Clinical Decision Making Evidence Based Medicine: What it is and what it isn’t. Sackett, BMJ 1996 • Best external evidence • Individual clinical expertise • Patient choice • What is CDM? • Decision analysis • Psychology of decision making

  8. CDM – Decision Analysis

  9. CDM – Rolling back the tree

  10. CDM Curriculum • Test characteristics • Sn, Sp, PVP, NVP, priors • Likelihood ratios • ROC curves • Deconstructing normal • CDM calculators: bgphthut.xl4 • Bird Library/Help/Evidence Based Info/Other Resources

  11. CDM Curriculum - Risk • EBM Risk • RR vs. absolute risk -> NNT • Communicating risks to physicians in the literature • Communicating personal risks to patients

  12. CDM Curriculum - Communicating personal risks to patients

  13. CDM Curriculum - Communicating personal risks to patients

  14. What are the Chances that a Man Might get Prostate Cancer? LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL LLLLLLLLLLLLLLLLLLLL JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ JJJJJJJJJJJJJJJJJJJJ Imagine a group of 1,000 men like you, who are currently in their mid 50’s. You could be any of these men. By the time these men reach age 70, about 220 men (22%) would have cancer cells in their prostates. By the time these men reach age 70, about 780 (78%)would not have prostate cancer. If this cancer is not discovered early and treated, about 66 of the220 men (30%) will eventually experience symptoms of advanced prostate cancer and most will die of it. LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ The other 154 men (70%) would not be severely affected by the cancer and would die of other causes.

  15. Will Prostate Cancer Treatment Save a Man’s Life? • Consider the 1000 men in their mid-50’s. • As we said in the first display (page 4), by the time these men reach age 70 about 220 of them would have prostate cancer cells. • This is what happens if they get screened • every year (annually) until age 70: LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLL Annual screening would miss finding prostate cancer in about 41 men (19%). Annual screening would discover prostate cancer in about 179 of these 220 men (81%). What happens if the 179 men who know they have prostate cancer get treated or do not get treated? Without treatment about 58 of these 179 men (32%) will eventually have advanced prostate cancer. These men can be treated at that time with hormone control or chemotherapy, but cannot be cured. Below are 179 men with Prostate Cancer Cells who do not get any Treatment (The Watchful Waiting Option) LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJJ Without treatment about 121 of these men (68%) will never experience advanced prostate cancer.

  16. Why is EBM so hard?

  17. CDM Curriculum – Physician decision making psychology • Scripts • Collection of patterns and knowledge structures • Pattern recognition quickly identifies appropriate knowledge structure for situation • Rules within structures are tuned by experience • Surgical Intuition. What It is and How to Get It. By CHARLES M. ABERNATHY and ROBERT M. HAMM

  18. Ways to Improve Decision Making • Education • Guidelines, reminders • Pull information at point of care • Decision tools • CQI • Outcomes studies 1 1,3 2 4 4 5 6

  19. CDM Conferences • Wednesday afternoon – 1 hour • 24 month schedule • 15 - 30 minutes • Diagnosis • Risks • Treatment • Outcomes • Ethics • Risk communication • Physician decision making Patient decision making • Decision analysis • Guidelines, algorithms • Health care policy

  20. CDM – Lessons learned the hard way • Cod liver oil • Spoonful of sugar • Less is more • Paradigms: uncertainty vs. pathophysiology

  21. Teaching Clinical Decision Making in a Family Practice Clerkship • CDM module imbedded in a third-year medical student (MSIII) family medicine clerkship • David R. Holtgrave, Frank H. Lawler, L. Peter Schwiebert • Teaching Clinical Decision Making in a Family Practice Clerkship. Med Decis Making 1993;13:114-117. • John Zubialde and Dewey Scheid until 2000 • Diagnosis: sensitivity, specificity, PPV, NPV, impact of prevalence • Decision analysis basics

  22. CDM MS4 Elective • Read and do exercises to learn basic concepts of clinical decision making. • Learn to use computer tools for analysis of decisions • CDM calculators • DATA • Consult frequently with faculty (Rob Hamm, Dewey Scheid). • Plan a month long project, carry it out, and report it in a brief paper.

  23. CDM MS4 Elective Projects • Decision analysis of the use of tPa for stroke • Evaluating post exposure prophylaxis for HIV infected needle sticks • Screening diabetics for microalbuminuria • Management of fever without source in children from 3 to 36 months in the post-H. influenza era: a decision-making analysis • Cost effectiveness of a three day inpatient stay versus seven day inpatient stay for bipolar type manic episode • Valproate use in pregnancy • Decision Analysis of Trial of Labor After Cesarean

  24. Clin-IQ Project • Critical Appraisal of Clinical Questions by Family Medicine Residents • Oklahoma Physicians Resource/Research Network (OKPRN) {and medical student and their 4th year Rural Preceptors} generate the questions • A panel of OKPRN members prioritizes the list of questions • Pairs of family practice residents (PGY2 and PGY3) select from the higher priority questions. • Residents work with a faculty mentor. • Mentoring occurs in one on one sessions with faculty focused on how to answer the questions. • Multiple sessions with research division faculty to assist residents in literature search.

  25. Clin-IQ Project • After the resident-faculty groups complete their work, the residents present their answers to each other in small group meetings. • Feedback is used to refine the answers. • The project is then reviewed by a panel of veteran researchers who provide a written critique of the work. • Further refinement is made as a result of this review, and then the project is submitted for evaluation and dissemination to the OKPRN clinicians, 4th year Rural Preceptors, and the medical students who generated the questions. • Some questions have been published in the Journal of the Oklahoma State Medical Association

  26. CLIN-IQ • What is the Most Sensitive Non-invasive Test for Initial Diagnosis of H.Pylori Infection in Adults? • Authors: Payne, I; Mold, JW • Journal- Oklahoma State Medical Association, 2006, vol. 99, no. 6, pp. 368-369 • Clinical Question: Is Insulin Glargine More Effective? • Authors: Kitowicz, A; Criswell, DF • Journal- Oklahoma State Medical Association, 2007, vol. 100, no. 1, pp. 26-27 • Clinical Question: Does Treatment with Corticosteroids Improve Pain Outcome in Patients with Acute Pharyngitis? • Authors: Rezaei, A; Criswell, D • Journal- Oklahoma State Medical Association, 2007, vol. 100, no. 2, pp. 49-51

  27. CQI • Continuous Quality Improvement Committee of the UFMC • All divisions involved with the clinical activities of the department are represented. • Since 1998, collaborated with the faculty members responsible for the PGY2 community medicine rotation to engage residents in the process of CQI. • Residents, in groups of 2-3, select a clinical service that has been recognized nationally by quality improvement organizations as a priority for monitoring and improvement. • They conduct an audit of Family Medicine Center medical records, complete a report, and present their findings at the monthly CQI committee meeting.

  28. CQI • Approximately 4-6 audits are performed each year. • The audit results are discussed and often used as a springboard for further quality improvement action. • Examples of audits include: • pneumococcal immunization, • breast cancer screening, • PAP screening results management, • cholesterol screening • management, microalbumin screening in diabetics, • tobacco cessation counseling.

  29. CQI • TITLE: OUFMC QUALITY CARE REVIEW OF ASPIRIN THERAPY FOR PATIENTS WITH DIAGNOSIS OF CAD (ICD9 414.00) • DATE: 08/07/2007 • PREPARED BY: Gregory Grant MD, David Speegle MD, and Darice Wiegel MD. • PERFORMED BY: GREGORY GRANT AND DAVID SPEEGLE • METHODS: We selected 300 charts with the ICD-9 code 414.00, Coronary Artery Disease for the purpose of reviewing documentation that the patient was on aspirin therapy. Only patients who had visited OUFMC once within the past 2 years were selected. Of the 300 hundred patients identified, 103 were selected at random for review. Patients with Aspirin listed on their medication list were considered to be on Aspirin therapy. Patients who did not have aspirin listed were examined further in both the face sheet and clinic notes for the previous 2 years to check for a documented aspirin adverse reaction or refusal of therapy. Adverse reaction included: GI bleed, any variation of GI intolerance, rash, or angioedema. If a patient was not on aspirin therapy, but was on other anticoagulation, then that was noted. • RESULTS: See Table and Graph attached. • DISCUSSION: With only 74% of patients on aspirin therapy, 79% of patients on some type of anticoagulation and a total of 85% either on anticoagulation or with a documented AVR, there is still a large room for improvement. We should be able to achieve 100% of patients on anticoagulation or a documented AVR. In order to quality for P4P on this issue, we will have to achieve close to this. Although the only ICD-9 code researched in this review was for CAD, a further review is warranted to include all patients with diagnosis of previous MI as well. It is likely that close to 100% of our patients have been screened for ASA therapy, but documentation must be improved in order to demonstrate that it actually is being done. • ACTION: Issue memo encouraging physicians to document clearly on face sheet any adverse reaction to any medication. Encourage physicians to make sure all patients with CAD diagnosis or previous MI are on ASA therapy. I anticipate, as with many documentation deficiencies, that the centralization of data that an EMR facilitates will improve the documentation deficit. Review in 1 year.

  30. CQI

  31. Summary

  32. Summary

  33. What are we trying to do? • Pascal likened the situation to a sphere representing all available knowledge floating in a sea of ignorance, the sphere continuously increasing in size as discoveries transform ignorance into new knowledge. • This process of growth not only causes the volume of the sphere to increase continually but also its surface area, so that in fact the size of the frontier between knowledge and the unknown also increases.

  34. Information growth is exponential, wisdom is not… "Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?" T.S. Eliot

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