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This project aims to develop a Continuous Quality Improvement (CQI) program and establish a clinical governance system in the St. Lucia Health Sector. The program will focus on evidence-based medicine to improve healthcare.
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Project: TECHNICAL ASSISTANCE FOR THE DEVELOPMENT OF A CONTINUOUS QUALITY IMPROVEMENT (CQI) PROGRAMME AND ESTABLISHMENT OF A CLINICAL GOVERNANCE SYSTEM FOR THE SAINT LUCIA HEALTH SECTOR - Request 2015/365-620 – Version 1 • Improving Health Care • with • Evidence-Based Medicine • Author: dr. Martin Rusnák Implemented by: AGREE II Introduction rusnakm@icloud.com Financed by the European Union
Where does it all come from? • Evidence-based medicine developed from a practical application of clinical epidemiology to a philosophy of rational clinical decision making. • Epidemiology is concerned with the quantitative research of distribution, determinants & risk factors of health & disease in populations (population groups) & the application of this evidence to control (prevent & treat) disease.
Where does it all come from? • Modern epidemiology found out i.e. that: • There are huge geographic variations in the treatment of patients with the same health problems. • There is great uncertainty about the effects of medical therapies (only 10-20% of all medical interventions are scientifically sound, e.g. proved by controlled studies)
Where does it all come from? • In the 90’s: a group around David Sackett & Gordon Guyatt, McMaster University, Canada developed a concept, which does not only qualify scientists to understand and interpret research literature, but • it is the conscientious, explicit and rational use of current best evidence in making decisions about the care of individual patients.
Evidence Based Medicine – What it is • The practice of evidence-based medicine means integrating individual clinical expertise and patient values with the best available external clinical evidence from systematic research. • Sackett DL et al. Evidence-based medicine: What it is and what it isn‘t, BMJ 312 (1996) 71-72
Work-experience External evidence Doctors, Nurses, other Time of work-experience Internal evidence – Intuition
Problems, questions Evaluation of performance The patient Individual experience & external evidence Search for best external evidence Critical appraisal und clinical applicability EBM is the conscientious, explicit and rational use of current best evidence in making decisions about the care of individual patients
Step 1 – Converting the need for information into an answerable question • Does mammography-screening • In women over 50 years • Compared with no screening • change mortality • By e.g.10% ? question
Step 1 – Converting the need for information into an answerable question • Does mammography-screening I • In women over 50 years P • Compared with no screeningC • change mortality O • By e.g.10% ? • PICO-Approach: Patients, Intervention, Control, Outcome
Step 2 – Search for best external evidence • Data base search (Medline,…) • Systematic reviews (Best Evidence, Cochrane reviews,…) • Other scientific articles • Experts External evidence
Step 2 – Search for best external evidence • Hierarchy of Evidence • Metaanalysis, systematic review • Randomised controlled trials (RCT) • Observational designs (Cohort- or case-control-studies) • Expert opinion, consensus conferences
Spread of the idea of evidence Evidence-belt Eminence-belt
Step 3 – Critically appraising that evidence for its validity, impact & applicability • Systematic reviews, RCT,… • Methodologically sound (randomisation, concealment, blinding, complete data set, ...) • Is the information valid for our patient? Validity and applicability
Step 4 • Integrating the critical appraisal with clinical experience & patients values Clinical experience & external evidence
Step 5 – Evaluation of performance Does it help my patient? Evaluation of performance