Evidence Based Decision Making in Health Care

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Evidence Based Decision Making in Health Care

• Antti Malmivaara, MD, PhD
• Senior Medical Officer
• Finnish Office for Health Care Technology
  Assessment, Stakes

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(No Transcript)
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Archie Cochrane

• It is surely a great criticism of our profession
  that we have not organised a critical summary, by
  specialty or sub-specialty, adapted periodically,
  of all relevant randomized controlled trials

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• International non-profit organization that
  prepares, maintains, and disseminates systematic
  up-to-date reviews of health care interventions

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Systematic review - definitions

• Systematic review the application of scientific
  strategies in order to prevent bias with the
  purpose of systematically identify, critically
  assess and summarise all relevant studies on a
  specific topic
• Meta-analyses a systematic review using
  statistical methods for combining and summarising
  the results of different studies

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Evidence-based medicine

• Sackett et al. EBM, Churchill Livingstone, 1997
• Conscientious, explicit and judicious use of
  current best evidence in making decisions about
  care of individual patients
• Integrates best external evidence with individual
  clinical expertise and patients preferences and
  expectations

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Hierarchy of Evidence on Effectiveness

• Meta-analysis of RCTs
• systematic review of RCTs

Individual RCT
Observational studies patient-important outcomes
Basic research test tube, animal, human physiology
Clinical experience
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Hierarchy of evidence

• Hierarchy is not absolute.
• Observational studies have allowed extremely
  strong inferences about the efficacy of insulin
  in diabetic ketoacidosis etc.
• Much of the evidence regarding the harmful
  effects of therapies comes from observational
  studies.
• The evidence may be extremely weak but there is
  always evidence.

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Questions to be answered

• Can it work?
• Efficacy
• Does it work?
• Effectiveness
• Should it be used, given other calls on a fixed
  budget?
• Cost-effectiveness
• Is it reaching those whom it should?
• Availability

Development
EBM
Policy
Audit
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What challenges do we face ?
Increasing need of health services as a result of
1. Population ageing 2. New technology Increasi
ng demand because of rising expectations Failure
of resources to grow as quickly as need and
demand
J.A.Muir Gray, Evidence Based Health Policy.
Churchill Livingstone, London 2002
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As a consequence we have to 1. Promote
health 2. Prevent disease 3. Increase the
value obtained by healthcare resources

Muir Gray 2004
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The value of the resources invested in healthcare
is maximised when no more benefit and no less
harm can be obtained by ALLOCATING or USING
resources in any other way
Muir Gray 2004
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Better Allocation of Resources
Low

High Value

Value Healthcare

Healthcare
Better use of Resources
Muir Gray 2004
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Doing the right things right
Allocating resources between or within
specialties or patient groups
Doing as much good and as little harm as possible
with any patient or group of patients
Muir Gray 2004
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Evidence based healthcare
Making use of best current knowledge in 1.
Policy making 2. Public health 3. Health
service management
Muir Gray 2004
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Health technology assessment (HTA)

• Domains of HTA in the EUnetHTA program
• Description of technology
• Current use of technology
• Effectiveness
• Safety
• Costs and economical evaluation
• Organisational, societal/social, ethical, legal
  aspects

Finohta/ Kristian Lampe et al
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Finohta's mission

• To promote the use of evidence-based technology
  in the Finnish health care system in order to
  enhance the effectiveness and cost-effectiveness
  of health care.

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Finohta's products

• Full Health Technology Assessments (including
  Cochrane reviews)
• Reviews on new technology (Managed Uptake of
  Medical Methods)
• Rapid Reviews
• Communication products
• Impakti
• Ohtanen

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Examples of full HTA's by Finohta

• Effectiveness of rehabilitation for children with
  cerebral palsy
• Effectiveness of advanced life support in
  emergency medicine
• Bariatric surgery effectiveness, cost's,
  organizational and ethical aspects
• Cost effectiveness of evidence-based guidelines
  for antihypertensive interventions
• Cost-effectiveness of glaucoma screening
• Cost-effectiveness of drug eluting stents for
  coronary artery disease

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Rapid implementation of new technology
Evaluation bypass due to rapid implementation
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Managed Uptake of Medical Methods - by Finohta
al

• Minna Kaila, MD, PhD, Pediatric Allergist, EPA
• Adjunct Professor, University of Tampere
• Senior Medical Officer, FinOHTA /STAKES
• minna.kaila(at)iki.fi or (at)stakes.fi
• mobile [phone]

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MUMM is a joint venture of the 21 hospital
districts providing specialized care and Finnish
Office for Health Technology Assessment at
STAKES. The aim is to develop a structure for
critical appraisal and joint decisions in uptake
of new methods.
Efficacy (effectiveness) Safety
THE FIRST (May 2006) Intravenous laser therapy
for varicose veins MARS liver dialysis
Vacuum treatment of wounds Long antithrombotic
treatment with joint replacement surgery
and 64-multislice-CT in the diagnosis of coronary
disease.
THE SECOND (December 2006) Spinal Cord
Stimulation for chronic back pain Radiofrequency
ablation for snoring Vagus nerve stimulator
treatment for treatment resistant depression
Treatment of AMD with intravitreal anti- VEGF
injections.
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Effectiveness and safety of endovenous laser
treatment. A systematic review.

• Anders Albäck, Jukka Saarinen, Pekka Kuukasjärvi,
  Antti Malmivaara
• Department of Vascular Surgery, Helsinki
  University Hospital
• Department of Surgery, Tampere University
  Hospital
• Finnish Office for Health Technology Assessment
  (FinOHTA)
• Managed Uptake of Medical Methods
  MUMM-programme in Finland

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The intervention

• Thermoablation of the main trunc (great/small
  saphenous veins)
• Adjuvant treatment for branches of these truncs
• Ultrasound guidance
• Local anaesthesia
• Outpatient treatment

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Studies included in the systematic review
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CONCLUSIONS

• No randomised trial has assessed the long-term
  effectiveness of endovenous laser treatment
  (ELT).
• Postprocedural recovery seems to be favourable in
  comparison to traditional open surgery for
  saphenous vein reflux, but differences in
  treatment settings weaken the generalisability of
  the findings.
• ELT seem to be a rather safe procedure.
• No reliable cost-effectiveness data is presently
  available.

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CONCLUSIONS

• Managed up-take of ELT requires training of
  vascular surgeons, especially in the use of
  ultrasound guided method.
• Patients should be informed of the evidence on
  the different treatment alternatives (surgery,
  laser, foam, conservative treatment), and of the
  scarcity of long follow-up data.

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PERFECT PERFormance, Effectiveness and Cost of
Treatment episodeshttp//info.stakes.fi/perfect/E
N/index.htm

• Research Consortium Stakes, five university
  hospitals and the Social Insurance Institution
• Research Programme on Health Services Research -
  Terttu, Finnish Academy
• FinWELL Tekes
• The Finnish Innovation Fund
• EUPHORIC-Consortium funded by the European
• Commission

Unto Häkkinen, Chess, Stakes
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Political Epidemiological Economic
Decision making
The values the public and politicians place on
benefits and harms of the options
Evidence
Choice Decision
The needs of the population other bids for
human and financial resources
Muir Gray 2004
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Values
Decision
Evidence
Resources
JA Muir Gray Evidence Based Health Policy
Churchill Livingstone, London 2002
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Knowledge is the enemy of disease
Muir Gray 2005
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Thank you !