The First International Conference for Evidence-based Healthcare

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The First International Conference for
Evidence-based Healthcare
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First International Conference on Evidence-based
healthcare The Inaugural Conference of the
International Society of Evidence-based Health
Care India International Centre, New
Delhi Workshops 6 October 2012 (Pre-Conference
workshops on topics related to EBHC) Conference
7-8 October 2012 www.isehcon2012.com
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• Who should attend?
• Physicians, nurses, pharmacists, chiropractors,
  naturopaths, involved in the implementation of
  evidence including frontline healthcare
  professionals
• Educators involved in teaching and training in
  evidence based healthcare
• Speakers
• Kameshwar Prasad, Paul Glasziou, Gordon Guyatt,
  Luz Letelier, Victor Montori
• www.isehcon2012.com

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The second principle of evidence-based medicine
changes everything
Victor M. Montori, MD, MSc Professor of
Medicine KER UNIT - Mayo Clinic
montori.victor_at_mayo.edu
_at_vmontori
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Disclosures

• Relevant Financial Relationships
• None
• Off Label Usage
• None

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• Our confidence in estimates of risk and benefit
• from the body of evidence
• contributes to
• our confidence in making decisions.

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• Our confidence in estimates of risk and benefit
• from the body of evidence
• contributes to
• our confidence in making decisions.

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Confidence in the estimates of risk and
benefit Bias Imprecision Inconsistency Indirectne
ss Biased reporting
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• Our confidence in estimates of risk and benefit
• from the body of evidence
• contributes to
• our confidence in making decisions.

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• body of evidence

Trelle et al. BMJ 2011342c7086
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• Our confidence in estimates of risk and benefit
• from the body of evidence
• contributes to
• our confidence in making decisions.

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Appropriate care
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Care lt Need
Underuse
Appropriate care
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Glasziou and Haynes ACP JC 2005
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Care gt Need
Care lt Need
Overuse
Underuse
Appropriate care
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Geographic variation in overuse Variation
in overuse by procedure (n172) Preventive
services PSA 16-36 Urinalysis 37 Follow-up
colonoscopy 61 Pap smear 58
Shah ND et al. NEJM 2012
Korenstein D, et al. Arch Intern Med 2012 172
171-8
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Sources of waste and their projected growth to
2020
Berwick, D. M. et al. JAMA 20123071513-1516
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Care gt Need
Care lt Need
Overuse
Underuse
Appropriate care
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Guidelines

• Every patient with diabetes is a coronary heart
  disease risk equivalent
• Every patient with diabetes should take a statin
  and achieve LDL lt 100 mg/dL

ATP III, 2004
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Minnesota Community Measurement
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Guideline implications
ATP III For every 1000 people treated, 150 events
avoided US per event avoided 139k in men, 144k
in women Canada For every 1000 people treated,
153 events avoided US per event avoided 148k in
men, 154k in women
Mason J et al PLoS ONE doiinfodoi/10.1371/journa
l.pone.0016170.t004
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Weymiller et al. Arch Intern Med 2007
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Weymiller et al. Arch Intern Med 2007
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Weymiller et al. Arch Intern Med 2007
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who opted for treatment
gt90
lt20
50
who should take statins based on ATP III
gt90
gt90
gt90
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• The evidence alone is never sufficient to make a
  decision.
• Context and patient values, preferences and goals
  should be considered.

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Encounter Research
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Care gt Need
Care lt Need
Overuse
Underuse
Appropriate care
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Care gt Want
Care lt Want
Overtreatment
Undertreatment
Desirable care
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A survey of 627 US primary care clinicians
50 of my patients get too much care 50 of
primary care docs are too aggressive 60 of
specialists are too aggressive 35 practice much
more aggressively than what they would like
Sirovich BE et al. Arch Intern Med 2011
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Statin Choice
Weymiller et al. Arch Intern Med 2007
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Statin Decision Aid
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Web-based tool
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Mullan et al Arch Intern Med 2009
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Summary of experience

• Age 40-92 (avg 65)
• Primary care, ED, hospital, specialty care
• 74-90 clinicians want to use tool again
• Adds 2.5-3.8 minutes to consultation
• 60 fidelity
• 20 improvement in knowledge
• 17 improvement in patient involvement
• Variable clinical outcomes

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3 2 1
Get a ride
Dietitian
Numbers dont add up
Take off work
Deadline is now
Endocrinologist
108 kg
take work home
Obese
High cholesterol
perform!
LDL high
Avoid salt, fats, carbs
insurance
Metformin
A1c 8.2
Diabetes
mortgage
Check sugars
Glipizide
debt
Hypertension
HCTZ
Dizzy
Take pills
Wasted!
Beta-blocker
Depression
Daughter back at home
Cant sleep
Exercise
2 beautiful girls
Bad back
Neuropathy
Pain
Podiatrist
Check his feet
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Care gt Need
Care lt Need
Overuse
Underuse
Appropriate care
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Care gt Want
Care lt Want
Overtreatment
Undertreatment
Desirable care
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Care gt Can
Care lt Can
Overtreatment
Undertreatment
Feasible care
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WORKLOAD
CAPACITY
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DESIRABLE
Encounter Research
WANT
CAN
NEED
APPROPRIATE
FEASIBLE
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Need
http//www.gradeworkinggroup.org
Want
http//shareddecisions.mayoclinic.org
Can
http//minimallydisruptivemedicine.org
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7th International Shared Decision Making
Conference

• Lima, Perú - June 16-19 2013
• www.isdm2013.org

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The evidence alone is never sufficient to make
a decision.

• Our confidence in the research contributes to
• our confidence in making decisions.

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