Bridging Patient-Centered Care and Evidence-Based Medicine

with the help of the Primary Care Provider:

桥接病人为中心的护理和循证医学与主治医生的帮助:

The Case of Localized Prostate Cancer

局限性前列腺癌的例子

Zackary Berger, MD, PhD

Division of General Internal Medicine/Berman Institute of Bioethics

Johns Hopkins School of Medicine

美国约翰霍普金斯大学一般内科院/Berman的生物伦理学学院

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Evidence-Based Medicine

循证医学

Patient-Centered

Care

病人为中心的护理

MIND THE GAP

什么是循证医学？

证据合成 医疗决策 病人的护理

Sackett, British Medical Journal, 1996: “…[t]he conscientious,

judicious and explicit use of current best evidence in making

decisions about the care of the individual patient”

Logic of decision-making

决策逻辑

T. Greenhalgh’s phrase: “Logic of decision-making versus the

logic of care” (J Primary Health Care, 2013)

Logic of care 护理的逻辑

Stewart’s global definition of patient-centered care全球病人为中心的护理

Understanding patient’s world 了解病人的世

界

Patient’s reason for visit

病人的理由

访问

Common ground on problem

问题的共同点

Prevention

预防

Patient-provider

relationship

医患关系

Stewart M. BMJ. 2001 Feb 24;322(7284):444-5.

A complicated relationship: EBM and

patient-centered care复杂的关系

EBM

Patient-centered care Decision-

making

医疗决策

Culture 文化

Bridging EBM and patient-

centered care: a case study

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Percent of Cases & 5-Year Relative Survival by Stage at Diagnosis: Prostate Cancer in US

12/10/2013http://seer.cancer.gov/statfacts/html/prost.ht

ml8

Localized

Confined to Primary Site

Regional

Spread to Regional LN

Distant

Cancer has metastasized

Unknown

Unstaged

Percent of Cases by Stage

病例由百分之阶段

5-Year Relative Survival

5年生存率

~10%

~90%

Of those with localized prostate cancer

局限性前列腺癌患者

get treatment

接受治疗 (radiation

therapy or surgery)

Adverse effects

不良反应

Cost

费用

active surveillance/

watchful waiting

主动监测/

观察等待

Decreased adverse

effects

降低 不良反应

Decreased cost(?)

降低费用

Comparable

outcomes

90% choose

treatment

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Why do only 10% choose

active surveillance?

Leaving active surveillance

Staying in active

surveillance

What are the factors?

Patient experience in active surveillance 主动监测的患者在方案经验

Those remaining (N=584)

Without disease reclassification

(103)

Left with disease reclassification

(N=311)

Withdraw w/o tx (31)Followed elsewhere

(69)Lost to f/u (15)Diseased (46)

1,159 men enrolled in

active surveillance

program since 1995

August, 2013

What factors are associated with leaving AS?

RRR, 95% CI

Left due to progression Self-elected to leaveAge at diagnosis

40yr to <60yr 1(reference) 1(reference)

60yr to <70yr 1.02(0.63,1.63) 0.55(0.29,1.04)

70yr+ 1.16(0.69,1.94) 0.16(0.06,0.42)

PSA at diagnosis

<4 ng/mL 1(reference) 1(reference)

4 to <10 1.79(1.25,2.58) 2.09(1.13,3.85)

10+ 0.78(0.38,1.61) 0.76(0.21,2.73)

What patient experiences

influence their decision-making?

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I wonder if I should get treatment for my prostate cancer

Clinical criteriaPersonal criteria

Time (+/- progression)

I wonder if I should get treatment for my prostate cancer

Clinical criteriaPersonal criteria

Ambiguous expression?

I wonder if I should get treatment for my prostate cancer

Cancer-related uncertainty

I wonder if I should get treatment for my prostate cancer

Time (+/- progression)

Demographic targeting might be hard

Assuaging patients’ anxieties, concerns

Including partners

Including families

Further work

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Partnership in

discussing options

Partnership

throughout course

of chronic illness

WARNING: SPECULATION!

建议

Perhaps primary care providers

should be more involved in all

cancers?

初级保健 医生应该 参在癌病

人护理

Acknowledgments

• Bal Carter

• Craig Pollack

• Jonathan Yeh

• Tricia Landis

• Fred Brancati

• Jeanne Clark

• Bimal Ashar

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