EVIDENCE BASED HEALTHCARE

MUHAYIL GENERAL HOSPITAL

Dr.Walid AlsayedDr.Imran JavedMr.MOHD ZeidMr.Amer Ahmad

•Evidence based medicine is the trio of good science, clinical excellence, and patient focus•It is undertaken by the five steps of:

Asking questionsAcquiring informationAppraising the quality of evidenceApplying the resultsAssessing performance

•Simple skills in focusing questions can be learnt easily•Basic rules of appraisal can greatly improve your ability to critique the clinical literature•Simple maths, not complicated statistics, can help you describe the results of scientific studies more clearly

Quality of Health Care Services in Pakistan & United States of America.

• Health Care Professionals

• Health Care Settings

• Financial aspects

• Awareness of health

• Impacts on community health.

Factors

• Attracts best minds from whole world.

• Career opportunities more than rest of the world.

• Private & Public Sectors both open.

• Still areas of deficiency exist geographically as well as per specialty.

• Immigration policies to retain.

• Continuous Medical Education programs.

• New Ideas respected.

Healthcare Professional in USA.

• More than 110 medical school.

• Still severe shortage of doctors and nurses.

• 90% from best medical schools emigrate to western world, Australia, Middle east.

• Gaps are filled by Russian, Chinese and central Asian trained doctors.

• Unsatisfied financially as well as career wise.

• Nepotism Law&Orders issue make it worse.

• Always looking for private practice.

Healthcare Professionals in Pakistan.

• University Hospitals.

• State hospitals.

• Community Hospitals.

• Veteran Affairs Hospitals.

• Private Hospitals.

• Diagnostic Centers.

• Research Centers.

• Specialty Institutes.

Healthcare Settings in USA

• Teaching Hospitals.

• District Head Quarter Hospitals.

• Tehsil Head quarter hospitals.

• Rural Health Centers.

• Basic Health Units.

• Military Hospitals.

• Private Hospitals.

Health Care Settings in Pakistan

• Insurance based practice.

• Private practice.

• Salary based practice.

• Share practice.

Financial Aspects in USA

• Government Salary.

• Private Practice.

• No Insurance.

• Share practice less liked.

Financial Aspects in Pakistan.

• Health Education Programs.

• Print Media

• Electronic Media.

• Social Media.

• General awareness.

• Companies imitative programs.

• Research Programs.

• Employer regulatory programs.

Awareness about health in USA

• No official Screening program.

• Media campaign are mostly centered on alternative care.

• Companies conduct hidden drug trials.

• No participation by community.

• Generally low education level.

• Health is a least priority by government and community both.

Awareness about Health in Pakistan

• Generally healthy community.

• Average age longer.

• Working age is longer.

• Diseases diagnosed at earlier stage.

• More productive life style.

• Independent living supported.

• Financially secured.

Impacts on Community Health in USA

• Generally poor health in rural communities.

• Diseases present at advanced stage.

• Financially not secured so look for government or private support.

• Controllable infections leads to worse outcome.

• TB is still a major burden.

• No follow up exits when treated.

Impacts on Community health in Pakistan

• For Government:• Plan with more finances for health care

professionals and healthcare setting.• Start medical insurance schemes.• Emphasize on health education.• For Communities:• To focus on personal health.• Take part in screening programs.• Keep on investing in future.• Adopt Healthy Life style.

Recommendation

• Comparison between advanced world and developing countries gives you to understand the factor lacking in development phases.

• Health Care Quality Control programs should be given more space than just provision of health care services.

• Professional trained in health care quality programs should keep on looking new strategies to develop subjective & objective tools for evaluation.

Conclusion

FSU College of Medicine 18

The EBM Process

“The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning in which caring for one's own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues.”(Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship

education. Am J Med. 1997 May;102(5):427-32.)

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The EBM Process

The patient 1. Start with the patient -- a clinical problem or question

arises out of the care of the patient

The question 2. Construct a well built clinical question derived from the

case

The resource 3. Select the appropriate resource(s) and conduct a search

The evaluation 4. Appraise that evidence for its validity (closeness to the

truth) and applicability (usefulness in clinical practice)

The patient 5. Return to the patient -- integrate that evidence with

clinical expertise, patient preferences and apply it to

practice

Self-evaluation 6. Evaluate your performance with this patient

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Constructing A Clinical Question

Ppatient

I intervention

C comparison

O outcome

Who? What?Alternative

Intervention?

Outcomes

“How would I

describe a group

of patients

similar to this

particular

patient?”

”Which

treatment, test

or other

intervention?”

“Compared to what

other treatment, test,

or perhaps compared

to doing nothing”

What is the

patient oriented

outcome – better

prognosis?

Higher rate of

cure? Etc.?”

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Examples

P I C O

Kids with acute otitis

media -2-4 y/oAntibiotics

No treatment except

acetaminophen

for pain/fever

No pain after two

days?

Adult with

microhematuriaIVP CT scan

Diagnostic accuracy

(Predictive value or

likelihood ratio)

Adult patients <70 TIA No TIARates of CVA within

90 days

Healthy adolescents

Routine

scoliosis

screen

No screening –

evaluate only if

problems

Pain, disability, need

for intervention

Why EBP?• To improve care

– To bridge the gap between research & practice

– “Kill as few patients as possible” (O. London)

– A new treatment might have fewer side effects.

– A new treatment could be cheaper or less invasive

– A new treatment may be necessary in case people develop resistance to existing therapies, etc.

• To keep knowledge and skills current (continuing education)

• To save time to find the best information

How does EBP help?A patient comes to a clinic with a fresh dog bite. It looks clean and the nurse and patient wonder if prophylactic antibiotics are necessary. The nurse searches PubMed and found a meta analysis indicating that the average infection rate for dog bites was 14% and that antibiotics halved this risk to 7%.

• For every 100 people with dog bites, treatment with antibiotics will save 7 from infection

• Treating 14 (NNT) people with dog bites will prevent 1 infection

• You explain these numbers to the patient along with possible

consequences and patient decides not to take antibiotics.

On a follow up visit you find out that he did not get infected.

Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.

What are some Barriers for EBP?

• Overuse, underuse, misuse of evidence

• Time, effort, & skill needed

• Access to evidence

• Intimidation by senior clinicians

• Environment not supportive of EBP

• Poor decision making

The 5 Step EBP Process

Ask

Access

AppraiseApply

Assess

Health care professionals

• a person who by education, training, certification, or licensure is qualified to and is engaged in providing health care.

What kinds of clinical uncertainty do HCP face?

• Interventions– Therapy

– Prevention

– Targeting

– Timing

• Diagnosis

• Communicating risks and benefits

• Referral

• Service Delivery/Organisation

One choice every 10 minutes in acute care

Six challenges for health care organizations

• 1. Design seamless, coordinated care

• 2. Make effective use of IT, including automating patient records

• 3. Manage knowledge so that it is delivered into patient care

• 4. Coordinate care across patient conditions, services, and settings over time

• 5. Advance the effectiveness of teams

• 6. Incorporate measurement of care processes and outcomes into daily practice

Process in creating collective organizational commitment of

•Quality improvement.• Organizational analysis.•Self-assessment.•Strategic formulation of the organizational development planning, Human resources development.•Team work and service systems focusing on patient-oriented mindedness.

"Hospital Accreditation"

What is Hospital Accreditation?

"The Hospital Accreditation"approach is a concept and practice that yields beneficial results to patients, customers, hospital personnel, the hospital, the Faculty of Medicine, the society and the country as a whole.History

In 1917, the American College of Surgeons established a set of minimum standards for hospitals.

In 1951, the American College of Surgeons joined with several other professional associations to form the Joint Commission on Accreditation of Hospitals.

Thirty years later, this voluntary accrediting body changed its name to the Joint Commission on Accreditation of Healthcare Organizations to more accurately reflect its scope of health services evaluation

Inadditiontohospitals,thebodyevaluatedlong-termcarefacilitieslike,•home health agencies,•hospices,•clinics,•pharmacies,•managed care organizations and,•healthcarenetworks.

JOINT COMMISSION INTERNATIONAL ACCREDITATION (JCIA)*Experience in accrediting health care organizations in U.S, the Joint Commission on Accreditation of Healthcare Organizations initiated the development of an international accreditation program in 1998 and was fully implemented in late 1999.

The JCIA standards, organized according to eitherPatient care functionsorManagement functions.

BENEFITS TO ACCREDITATION1.BENEFITS OF PATIENTS:-

Continuity of care&Safe transportPain management& Focus on patient safetyPatient satisfaction is evaluated Rights are respected and protected Access to a quality focused organizationCredentialed and privileged medical staffHigh quality of careUnderstandable education and communication

2. BENEFITS FOR THE STAFFS:-

Improves professional staff development.Provides education on consensus standards. Provides leadership for quality improvement within medicine

and nursing.Increases satisfaction with continuous learning, good working

environment, leadership and ownership.

3. BENEFITS FOR THE HOSPITAL:-Improves care.Stimulates continuous improvement.Demonstrates commitment to quality care.Raises community confidence.Opportunity to benchmark with the best.

4. BENEFITS TO THE COMMUNITY:-Quality revolution Disaster preparedness Epidemics Access to comparative database

EVERYONE'S HAPPY!

CustomerOrganization

References

• Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(7023):71-2.

• [Pubmed]

• Lau AYS, Coiera E. How do clinicians search for and access biomedical literature to answer clinical questions? Medinfo 2007;12(Pt 1):152-6.

• [Pubmed]

• Green ML, Ciampi MA, Ellis PJ. Residents’ medical information needs in clinic: are they being met?AJM 2000;109(3):218-23.

• [Pubmed]

• [URL]

• Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews: Reviews 2006 Issue 2 John Wiley & Sons Ltd, Chichester, UK.

• [Pubmed]

• Walton RT, Harvey E, Dovey S, Freemantle N. Computerised advice on drug dosage to improve prescribing practice. Cochrane Database of Systematic Reviews: Reviews 2001 Issue 1 John Wiley & Sons Ltd, Chichester, UK.

• [Pubmed]

• O’Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews: Reviews 2001 Issue 1 John Wiley & Sons Ltd, Chichester, UK.

• [Pubmed]

• Thomas L, Cullum N, McColl E, Rousseau N, Soutter J, Steen N. Guidelines in professions allied to medicine. Cochrane Database of Systematic Reviews: Reviews 1999 Issue 1 John Wiley & Sons Ltd, Chichester, UK.