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The First International Conference for Evidence-based Healthcare
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First International Conference on
Evidence-based healthcareThe Inaugural Conference of the
International Society of Evidence-based Health Care
India International Centre, New DelhiWorkshops: 6 October 2012
(Pre-Conference workshops on topics related to EBHC)
Conference: 7-8 October 2012www.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 everythingVictor M. Montori, MD, MSc
Professor of MedicineKER UNIT - Mayo Clinic
[email protected] @vmontori
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DisclosuresDisclosures
Relevant Financial RelationshipsRelevant Financial RelationshipsNoneNone
Off Label UsageOff Label UsageNoneNone
Relevant Financial RelationshipsRelevant Financial RelationshipsNoneNone
Off Label UsageOff Label UsageNoneNone
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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
Indirectness
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 2011;342:c7086
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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 < Need
Underuse
Appropriate care
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Glasziou and Haynes ACP JC 2005
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Care > NeedCare < Need
Underuse Overuse
Appropriate care
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Geographic variation in overuse
Variation in overuse by procedure (n=172)Preventive services
PSA 16-36%Urinalysis 37%
Follow-up colonoscopy: 61%Pap smear: 58%
Korenstein D, et al. Arch Intern Med 2012: 172: 171-8
Shah ND et al. NEJM 2012
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Sources of waste and their projected growth to 2020
Berwick, D. M. et al. JAMA 2012;307:1513-1516
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Care > NeedCare < Need
Underuse Overuse
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 < 100 mg/dL
ATP III, 2004
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Minnesota Community Measurement
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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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>90% <20%~50%
% who opted for treatment
% who should take statins based on ATP III
>90% >90%>90%
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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 > NeedCare < Need
Underuse Overuse
Appropriate care
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Care > WantCare < Want
Undertreatment Overtreatment
Desirablecare
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A survey of 627 US primary care clinicians
Sirovich BE et al. Arch Intern Med 2011
50% of my patients get too much care
50% of primary care docs are too aggressive60% of specialists are too aggressive
35% practice much more aggressively than what they would like
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Weymiller et al. Arch Intern Med 2007
Statin Choice
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Statin Decision Aid
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Web-based tool
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34
Mullan et al Arch Intern Med 2009
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55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
Neuropathy
108 kg
Pain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
Exercise
Check his feet
3 2 1Numbers don’t add up
Deadline is nowtake work home
perform!
Daughter back at home2 beautiful girls
Wasted!
mortgagedebt
insurance
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Care > NeedCare < Need
Underuse Overuse
Appropriate care
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Care > WantCare < Want
Undertreatment Overtreatment
Desirablecare
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Care > CanCare < Can
Undertreatment Overtreatment
Feasiblecare
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WORKLOAD
CAPACITY
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Encounter Research
NEED
WANT
CAN
APPROPRIATE
DESIRABLE
FEASIBLE
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http://shareddecisions.mayoclinic.org
http://minimallydisruptivemedicine.org
Needhttp://www.gradeworkinggroup.org
Want
Can
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7th International Shared Decision Making Conference
Lima, Perú - June 16-19 2013
www.isdm2013.org
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Our confidence in the research contributes to
our confidence in making decisions.The evidence alone is never sufficient
to make a decision.
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