LabDx
10/11/99
Evidenced-based Health Care
The practice of evidenced-based health care is a process of life
long, self directed learning in which caring for our pts creates the need
for clinically important information about dx, prognosis therapy and other
clinical health care issues and in which we:
- Convert
this information into answerable questions
- Track
down the best evidence to answer the questions (clinical exam diagnastic
tests, research evidence)
- Critically
appraise the evidence for its validity and clinical applicability
- Apply
the results of this appraisal in our clinical practice
- Evaluate
our performance
Selection of Treatment(s)
- By
method of induction (seems to work or ought to work)
- Own
experience
- Experience
of others
- Current
concepts of pathophysiology to arrive at treatment approach
- Method
of deduction (from research evidence)
- Exposure
of worthless or dangerous treatments
- Weight
of evidence of clinical studies on treatment
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Strength
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Design
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STRONG
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Large random control trial
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Systemic reviews of RCT's
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Small RCT's
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Controlled trials w/o single subject
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Experimental designs (including "N or 1")
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Observational studies (Cohort, Case Control)
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Evidence-based reports of expert committees
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Case studies
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Case reports
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Clinical hunches
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WEAK
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Anecdotes
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- ABDICATION
- Acceptance
of faith
- Recommendations
from authority figures (e.g. consultants), colleagues
- Advertisements,
company representatives
Dealing w/Company Representatives
- See
only by appointment
- Take
charge of meeting
- Request
independent (peer-reviewed) evidence
- Read
promotional brochures w/skeptical eye
- Ignore
testimonial evidence as fact
- Use
"STEP"
- Safety
- Tolerability
- Efficacy
- Price
- Do not
accept newness of a treatment as an argument to use it
Specify the Treatment Target
- Knowing
when to stop treatment, change ist intensity (frequency and duration) or
to switch to some other treatment
Clinical Endpoints and Outcomes
- Traditional
clinical endpoints-a relatively easily measured procedure for a treatment
which indicates (usually indirectly) its harm or clinical benefit
- Examples
include measurement of ROM and muscle strength measures
Outcome Measures
- Markers
for the results of the tx process to determine if tx goals have been
achieved
- Doctor
centered objective (clinical endpoint) measures
- Pt centered
subjective measures
- Pt
satisfaction
- Health-related
quality of life (fxning and well being)
- Why
measure health related quality of life if you have traditional clinical
endpoints?
- Treatment
effects may:
- Be
an equivalent to clinical endpoint (e.g. lumbar spine mobility), but
differ in impact on fxning and well being
- Represent
tradeoff b/w improvement in clinical parameter vs. decrement in fxning
and well being