Component 1: Introduction to Health Care and Public Health in the U.S.

Component 1: Introduction to Health Care and Public Health in the U.S.

1.9: Unit 9: The evolution and reform of healthcare in the US

1.9a: Evidence Based Practice

Component 1/Unit 9a Health IT Workforce Curriculum Version 1.0/Fall 2010

Objectives

1. Describe evidence-based medicine, clinical practice guidelines, and quality indicators in medicine

2. Introduction to the patient-centered medical home

3. Discuss the key aspects of health care reform in the U.S.

Component 1/Unit 9a 2Health IT Workforce Curriculum Version 1.0/Fall 2010

Evidence Based Practice

• Evidence Based practice (EBP) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.”

• EBP integrates “...individual clinical expertise with the best available external clinical evidence from systematic research.”


Evidence Based Practice

• EBP is a method that helps clinicians make decisions about patient care

• EBP combines:– Clinician skills– Patient values– Evidence from research

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Evidence Based Practice:Practice Guidelines

• Practice Guidelines are evidence-based recommendations

• In 1990, Institute of Medicine (IOM) Committee advised the Public Health Service on Clinical Practice Guidelines:– Practice guidelines are “systematically developed

statements to assist practitioners and patients in making decisions about appropriate health care”


Evidence Based Practice:Clinical Decision Support (CDS)

• CDS is “...a clinical system, application or process that helps health professionals make clinical decisions”

• Clinical Decision Support Systems are “active knowledge systems which use two or more items of patient data to generate case-specific advice”


Evidence Based Practice:Clinical Decision Support (CDS)• Some functions of decision support systems:

– Administration– Management of complexity– Cost control

• Decision support: Supporting clinical reasoning, promoting use of best practices

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Hierarchy Of Evidence• Literature is ranked in a hierarchy• The higher up in the ladder of evidence, the “better” the

quality of the study• Why have a hierarchy?

– Allows grading of studies – Allows comparison of methodologies– Provides a framework that can be used during the development

of systematic review protocols

• One method of hierarchical ordering: classify according to effectiveness, appropriateness and feasibility


Hierarchy of Study Designs

level design comment

I Randomized controlled trials Equal probability of assignment of subjects

II Cohort Studies Defined by exposure to factor

II Case Control Studies Defined by outcome of interest

IV Case series Systematic observation without controls

V Expert opinion, physiologic studies Only as good as the expert


Some Terms Defined

• Bias: Inaccuracies that produce a false pattern of differences

• Blinding: Attempt to eliminate bias by hiding the intervention

• Validity: The extent to which a variable or intervention measures what it is supposed to measure


Systematic Reviews

• Systematic review: Search of the medical literature is conducted systematically using specific methods – Meta-analysis: A systematic review which

uses quantitative methods to summarize the results

• Systematic reviews can be conducted– Via journal clubs– Via data mining

• Example: Cochrane Collaboration


PICO• Questions that are asked during evidence

based practice and research:• P = Patient

– What are the characteristics of the patient/population/problem?

• I = Intervention– What is the intervention, prognostic factor or exposure?

• C = Comparison– What is the main alternative to compare with the

intervention? • O = Outcomes

– What is the measurement or improvement?


Evidence Hierarchy SummarizedOxford EBM Hierarchy

Ia Systematic review RCTs

Ib Individual RCTs

Ic All or none

IIa Systematic review cohort studies

IIb Individual cohort studies

IIc Outcomes research

IIIa Systematic review case control studies

IIIb Individual case control studies

IV Case series

V Expert opinion etc


Component 1: Introduction to Health Care and Public Health in the U.S.

Documents

workforce curriculum

health professionals

public health service

clinical practice guidelines

ladder of evidence

clinical reasoning

clinical system

practice ebp