1. 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

2. 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 9a2 Health IT Workforce Curriculum Version 1.0/Fall 2010

3. 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.” Component 1/Unit 9a3 Health IT Workforce Curriculum Version 1.0/Fall 2010

4. Evidence Based Practice EBP is a method that helps clinicians make decisions about patient care EBP combines: –Clinician skills –Patient values –Evidence from research Component 1/Unit 9a Health IT Workforce Curriculum Version 1.0/Fall 2010 4

5. 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” Component 1/Unit 9a5 Health IT Workforce Curriculum Version 1.0/Fall 2010

6. 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” Component 1/Unit 9a6 Health IT Workforce Curriculum Version 1.0/Fall 2010

7. 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 Component 1/Unit 9a Health IT Workforce Curriculum Version 1.0/Fall 2010 7

8. 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 Component 1/Unit 9a8 Health IT Workforce Curriculum Version 1.0/Fall 2010

9. Hierarchy of Study Designs leveldesigncomment IRandomized controlled trials Equal probability of assignment of subjects IICohort StudiesDefined by exposure to factor IICase Control StudiesDefined by outcome of interest IVCase seriesSystematic observation without controls V Expert opinion, physiologic studies Only as good as the expert Component 1/Unit 9a9 Health IT Workforce Curriculum Version 1.0/Fall 2010

10. 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 Component 1/Unit 9a10 Health IT Workforce Curriculum Version 1.0/Fall 2010

11. 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 Component 1/Unit 9a11 Health IT Workforce Curriculum Version 1.0/Fall 2010

12. 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? Component 1/Unit 9a12 Health IT Workforce Curriculum Version 1.0/Fall 2010

13. Evidence Hierarchy Summarized Oxford EBM Hierarchy IaSystematic review RCTs IbIndividual RCTs IcAll or none IIaSystematic review cohort studies IIbIndividual cohort studies IIcOutcomes research IIIaSystematic review case control studies IIIbIndividual case control studies IVCase series VExpert opinion etc Component 1/Unit 9a13 Health IT Workforce Curriculum Version 1.0/Fall 2010