Dr.SHIVA KUMAR.S Professor of medicine Stanley medical college.

Treatment most often effective Infectious diseases Diabetes mellitus Hypertension Cardiovascular diseases Organ failure Some malignancies

 Will be challenged by findings from new studies  New approaches will appear regularly for almost all conditions Physician should judiciously consider new treatments,particularly those that promise to make an impact.

 Standard against which every treatment must be measured  Enables patient to feel better live longer be cured of the disease

 What should the clinician read about management?  What should the clinician do in the face of assertions in the literature that one or more treatment is effective?  How should the clinician select a therapy for the individual patient?

 Clinician should brouse journals/books/net for relevant articles in corresponding field  Practical clinical guidelines should be evolved- protocol based treatment  CME is essential

 Fundamental to making valuable therapeutic decision is a grasp of architecture of clinical skills  The following is the list of clinical research designs

OBSERVATIONAL INTERVENTIONAL Descriptive studyRCT Case control study Cohort study A.Prospective B.Retrospective C.A+B cochrane colloborative reviews-

Cochrane colloborative reviews  Each review takes into consideration all recently published studies from prominent journals,non-indexed journals as well as meta- analysis and these data are systematically analysed to arrive at a statistically reliable result

 Following is the hierarchy list for which treatment is prescribed Rx decreases mortality Rx decreases symptoms Rx decreases spread of the disease Patient is anxious to have something done The doctor derives economic gain from the treatment given--UNETHICAL

 Effective RX is the best available-Treatment of choice  Effective Rx is equal to certain other treatment- either one is preferred based on clinical conditions  Effective Rx-role uncertain.Relative efficacy compared to the other is unknown and is not considered the treatment of choice as its relatively new  Effective Rx inferior to some other modality-though preferable to a placebo,it is not the Rx of choice

 Efficacy unproved but widely applied.Eg.Angio for all patients of CAD  Efficacy unproved not widely applied-new modality would fall into this category

INEFFECTIVE THERAPY  Generally ineffective--can be used occasionally  Consistently ineffective—newer modality needed

 Practice of medicine on sound scientific basis of medical knowledge  ART OF MEDICINE INTUITIONEXPERIENCEJUDGEMENT

 Patient-Physician relationship—human approach in the face of change  Technomedicine—increased reliance on technical advances  One to one care  team effort with physician as the centre to guide patients effectively

 Evidence based medicine  Protocol based treatment  Medical decision making--- history,examination,relevant inv,Rx-evidence based  Assess outcome of treatment- objective/subjective  Care of elderly

 Diseases in women(during pregnancy)  Respect for autonomy of patients  Medication errors(ADR)  Continued learning— CME/books/journal/internet  Accountability

 Adverse event(AE):a definable injury caused atleast in part by medical management  Adverse drug event:AE caused by a drug  Adverse drug reaction:due to drug dosage which is in recommended and appropriate dose  Medication error:is a failure in the drug treatment process that has the potential to harm the patient

EPIDEMIOLOGY OF ADVERSE EVENTS AE-3.7% ADE-19.4% ADE-2.4 to 6.5% for 100 admission Harvard medical practice 1% of ADE-fatal 12%--life threatening 30%--serious 57%--significant

 Various ADE— fever,bleeding,diarrhoea,rash,cardiac arrythmias,renal failure,nausea & vomitting,confusion  In USA annually 1,80,000 deaths due to AE 1,00,000 deaths due to ADR ADR 4 th common cause of death

 Inappropriate drug.eg.sublingual nifedipine  Incorrect dose—Aminoglycosides/NSAIDs in renal failure  Contraindicated therapy—B blockers in asthma  Inappropriate indication—Roxithromycin in CAD  Inappropriate combination—Verapamil + B blocker

 Not using a drug when indicated—Aspirin for CVA  Wrong route/method—IV Kcl as bolus  Wrong duration—Antibiotics for less than the desired period  Failure of therapy  Inappropriate management—continuing drug inspite of hypersensitivity

 The most common error is in prescribing drugs  The common cause of medical error is a)Lack of knowledge about drugs-30% b)Lack of information about the patient-15%

 Write prescription legibly  Medical errors occur due to mistakes  Review basic drug related information  Be careful while writing route/dose  Assess basic patient characteristics such as age,sex,renal function etc  Use only few drugs in lowest effective doses

 Communicate effectively when prescriptions are questioned by patient,family,pharmacists,doctors

 Most studies of malpractice cases suggest that medical care is of bad and ambiguous quality in 60%