HOLISTIC CONCEPT IN GP/FM

using the best available evidenceto manage comorbidity

Manfred Maier

CONTENT

• Holistic Care

• EBM – sources

• – problems

• recommendations

LEARNING GOALS

• analyze some problems with EBM - sources

• explain the tension between EBM and individual care for patients with comorbidity

• appreciate the holistic approach

HOLISTIC CARE

•An approach to patient care in which all thepatient’s physical, mental and social factorsare always taken into account, rather than just the diagnosed disease with or without psychosocial factors that influence the disease or the result.It allows comprehensive care of the patient.

• Wonca Dictionary

HOLISTIC CARE

•It is much more important to know what sort of patient has a disease than what sort of disease a patient has.

•

•Sir William Osler, 1904

HOLISTIC CARE

•Never forget that it is not a pneumonia

•but a human being with pneumonia

•who is your patient.

•Sir William Gull (1816 – 1890)

HOLISTIC CARE - DIAGNOSIS

• disease centered

• patient centered– patient as a person– emotional reactions to the illness– the family– the effect on relationships– work and leisure– lifestyle– the environment

HOLISTIC CARE - MANAGEMENT

• disease centered• patient centered

– psychological support– reassurance– patient education, guidance– Empowering, self- responsibility– prevention, health promotion– lifestyle recommendations– social support– alternative options– referral– follow up

EVIDENCE-BASED MEDICINE (EBM)

•A concept based on conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research, including meta-analysis.

• Wonca Dictionary

EBM - SOURCES

• original articles

• systematic reviews, meta-analysis (Cochrane Collaboration)

• EBM - Journals (e.g. Evidence Based Mental Health)

• clinical guidelines

RANDOMIZED CONTROLLED TRIALS (RCT)

• most reliable method of determining the effects of treatment

• possibility of bias must be kept to a minimum (internal validity)

• results should be relevant to a definable group of patients in a particular clinical setting (external validity)

ASSESSMENT OF EXTERNAL VALIDITY (1)

• setting of the trial– recruitment from primary, secondary, tertiary

care

• selection of patients– exclusion criteria– run in periods

• characteristics of randomized patients– uniformity of pathology– severity of disease– comorbidity

ASSESSMENT OF EXTERNAL VALIDITY (2)

• differences between trial protocol and routine practice

– timing of treatment– prohibition of non-trial treatments

• outcome measures and follow up– clinical relevance– patient centered outcome

• adverse effects of treatment– exclusion of patients at risk (run in period)– rates of discontinuation of treatment

RANDOMIZED CONTROLLED TRIALS

• judgment is left to clinicians

• should be designed and reported in a way that allows clinicians to judge to whom results can reasonably be applied

META - ANALYSES

• summarize the effects of interventions from RCT

• many patients

• relevant for treating individuals?

WHO WILL BENEFIT?

• meta - regression• relates the overall effect in every trial to

summaries of patients characteristics (other characteristics ?)

• meta – analysis of subgroup differences• compares given subgroups of patients

within every trial and combines these result across trials (consistent information ?)

• individual patient data meta – analysis• shares individual patient data from

different trials (collated centrally?)

CLINICAL GUIDELINES

•The recommended reference programmes developed on the basis of evidence-based medicine to assist the physician and the patient choosing appropriate health care for specific clinical conditions.

•Wonca Dictionary

CLINICAL GUIDELINES

• provide recommendations for patients with a particular disease

• The goal is to maximize benefits to patients with that specific disease by encouraging standardization among providers

GUIDELINES – COMORBIDITY ?

• tension between the standardized treatment of disease and the individualized care of patients with multiple conditions

GUIDELINES - CHARACTERISTICS

• recommendations to reduce risks– older patients ? multiple health conditions ?

• recommendations for medication– adverse events ? long term effect ?

• coexisting conditions – additional medication

– Priorities ? health preferences ? quality of life ?

QUESTIONS

• multiple guidelines – adherence ?

• combination of medications • – benefit ?

– adverse events ? – how long ?– patients preferences ?– added benefit ?

HOLISTIC APPROACH

• presentation of the evidence• benefit and harm over time with respect to a

spectrum of outcomes• consider drug interactions• discussion of preferences and health

priorities• consider convenience, compliance and

costs• communicate effectively with patient