Scientifically Informed Medical Practice and Learning

PROCEP Teaching and Research CenterRio de Janeiro, Brazil

Scientifically Informed Medical Practice and LEarning (SIMPLE)

The Roadmap for Evidence Based Health Care

Suzana Alves da Silva, MD, PhD

1Wednesday, August 8, 12

“The integration of best research evidence with clinical expertise and patient values and circumstances”

David Sackett, 1992

Evidence-Based Medicine


2. Acquire

1. Ask

3. Appraise

4. Apply

EBM Skills Cycle


2. Acquire

1. Ask

3. Appraise

4. Apply

0. Problem Delineation

EBM Skills Cycle


Patients rarely knew to whom they had been talking, either by name or designation

Patients knew that something was going wrong but rarely knew what was going wrong. They only knew that it was not a heart attack

“But it is something, you know, there is something going on”

Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008

Patient’s Opinion after a Chest Pain Unit Experience

Based on ESCAPE Trial, Goodacre et al. BMJ 2007.


• Low risk patient

• Follow the algorithm for low risk chest pain in the ER which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram + non-invasive test for stratification before discharge

Chest Pain Unit



+



Chest Pain Unit



• Low Patient Satisfaction• Overwhelming• $$$$$$

+

=



Chest Pain Unit



The SIMPLE Model


The SIMPLE Model

Values

Preferences

Priorities


The SIMPLE Model


The SIMPLE Model

Problem delineation

“The process of problematization implies a critical return to action. It

starts from action and returns to it”

Paulo Freire, 1972


P Problem

AAction

CChoices

TTargets

Utility

Performance

Probability

Silva, Charon, Wyer. JECP 2010.

Pati

ent-

Prac

titi

oner

Rel

atio

nshi

p an

d Pr

acti

ce C

ircu

mst

ance

s


P Problem

AAction

CChoices

TTargets

Utility

Performance

Probability

P Problem

AAction

CChoices

TTargets

Share consideration of

the utilityalternatives

Estimate of impact on patient outcomes

Share consideration of

the performance

alternatives Estimate of effect

Share consideration of the probability

Estimate of likelihood of possible causes


Pati

ent-

Prac

titi

oner

Rel

atio

nshi

p an

d Pr

acti

ce C

ircu

mst

ance

s


Clinical Scenario

‘I woke up with palpitations and chest pressure this morning. I just want to get it checked out, that’s all.’

This is how a 31-year-old worker, who has come to the emergency department during lunch break, describes his problem. The patient has no significant past medical history but that his father died in his 50’s of a ‘massive heart attack’. The patient lives alone, has an unclear history of similar symptoms. He states that he occasionally takes benzodiazepine ‘for sleep’. However, he stresses that, for now, he just wants his chest symptoms ‘checked out. ’

EKG, vital signs and physical examination and first cardiac enzymes are normal.


Patient Practitioner

Chest Pain UnitPriorities



Am I having a Heart Attack?




Am I having a Heart Attack?Diagnosis likelihood





Will the algorithm for low risk chest pain help me out excluding

ACS for this patient?






ACS for this patient?Diagnosis performance





If I come back to work what is the probability of

something bad happening?








something bad happening?Prognosis likelihood











If this patient in fact has ACS what will be the probability of being

sued as a result of a bad outcome?










sued as a result of a bad outcome?Prognosis likelihood












Is it safe to perform an outpatient investigation in this low risk patient?

What is the impact on outcomes?












What is the impact on outcomes?Diagnosis utility













I would like to perform the tests later. Is that okay?













I would like to perform the tests later. Is that okay?

Diagnosis utility


P Problem

AAction

CChoices

TTargets

UtilityDiagnostic Intervention

Utility of out patient

investigation within few days

To follow the algorithm for low risk chest pain in the ER

Estimate of impact on

cardiovascular events

PerformanceDiagnosis

Performance of negative cardiac

markers 6 hours after symptoms

Criterion Standard

Estimate of accuracy

Probability Differential Dx

Probability of ACS when chest pain is present

Estimate of likelihood of

possible causes


Pati

ent-

Prac

titi

oner

Rel

atio

nshi

p an

d Pr

acti

ce C

ircu

mst

ance

s


10%

1%

Pre-Test Probability of ACS

Probability of a Bad Outcome if the patient has ACS

Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.

Low Risk Chest PainSolving the issues of probability

Diagnosis

Prognosis

Goldman. PREDICTION OF THE NEED FOR INTENSIVE CARE IN PATIENTS WHO COME TO EMERGENCY DEPARTMENTS WITH ACUTE CHEST PAIN. NEJM 1996.


10%

1%



1 out of1.000


Within 1 month

Will have a heart attack


Diagnosis

Prognosis



10%

1%



1 out of1.000


Within 1 month

Will have a heart attack

100%

of p

atie

nts

> 4

0 y/

o3%

with

mul

tiple

ris

k fa

ctor

s


Diagnosis

Prognosis



PACT


PACTAction Domains


PACTAction Domains

Categories of Problems


PACT

THERAPY DIAGNOSIS PROGNOSIS HARM

Utility

Performance

Probability

Utility

Performance

Probability

Utility

Performance

Probability

Utility

Performance

Probability

Action Domains


The Anatomy of the Question

opulation

ntervention

omparison

utcome


Clinical ScenarioYou are seeing new patients in the “major care” area of the ED. You reassess a 45 yo male who had been held in the ED overnight while

being treated for renal colic, in the hope he could be discharged.

Unfortunately, this patient is not doing so well; he is extremely weak, nauseous and suffering extensive rigors. He has spiked a temp to 39.9

oC and his BP is 90/50, HR 135, and RR 22. His O2 saturation is 98% on room air.

You initiate a septic work-up and order aggressive hydration and broad-spectrum antibiotics. Based on tests you diagnose septic shock

secondary to UTI, complicated by an obstructing stone.


In patients with septic shock, does Early Goal Directed Therapy affect mortality?

Utility

Performance

Probability


TherapyUtility

TherapyProbability

P In patients with septic shock

IF a pt with septic shock IS submitted to EGDT

I Does EGDTDuring the hospitalization

phase

C Compared to the usual care

O Decrease mortality?What is the expected

mortality?


Acquiring the Best Available Evidence


Utility of a Therapeutic Intervention

Guidelines

Systematic Reviews

Randomized trials


Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008

The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis*


Guidelines

Systematic Reviews

Observational Studies

Likelihood of outcome if submitted to therapy


In-Hospital mortality in SepsisPatients submitted to EGDT

Lagu et al. Incorporating initial treatments improves performance of a mortality prediction model for patients with sepsis. Pharmacoepidemiology and drug safety 2012; 21(S2): 44–52


Silva and Wyer, Where is the wisdom? II, JECP 2009

Clinical Research

Basic Science

Clinical ExpertiseEv

idenc

e Hier

archy

JAM

A 1992

Wis

dom

Oxford Classification

Guidelines

Integration of Knowledge


Silva and Wyer, Where is the wisdom? II, JECP 2009

Clinical Research

Basic Science

Clinical Expertise

Clinical Knowledge“Problematization” - Constructivism

Scientific KnowledgePos-Positivism - Pragmatism

InformationPositivism

Evide

nce H

ierarc

hy

JAM

A 1992

Epist

emolo

gical

Hierarc

hy

Comple

xity

Wis

dom

Oxford Classification

Guidelines

Integration of Knowledge


David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.Wyer, Silva. Where is the Wisdom I. JECP 2009.Sival, Wyer. Where is the Wisdom II. JECP 2009.

TS Eliot. The Rock.Acknowledgement to Peter Wyer

“Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in

information?”

Where is the Wisdom?


Obrigada!

Gracias!

Thank You!

Danke!

Merci!


Randomized Controlled Trials

Observational Studies

All the rest In

form

atio

n Av

aila

ble

Research and Practice

Dec

ision

Mak

ing

Nee

ds < 20%

> 80%

David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.


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