The Culture of Healthcare

Evidence-Based Practice
Lecture a
This material (Comp2_Unit5a)was developed by Oregon Health and Science University, funded by the Department of Health
and Human Services, Office of the National Coordinator for Health Information Technology under Award Number
IU24OC000015.
Evidence-Based Practice
Learning Objectives
Define the key tenets of evidence-based medicine (EBM) and its
role in the culture of health care (Lectures a, b)
Construct answerable clinical questions and critically appraise
evidence answering them (Lecture b)
Apply EBM for intervention studies, including the phrasing of
answerable questions, finding evidence to answer them, and
applying them to given clinical situations (Lecture c)
Understand EBM applied to the other key clinical questions of
diagnosis, harm, and prognosis (Lectures d, e)
Discuss the benefits and limitations to summarizing evidence
(Lecture f)
Describe how to implement EBM in clinical settings through clinical
practice guidelines and decision analysis (Lecture g)
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
What is Evidence-Based Medicine
(EBM)?
A set of tools and disciplined approach to informing
clinical decision-making
Applies the best evidence available
Though cannot forget the caveat: Absence of
evidence is not evidence of absence (Carl
Sagan)
Allows clinical experience (art) to be integrated with
best clinical science
Makes medical literature more clinically applicable
and relevant
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
Why Are We Not Evidence-Based?
Thomas Kida (Kida, 2006) lists six ways we arrive at
false beliefs
We prefer stories to statistics
We seek to confirm, not to question, our ideas
We rarely appreciate the role of chance and
coincidence in shaping events
We sometimes misperceive the world around us
We tend to oversimplify our thinking
Our memories are often inaccurate
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
Growing Advocacy For Medicine Being
More Evidence-Based
Effectiveness was one of 6 attributes
advocated in IOM Quality Chasm report
(Anonymous, 2001)
A recent report in this series advocates this in
more detail and advocates use of informatics for
a learning health care system (Eden, Wheatley,
McNeil & Sox, 2008)
Descriptions of methodological details and
challenges for EBM, in supplement to Medical
Care (2007, 47:10 Supp 2)
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
Cultural Pushback on EBM
Not everyone agrees with the experimentally
oriented approach of EBM (Luce, et al., 2009)
There are some valid criticisms of EBM (Cohen,
Stavri, & Hersh, 2004)
Challenges physician-patient autonomy
Focuses on large-scale randomized controlled
trials that homogenize individual differences
Concerns about manipulations of clinical trials
data and reports
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
The New EBM Mantra: Comparative
Effectiveness Research
Achieved new prominence when American Recovery
and Reinvestment Act (ARRA) allocated $1.1 billion for
comparative effectiveness research (CER)

Required preparation of two reports to inform operational plan
Federal Coordinating Council for CER (Anonymous, 2009a)
Defined CER (next slide)
Called for development not only of research but also
human and scientific capital, data infrastructure, and
dissemination
IOM report for prioritizing research (Anonymous, 2009b;
Anonymous, 2009c)
Identified top 100 research priorities
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
Comparative Effectiveness
Research (continued)
Definition of CER from Federal Coordinating Council report
research comparing different interventions and strategies
to prevent, diagnose, treat and monitor health conditions
must assess a comprehensive array of health-related
outcomes for diverse patient populations
necessitates the development, expansion, and use of a
variety of data sources and methods (informatics!)
Healthcare reform legislation (Affordable Care Act, ACA)
allocated funding for Patient-Centered Outcomes Research
Institute (PCORI, www.pcori.org)
Independent body with multiple stakeholder representation
to advance and carry out research in CER (Washington,
2011)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
8
Unit Topics
1. Definitions and Application of EBM
2. Intervention
3. Diagnosis
4. Harm and Prognosis
5. Summarizing Evidence
6. Putting Evidence into Practice
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
Evidence-Based Practice
Summary Lecture a
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
EBM is an approach to informing clinical
decision-making that applies the best evidence
available
Allows clinical experience (art) to be integrated
with best clinical science
Makes medical literature more clinically
applicable and relevant
Evidence-Based Practice
References Lecture a
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
The Culture of Healthcare
Evidence-Based Practice
Lecture a
References
Anonymous. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC:
National Academies Press.
Anonymous. (2009a). Federal Coordinating Council for Comparative Effectiveness Research - Report to the President
and the Congress. Washington, DC: Department of Health and Human Services. Retrieved from
http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf
Anonymous. (2009b). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: Institute of
Medicine. Retrieved from http://www.iom.edu/Reports/2009/ComparativeEffectivenessResearchPriorities.aspx
Anonymous. (2009c). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: National
Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=12648
Cohen, A., Stavri, P., & Hersh, W. (2004). A categorization and analysis of the criticisms of evidence-based medicine.
International Journal of Medical Informatics, 73, 35-43.
Descriptions of methodological details and challenges for EBM. (2007). In Medical Care Supplement 2 (47:10).
Eden, J., Wheatley, B., McNeil, B., & Sox, H. (Eds.). (2008). Knowing What Works in Health Care: A Roadmap for the
Nation. Washington, DC: National Academies Press.
Kida, T. (2006). Dont Believe Everything You Think: The 6 Basic Mistakes We Make in Thinking. Amherst, NY:
Prometheus Books.
Luce, B., Kramer, J., Goodman, S., Connor, J., Tunis, S., Whicher, D., & Schwartz, J. (2009). Rethinking randomized
clinical trials for comparative effectiveness research: the need for transformational change. Annals of Internal
Medicine, 151, 206-209.
Washington, A., & Lipstein, S. (2011). The Patient-Centered Outcomes Research Institute promoting better
information, decisions, and health. New England Journal of Medicine, 365, e31. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMp1109407