skills for evidence-based health care suzana alves da silva, md, msc, phd senior researcher at the...
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Skills for Evidence-Based Health Care
Suzana Alves da Silva, MD, MSc, PhDSenior Researcher at the Health Technology Assessment Unit of Amil Assistência Médica Internacional S/A, Rio de Janeiro, Brazil
Suzana Silva, JECP 2010
“Knowledge does not extend from
those who consider they know to those who consider they
do not know. Knowledge is built in the relationship between human
beings and perfects it self in the critical problematization of
these relations.”Paulo Freire
Scientifically Informed Medical Practice and Learning - SIMPLE Model
Scientifically Informed Medical Practice and Learning - SIMPLE Model
Circumstances
Expertise
Patients Evidence
Suzana Silva, JECP 2010
Problem Delineation
Problem Delineation
“Knowledge does not extend from
those who consider they know to those who consider they
do not know. Knowledge is built in the relationship between human
beings and perfects it self in the critical problematization of
these relations.”Paulo Freire
Scientifically Informed Medical Practice and Learning - SIMPLE Model
Categories of problems
Categories Targets Description
Probability Frequency of outcomes over time of a condition
Performance
Effect
of a characterisc on the risk of an outcomeof a test on the presence of a condition
Utility Magnitude of the benefit offeredof the harm caused
Actions and Choices will varie according to the domains of Therapy, Diagnosis, Prognosis and Harm
Prognosis
Probability
Performance
Utility
What is the risk of AMI in 1 year in a asymptomatic pt with dislipidemia and calcium score of 100?
For how many times this risk will be increased if this pt has diabetes and smokes?
For how much the use of calcium score as a prognostic test decrease the risk of cardiovascular events in asymptomatic pt with dislipidemia?
Diagnosis
Probability
Performance
Utility
What is the pretest probability of coronary artery disease in a 40 y/o women with atypical chest pain?
What is the test with best performance to investigate this patient?
For how much the use of angiotomography to investigate CAD in patients like mine decrease the risk of cardiovascular events compared to other strategies?
Actions and Choices will varie according to the domains of Therapy, Diagnosis, Prognosis and Harm
Analytical Framework
DIAGNOSIS HARM
Probability Performance Utility Probability
PP40 y/o female with atypical chest pain, with fears and priorities
Patient wonders about AngioCT scan
Health ManagersPatient and physician wonders about safety
AATo assess the predictors: type of chest pain, age and sex
AngioCT scan, TTest, Cintigraphy, Stress echo
AngioCT scan AngioCT scan
CC No alternative is available
Coronariography
TTest, Cintigraphy, Stress echo
TTest, Cintigraphy, Stress echo
TTPre-test probability of coronary artery disease
Accuracy of the tests
Impact on cardiovascular events rate and costs
Risk of cancer due to radiation exposureRisk of renal failure dure to contrast exposure
Analytical Framework
DIAGNOSIS HARM
Probability Performance Utility Probability
PP 40 y/o female with atypical chest pain
40 y/o female with low to intermediate pre-test prob
40 y/o female with low to intermediate pre-test prob
40 y/o female with low to intermediate pre-test prob
II Type of chest pain, age and sex
AngioCT scan, TTest, Cintigraphy, Stress echo
AngioCT scan AngioCT scan
CC Coronariography
TTest, Cintigraphy, Stress echo
TTest, Cintigraphy, Stress echo
OOProbability of coronary artery disease
Accuracy of the tests
Cardiovascular events rate and costs
CancerRenal failure
Suzana Silva and Peter Wyer. The Roadmap: a blueprint for evidence literacy within a Scientifically Informed Medical Practice and Learning model. The International Journal of Person Centered Medicine. In press.
The TDS Evidence Pyramids
• Types of informationSummariesSynthesesSingle Studies
• DesignsGuidelinesSystematic ReviewsRandomized and non randomized studies
• SourcesSynopsesFiltered DatabasesLarge Biomedical Databases
DIAGNOSIS PROBABILITYDIAGNOSIS PROBABILITYSummary
Synthesis
Single Study
CAD indicates coronary artery disease; and CASS, Coronary Artery Surgery Study. *Each value represents the percent with significant CAD on catheterization. Adapted from Forrester and Diamond
Pretest Likelihood of CAD in Symptomatic Patients According to Age and Sex* (Combined Diamond/Forrester and CASS Data)
Finh et al. ACCF/AHA/ACP Guideline on Stable Ischemic Heart Disease. JACC 2012.
22222222
TestTest Author, Author, yearyear SexSex SensitivitySensitivity SpecificitySpecificity + LR+ LR - LR- LR
Treadmill Test
Morise and
Diamond,
1995
M 0,96 (0,94-0,98)
0,40 (0,34-0,46)
10,00 (5,67-23)0,63 (0,55-
0,70)
F 0,89 (0,85-0,93)
0,33 (0,25-0,41)
3,00 (1,67-5,86)
0,75 (0,63-0,88)
SPECTSantana
Boado, 1998
M 0,89 (0,67-0,99)
0,93 (0,87-0,98)
8,45 (2,64-98)0,08 (0,02-
0,19)
F 0,91 (0,78-0,97)
0,85 (0,62-0,97)
9,44 (2,82-32,33)
0,16 (0,03-0,49)
Multislice CT Mowat, 2008 T 0,87 (0,85-0,91)
0,96 (0,95-0,99)
7,38 (5,28-11)0,05 (0,01-
0,06)
DIAGNOSIS PERFORMANCEDIAGNOSIS PERFORMANCESummary
Synthesis
Single Study
Does the use of angiotomography
compared to myocardium perfusion decreases the
risk of cardiovascular outcomes?
Sheribati el al. Association of Coronary CT Angiography or Stress Testing with Subsequent Utilization and Spending Among Medicare Beneficiares. JAMA 2011
DIAGNOSIS UTILITYDIAGNOSIS UTILITYSummary
Synthesis
Single Study
HARM PROBABILITYHARM PROBABILITYSummary
Synthesis
Single StudyEstimated Number of Patients Undergoing Computed Tomography (CT) That Would Lead to the Development of 1 Radiation-Induced Cancer, by Type of CT Examination and Age at the Time of Exposure, Based on the Median and Interquartile Radiation Dose Observed