Week 12. Application/Practice and Clinical Decision Support Tools Flashcards
Decision making approach: Paternalistic or parental approach
- usually clinician appraising the evidence (minimal or no attempt to ensure decision consistent with patient values/preference)
- Act upon patient
Decision making approach: clinician-as-perfect agent approach
- Discussing the evidence with the patient/family and engaging them to use the evidence (approaches that attempt to ensure decision consistent with patient values and experiences)
- Informed decision making process
- Shared decision making
Optimal decision-making approach
Shared decision making is likely optimal
3 questions when considering if results are relevant to patient?
- Participants in the study similar to patients to whom I wish to apply findings
- Were interventions applied appropriately
- Are outcomes useful (good>harm)
Major issue when determining relevance to patients
Generalization
- one better than the other
- finding is relevant to everyone
Evaluating Evidence: Efficacy
“lab study”
- does treatment/study work under ideal settings
- one step beyond an animal study; if it doesn’t work in this stage there’s no point on going further
Evaluating Evidence: Effectiveness
“clinical setting”
- does treatment/study work in the real world (clinical setting).
Why can “effectiveness” not be measured in RCT?
- Cannot be measured in controlled trails because act of inclusion into study is a distortion of usual practice.
Evaluating Evidence: Efficiency
“Cost”
Is the treatment worth it’s cost.
- relationship between inputs (costs) and outputs (quality adjusted life-years, QALYs).
- More QALYs for the same or ferwer resources are more efficient
How is efficiency assessed?
- cost minimalization, 2. cost-effectiveness,
3. cost-utility analysis
Frozen Shoulder Timeline between phases
- 3-6months/phase
- Can take up to/over a year
Frozen shoulder: causes and capsular pattern
idiopathic
- ER, AB, IR
Making clinical decision: requirements
Define the:
- Question
- Clinical situation
- Clinical Knowledge
- Knowing the evidence
Making clinical decisions: what is the researcher contributing?
only contribute one component: information on the study
- who was treated and
- what intervention by what clinicians to reach what outcome
Making clinical decisions: relevance of results
- The average effect of the intervention
“Clinical trial can tell us about the effects of an intervention on patients with particular characteristics is the average effect of the intervention on a heterogenous population from which sample patients were drawn”
5S Hierarchy of Evidence
- Systems
(e. g. computerized decision support system) - Summaries
(e. g. EBG/Textbooks) - Synopses
(e. g. Critically Appraised Journal articles/abstracts) - Syntheses
(e. g. systematic reviews) - Studies
(e. g. RCTs, Cohort, Case control/series) - Expert opinion: Classical Textbooks
Knowledge Translation: Passive Diffusion
research papers and conference talks to other scientists
Knowledge translation: Dissemination
targeted messaging to defined groups
Knowledge translation: Implementation
actively identifying and overcoming barriers to the use of knowledge; uses not only the message itself, but organizational and behavioural tools for use of evidence
Two potential futures due to technology
- A more efficient version of what we do today - streamlined and optimized
- Transformation of how we work, think, and make decisions
