HINZ Education WorkshopEvidence-based Practice<br />Dr Sue Wells<br />Senior lecturer: Clinical Epidemiology, Health Innov...
Outline- game of 2 halves<br />Take the health statistic challenge<br />What is evidence-based practice?<br />What skills ...
Drinking coffee, hard exercise, and nose blowing are everyday activities most likely to raise BP and cause a special kind ...
Take the health statistic challenge<br />Making sense of Health Statistics Questionnaire<br />Outcomes Group, VA White Riv...
1. Which would best help you to determine how much a person could benefit from Gritagrel? (Circle one)<br />a. How often p...
2. Which would best help you to decide whether you will benefit from Gritagrel? (Circle one)<br />a. How many people were ...
3. Which additional piece of information would be the best evidence that Gritagrelhelped people? (Circle one)<br />a. Grit...
Your doctor says there is a 10% risk of dying from pneumonia.4. Which information best helps you understand whether this r...
5. To better understand how much of a threat pneumonia is to your health,which information is most helpful? <br />a. How m...
A new study finds that there were 30 deaths among people who eat broccoli regularly compared to 100 deaths among people wh...
Mrs. Smith is told she has a 1 in 296 chance of dying from cancer and a 1 in 407 chance of dying from a stroke.8. Which is...
About 51,000 Americans will be diagnosed with melanoma (the most serious skin cancer) this year.10. What is your best gues...
Mrs. Jones is told she has a 28 in 1,000 chance of dying from cancer and a 59 in 1,000 chance of dying from a stroke.Mrs. ...
Mrs. Jones is told she has a 28 in 1,000 chance of dying from cancer and a 59 in 1,000 chance of dying from a stroke. 12. ...
Please read the following news story about Dr. Womba's study.<br />Promising new drug hailed*<br />Washington, DC -- Resea...
13. Which question would you most like to ask Dr. Womba?<br />a. Who paid for the study?<br />b. Has Argentex been shown t...
In a new study, people either took pill X or placebo (a sugar pill).3% of people taking placebo died; 1% of people taking ...
In a new study, people either took pill X or placebo (a sugar pill).3% of people taking placebo died; 1% of people taking ...
What is Evidence-based Practice<br />2mins- talk to those beside you and come up with your ideas of what it is<br />
Sicily Statement<br />“Evidence-Based Practice (EBP) requires that decisions about health care are based on the best avail...
 ‘Traditional’ Evidence Based Practice (EBP)<br />Anatomy<br />Physiology<br />Pathology<br />Biochemistry<br />Psychology...
‘Modern’ EBP emphasises ‘current’ clinical epidemiological evidence of outcomes<br />
Clinical Epidemiological* evidence<br />The accuracy of diagnostic tests<br />The power of prognostic markers<br />The eff...
Clinical evidence increasing so rapidly that we all need EBP skills to keep up-to-date<br />MEDLINE 2006<br />1,600 articl...
Less that 10% of published evidence is worth reading<br />About 1/3 of evidence eventually refuted or attenuated<br />
The first 4 steps of EBP<br />1. Ask a focused question.<br />2. Access (systematically search for) epidemiological eviden...
About 1/2 of relevant evidence is not implemented<br />
The 5th step of EBP<br />Audit your practice:<br />check your actual practice against best (evidence-based) practice<br />...
Step 1. Ask a focused question<br />1  Participants(patient group,problem,setting)<br />How would I describe a group of pa...
Scenario<br />You are a doctor who is conducting heart health checks for adults over 35 yrs in your practice.<br />You are...
Reframe question into the 5-PECOT parts<br />(P) What group of people, with what problem, in what setting?<br />   In adul...
Common Questions<br />Question type<br />Does this person have a disease/condition? <br />What causes it?<br />What should...
Intervention/treatment<br />Aetiology & Risk factors<br />Diagnosis<br />Prognosis & incidence<br />Prevalence<br />Experi...
Family history question<br />What type of question is this?<br />What is the best study design to answer this question?<br />
Step 2. Access the Evidence<br />~600,000  new articles/yr<br />Brian Haynes R Evid Based Med 2006;11:162-164<br />©2006 b...
the GATE picture: a framework for EBP<br />Graphic Approach To EBP<br />Prof Rod Jackson’s<br />
 PECOT: the 5 parts of every epidemiological study<br />P<br />Participants<br />Exposure Group<br />Comparison Group<br /...
Cohort Study : family hx & risk of CVD event<br />Population<br />Men and women 35-75yrs without previous CVD <br />Family...
Step 3. Appraise the evidence<br />A tool for documenting the steps of EBP www.epiq.co.nz<br />
 EBP Steps 4 and 5<br />Ask a focused question.<br />Access (systematically search for) epidemiological evidence to help a...
X-factor: making evidence-based decisions<br />Evidence including clinical epidemiology<br />Clinical / health considerati...
How can busy people do EBP?<br />
   1. use evidence-based “electronic decision support systems”<br />
2. use evidence-based guidelines (& EB text bks?)<br />
3. use Systematic Reviews<br />MEDLINE 2006/day<br />1,600 articles<br />     95 trials<br />       4 reviews*<br />*Cochr...
Outline- second half<br />Take the health statistic literacy challenge<br />What is evidence-based practice?<br />What ski...
NZ CVD guidelines 2003<br />
NZGG CVD guidelines in a nutshell<br />Plus adjustments for ethnicity, fam Hx, diabetes, <br />>15% or prior CVD event<br ...
NZGG CVD guidelines in a nutshell<br />If we did this we could prevent/delay more than 50% of the CVD events in the next 5...
Problems<br />
Problems with risk assessment tool<br />Framingham CVD equation -based on ~5200 patients starting originally in 1948 throu...
How often do you use CVD risk charts?(GPs n=500 response rate 83%)<br />Arroll et al. NZ Family Physician 2002:29:177-83<b...
PREDICT-CVD Evaluation Study 2004: <br />Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8 <br />
Treatment gaps in 1º care in NZ<br />Rafter et al NZMJ 2005<br />Electronic records of 25,384 men over 45 yrs & women over...
TM<br />1998-2002<br />a web-based clinical decision support system <br />
Evidence-based care for populations<br />Anonymised linkage to CVD outcomes, drug dispensing & laboratory results<br />Evi...
Acknowledgements- PREDICT<br />Research team- Rod Jackson, Tania Riddell, Andrew Kerr, Romana Pylypchuk, Roger Marshall, C...
Break down the complexity of guidelines into tailored management for a patient<br />
PREDICT in PHOs Recruitment <br />> 200,000<br />May 2011<br />
Impact of electronic decision support in 1o care<br />Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8 <br />
Impact of electronic decision support in 1o care<br />Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8 <br />
Impact on documented CVD risk assessment<br />estimate<br />*<br />*<br />* Wells et al. Eur J CardiovascPrev Rehab 2008; ...
50% CVD events occur in small % of population<br />High risk<br />CVD events<br />Sue Wells PhD Auckland 2009<br />
But we need to improve our risk prediction<br />CVD events<br />Predicted risk<br />
Communicating risk<br />I give you six months or 600 miles<br />
CVD risk = abstract concept<br />Probability of having a symptomatic CVD event in next 5 or 10 years<br />
Your CVD risk is 15%<br />If you stop smoking you can go from yellow to green!<br />out of 100 people like you 15 are pred...
A problem with short-term CVD risk communication: case history<br />35 yr old Clarke Kent, smoker, BP 150/80mmHg, TC/HDL 5...
5-yr CVD risk is 5% = mild<br />But we know that with these risk factors longer-term risk must be high. <br />Problem – fa...
Telling CVD risk story in another way<br />http://www.heartfoundation.org.nz/index.asp?pageID=2145881453<br />
Acknowledgements<br />National Heart Foundation<br />Enigma Publishing Ltd<br />Our team<br />Andrew Kerr, Stewart Eadie, ...
Telling the story<br />
Telling the story: Relative risk<br />
Telling the story: Arterial Age or Heart Age<br />
Telling the story: long term risk <br />
Telling the story: Risk modification<br />
consumer version 2010<br />http://www.knowyournumbers.co.nz/your-heart-age-forecast.aspx<br />
Outline- game of 2 halves<br />Take the health statistic challenge<br />What is evidence-based practice?<br />What skills ...
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HINZ Education Workshop: Evidence Based Practice

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Dr Sue Wells
Senior lecturer in Clinical Epidemiology, Health Innovation & Quality Improvement
School of Population Health
University of Auckland

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  • Herald May 2011
  • 5 major study designs
  • Appraise evidence for Bias in recruitment, allocation of exposure/comparison, maintenance into groups (follow-up, compliance, contamination, co-intervention), blind or objective measurement of outcomesAppraise evidence found for its validity, effect size, precision
  • historical data in very different populations, lifestyles
  • Public private partnership with Enigma Publishing Ltd, a NZ company (web-based health information software development experts) for over 10 years. They provide the software platform for much of our data collection and sell licences for use of software to PHOs and DHBs. We determine all the clinical content and are responsible for all research data and are completely publicly funded. All research outputs from PREDICT are publicly owned and available
  • This is where we are up to now. 2 HRC project grants, 47 papers, multiple masters theses &amp; dissertations, training fellows, presentations. Our data has already been used to update national guidelines and
  • Demonstrated equal (if greater) impact in Maori than in non Maori. Recently won a prize for the most cited paper in the journal in 2009/10
  • But when you are there with a patient -understanding and communicating risk is really challenging
  • Both the clinician and patient may be falsely reassured by the low score or worse- demotivated
  • In 2008 , we wanted to tell a story in pictures
  • absolute risk vs “ideal” peer.“Your current risk is higher than it should be”
  • 2. Arterial age – “Your current risk is the same as a 57y old with ideal risk factors.”
  • 3. Risk trajectory-“This is your risk as you age if nothing changes”
  • 4. Risk modification – “If you stop smoking your current and future risk falls”So the Heart forecast combines absolute, relative and long-term CVD risk to support health professional CVD risk communication
  • HINZ Education Workshop: Evidence Based Practice

    1. 1. HINZ Education WorkshopEvidence-based Practice<br />Dr Sue Wells<br />Senior lecturer: Clinical Epidemiology, Health Innovation & Quality Improvement <br />School of Population Health<br />
    2. 2. Outline- game of 2 halves<br />Take the health statistic challenge<br />What is evidence-based practice?<br />What skills do you need?<br />Acknowledge Rod Jackson, Gill Robb- EBP SOPH<br />Evidence suggests that we can reduce heart attacks and strokes in New Zealand by half<br />The PREDICT collaboration: the use of informatics to put evidence into practice<br />
    3. 3. Drinking coffee, hard exercise, and nose blowing are everyday activities most likely to raise BP and cause a special kind of stroke ....together account for nearly ¼ of all cases in which a blood vessel bursts in the brain (aneurysm)<br />
    4. 4. Take the health statistic challenge<br />Making sense of Health Statistics Questionnaire<br />Outcomes Group, VA White River Junction, Vermont, USA<br />Affiliated Dartmouth Medical School<br />www.vaoutcomes.org/downloads/medical_data_test.pdf<br />
    5. 5.
    6. 6. 1. Which would best help you to determine how much a person could benefit from Gritagrel? (Circle one)<br />a. How often people experience side effects<br />b. The chance of stroke for people who do not take Gritagrel<br />c. How many people take Gritagrel<br />d. How recently Gritagrel was developed<br />
    7. 7. 2. Which would best help you to decide whether you will benefit from Gritagrel? (Circle one)<br />a. How many people were in the study<br />b. Age and sex of people in the study<br />c. Whether a doctor confirmed that people had strokes<br />d. Who paid for the study<br />
    8. 8. 3. Which additional piece of information would be the best evidence that Gritagrelhelped people? (Circle one)<br />a. Gritagrel lowered antioxidant levels<br />b. Fewer people died for any reason in the Gritagrel group than in the placebo group<br />c. Many doctors prescribe it<br />d. Fewer people died from strokes in the Gritagrel group than the placebo group<br />
    9. 9. Your doctor says there is a 10% risk of dying from pneumonia.4. Which information best helps you understand whether this risk applies to you? (circle one)<br />a. Most people who die from pneumonia are 75 years or older<br />b. More than 110,000 people get pneumonia each year<br />c. Pneumonia is one of the most common reasons for hospitalization<br />d. About 15,000 people die from pneumonia each year<br />
    10. 10. 5. To better understand how much of a threat pneumonia is to your health,which information is most helpful? <br />a. How much money is spent on pneumonia research<br />b. Whether pneumonia is more common in the US than Europe<br />c. Your chance of dying of other important diseases<br />d. Celebrities who have had pneumonia<br />
    11. 11. A new study finds that there were 30 deaths among people who eat broccoli regularly compared to 100 deaths among people who don't eat broccoli at all.6. According to this study, which statement best describes how eating broccoli relates to death?<br />a. Lowers the risk of death<br />b. Doesn't change the risk of death<br />c. Raises the risk of death<br />d. Can't tell from this information<br />
    12. 12. Mrs. Smith is told she has a 1 in 296 chance of dying from cancer and a 1 in 407 chance of dying from a stroke.8. Which is bigger, Mrs. Smith’s chance of dying from a stroke or cancer?<br />a. Stroke<br />b. Cancer<br />c. Chances are the same<br />
    13. 13. About 51,000 Americans will be diagnosed with melanoma (the most serious skin cancer) this year.10. What is your best guess about an American's chance of being diagnosed with melanoma in the next year?<br />a. 51,000<br />b. 51,000 divided by the number of Americans<br />c. Don’t know how to figure this out<br />
    14. 14. Mrs. Jones is told she has a 28 in 1,000 chance of dying from cancer and a 59 in 1,000 chance of dying from a stroke.Mrs. Jones's doctor now tells her that a new pill, STROKE, will lower her chance of dying from stroke by 50%. Another pill, CANCER will lower her chance of dying from cancer by 50%. She can only take 1 pill. Assuming the 2 pills are equally safe and cost the same, which do you suggest she take if her goal is to lower her chance of dying?<br />a. STROKE pill<br />b. CANCER pill<br />c. Either pill is okay<br />
    15. 15. Mrs. Jones is told she has a 28 in 1,000 chance of dying from cancer and a 59 in 1,000 chance of dying from a stroke. 12. Mrs. Jones decides to take the CANCER pill (reduce risk 50%). Now, what is her chance ofdying from cancer?<br />a. 0 in 1,000<br />b. 7 in 1,000<br />c. 14 in 1,000<br />d. 21 in 1,000<br />
    16. 16. Please read the following news story about Dr. Womba's study.<br />Promising new drug hailed*<br />Washington, DC -- Researchers announced the results of a<br />long awaited study of Argentex, a drug designed to prevent<br />prostate cancer. In the study, 1000 men age 45 to 75 were<br />randomly assigned to take either Argentex or a sugar pill<br />called a placebo. The men were followed for 4 years. Only<br />3 of the men taking Argentex developed prostate cancer.<br />Lead scientist Bernard Womba described the findings as<br />“extremely promising” and predicted the drug would be in<br />wide use shortly.<br />*Not a real drug<br />
    17. 17. 13. Which question would you most like to ask Dr. Womba?<br />a. Who paid for the study?<br />b. Has Argentex been shown to work in animals?<br />c. What was the average age of the men in the study?<br />d. How many men taking the sugar pill developed prostate cancer?<br />
    18. 18. In a new study, people either took pill X or placebo (a sugar pill).3% of people taking placebo died; 1% of people taking pill X died.15. Which statement is correct about how pill X changes the chance of death?<br />a. 2 more deaths per 100 people<br />b. 1 more death per 100 people<br />c. 1 fewer death per 100 people<br />d. 2 fewer deaths per 100 people<br />
    19. 19. In a new study, people either took pill X or placebo (a sugar pill).3% of people taking placebo died; 1% of people taking pill X died.14. Which statement is correct about how pill X changes the chance of death?<br />a. Lowers by 67%<br />b. Lowers by 33%<br />c. Raises by 33%<br />d. Raises by 67%<br />
    20. 20. What is Evidence-based Practice<br />2mins- talk to those beside you and come up with your ideas of what it is<br />
    21. 21. Sicily Statement<br />“Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources”<br />This statement was conceived by the delegates of the second international conference of Evidence-Based Health Care Teachers and Developers held in Sicily in September 2003 <br />
    22. 22. ‘Traditional’ Evidence Based Practice (EBP)<br />Anatomy<br />Physiology<br />Pathology<br />Biochemistry<br />Psychology<br />etc.<br />
    23. 23. ‘Modern’ EBP emphasises ‘current’ clinical epidemiological evidence of outcomes<br />
    24. 24. Clinical Epidemiological* evidence<br />The accuracy of diagnostic tests<br />The power of prognostic markers<br />The effectiveness of interventions<br />Therapy<br />Screening<br />Prevention<br />* the study of the frequency of outcomes in groups of patients <br />
    25. 25. Clinical evidence increasing so rapidly that we all need EBP skills to keep up-to-date<br />MEDLINE 2006<br />1,600 articles / day<br />approx 100 new<br /> trials published<br /> every day<br />Bastian, Glasziou, Chalmers, ( PLoS 2009)<br />
    26. 26. Less that 10% of published evidence is worth reading<br />About 1/3 of evidence eventually refuted or attenuated<br />
    27. 27. The first 4 steps of EBP<br />1. Ask a focused question.<br />2. Access (systematically search for) epidemiological evidence to help answer question.<br />3. Appraise evidence found for its validity, effect size, precision (ideally all the relevant evidence)<br />4. Apply the evidence:<br />a. amalgamate the valid evidence with other relevant information (patient/community values, clinical/health issues, & policy context) and make an evidence-based decision; and<br />b. Act (implement) the decision in practice<br />
    28. 28. About 1/2 of relevant evidence is not implemented<br />
    29. 29. The 5th step of EBP<br />Audit your practice:<br />check your actual practice against best (evidence-based) practice<br />i.e. the gap between your evidence-based decisions and your actions<br />
    30. 30. Step 1. Ask a focused question<br />1 Participants(patient group,problem,setting)<br />How would I describe a group of patients like mine?<br />2. Exposure(cause,factor, treatment, disease)<br />3. Comparison(compared to what?)<br />4. Outcome (what does this exposure affect? what do I hope to avoid (hospital admission) or achieve (survival)?<br />5. Time (over what time period is it reasonable to expect an effect?<br />= 5 parts of an epidemiological study<br />
    31. 31. Scenario<br />You are a doctor who is conducting heart health checks for adults over 35 yrs in your practice.<br />You are interested in a family history of premature heart disease and whether this might increase the risk of a person having a future heart attack<br />Convert this into a PECOT question<br />P (population/problem)<br />E (exposure)<br />C (comparator)<br />O (outcome)<br />T (over what time frame)<br />
    32. 32. Reframe question into the 5-PECOT parts<br />(P) What group of people, with what problem, in what setting?<br /> In adults over 35 years<br />(E) What exposure am I considering?<br />Does having a family history of premature heart disease<br />(C) what am I comparing the exposure to?<br />No family history<br />(O) What does this exposure affect, what do I hope to avoid (hospital admission) or achieve (survival)<br />affect the risk of a heart attack<br />(T) Over what time period is it reasonable to expect an effect?<br />over the next 5 years <br />
    33. 33. Common Questions<br />Question type<br />Does this person have a disease/condition? <br />What causes it?<br />What should I do about it?<br />What things about them or the disease determine whether they have a good/bad outlook?<br />How common is the problem?<br />What are the issues around these problems? What do people think about it?<br />Diagnosis<br /> Aetiology & Risk factors<br />Intervention/Rx<br />Prognosis<br />Prevalence & Incidence <br />Meaning , perspectives, psychosocial context <br />
    34. 34. Intervention/treatment<br />Aetiology & Risk factors<br />Diagnosis<br />Prognosis & incidence<br />Prevalence<br />Experiences & meaning<br />Which study design will best answer my question?<br />Question type<br />Randomised controlled trial<br />Cohort or case control study<br />Cross-sectional study<br />Cohort study<br />Cross-sectional study<br />Qualitative study<br />In each case, a systematic review of all available studies is better than a individual study<br />
    35. 35. Family history question<br />What type of question is this?<br />What is the best study design to answer this question?<br />
    36. 36. Step 2. Access the Evidence<br />~600,000 new articles/yr<br />Brian Haynes R Evid Based Med 2006;11:162-164<br />©2006 by BMJ Publishing Group Ltd<br />
    37. 37. the GATE picture: a framework for EBP<br />Graphic Approach To EBP<br />Prof Rod Jackson’s<br />
    38. 38. PECOT: the 5 parts of every epidemiological study<br />P<br />Participants<br />Exposure Group<br />Comparison Group<br />E C<br />Outcomes<br />O<br />Time<br />T<br />All epidemiological studies can be hung on the GATE frame<br />
    39. 39. Cohort Study : family hx & risk of CVD event<br />Population<br />Men and women 35-75yrs without previous CVD <br />Family Hx<br />No Family Hx<br />Time <br />Outcomes<br />yes<br />MI, angina, stroke/TIA, <br />no<br />
    40. 40. Step 3. Appraise the evidence<br />A tool for documenting the steps of EBP www.epiq.co.nz<br />
    41. 41. EBP Steps 4 and 5<br />Ask a focused question.<br />Access (systematically search for) epidemiological evidence to help answer question.<br />3. Appraise evidence AND then meta-analyse (systematically review) ALL relevant valid evidence.<br />4. Apply the best evidence:<br />amalgamate the valid evidence with other relevant information to make a good decision; and<br />b. ACT on your decision<br />5. AUDIT your practice (i.e. check your actual practice – ‘actions’ - against ‘best’ evidence-based practice)<br />
    42. 42.
    43. 43. X-factor: making evidence-based decisions<br />Evidence including clinical epidemiology<br />Clinical / health considerations<br />Patient / community preferences<br />Policy issues<br />expertise: ‘putting it all together’ the art of practice<br />
    44. 44. How can busy people do EBP?<br />
    45. 45. 1. use evidence-based “electronic decision support systems”<br />
    46. 46. 2. use evidence-based guidelines (& EB text bks?)<br />
    47. 47. 3. use Systematic Reviews<br />MEDLINE 2006/day<br />1,600 articles<br /> 95 trials<br /> 4 reviews*<br />*Cochrane Database of<br />Systematic Reviews (SR)<br />per day<br />1 new SR<br />1 updated SR<br />It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials.<br />Bastian, Glasziou, Chalmers, (accepted for PLoS 2009)<br />
    48. 48. Outline- second half<br />Take the health statistic literacy challenge<br />What is evidence-based practice?<br />What skills do you need?<br />Evidence suggests that we can reduce heart attacks and strokes in New Zealand by half<br />The PREDICT collaboration: the use of informatics to put evidence into practice<br />
    49. 49. NZ CVD guidelines 2003<br />
    50. 50. NZGG CVD guidelines in a nutshell<br />Plus adjustments for ethnicity, fam Hx, diabetes, <br />>15% or prior CVD event<br />< 10%<br />10-15%<br />Intensive CVD risk management- <br />patient specific lifestyle advice + drug therapy<br />CVD general advice only<br />Specific lifestyle assessment and advice<br />Select people for <br />risk assessment<br />
    51. 51. NZGG CVD guidelines in a nutshell<br />If we did this we could prevent/delay more than 50% of the CVD events in the next 5 years<br />
    52. 52. Problems<br />
    53. 53. Problems with risk assessment tool<br />Framingham CVD equation -based on ~5200 patients starting originally in 1948 through 1960s and 70s in Framingham MA <br />validated for New Zealanders as a whole population<br />accuracy unknown for Māori, Pacific and Indian<br />accuracy unknown for those with a family history<br />limited number of people with diabetes <br />developed for those aged 30-74yrs<br />
    54. 54. How often do you use CVD risk charts?(GPs n=500 response rate 83%)<br />Arroll et al. NZ Family Physician 2002:29:177-83<br />
    55. 55. PREDICT-CVD Evaluation Study 2004: <br />Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8 <br />
    56. 56. Treatment gaps in 1º care in NZ<br />Rafter et al NZMJ 2005<br />Electronic records of 25,384 men over 45 yrs & women over 55 yrs visiting GP in 2000<br />Dunedin RNZCGP research data base<br />28%<br />25%<br />18%<br />
    57. 57. TM<br />1998-2002<br />a web-based clinical decision support system <br />
    58. 58. Evidence-based care for populations<br />Anonymised linkage to CVD outcomes, drug dispensing & laboratory results<br />Evidence-based care for individuals<br />
    59. 59. Acknowledgements- PREDICT<br />Research team- Rod Jackson, Tania Riddell, Andrew Kerr, Romana Pylypchuk, Roger Marshall, Cam Kyle, Elizabeth Robinson, Sue Crengle, Dale Bramley, Tim Kenealy, Raina Elley, Shanthi Ameratunga, Jeff Harrison, Paul Drury, Dudley Gentles<br />General practitioners, practice nurses and patients: ProCare Network North, Auckland and Manukau, HealthWest, Te Tai Tokerau, Manaia, Kaipara Care, TihewaMauriora and Whangaroa PHOs.<br />PREDICT developed by a collaboration of clinical epidemiologists at the University of Auckland, IT specialists at Enigma Publishing Ltd, clinicians and members of primary health care organisations, New Zealand Guidelines Group, National Heart Foundation, Diabetes New Zealand, Diabetes Auckland, several district health boards and the Ministry of Health.<br />PMS companies- MedTech, My Practice, Profile<br />Funding: The PREDICT research project has support by HRC grants 03/183 and 08/121 from the Health Research Council.<br />
    60. 60.
    61. 61. Break down the complexity of guidelines into tailored management for a patient<br />
    62. 62. PREDICT in PHOs Recruitment <br />> 200,000<br />May 2011<br />
    63. 63. Impact of electronic decision support in 1o care<br />Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8 <br />
    64. 64. Impact of electronic decision support in 1o care<br />Wells S et al. Eur J Cardiovasc Prev Rehab 2008;15:173-8 <br />
    65. 65. Impact on documented CVD risk assessment<br />estimate<br />*<br />*<br />* Wells et al. Eur J CardiovascPrev Rehab 2008; 15:173–178<br />
    66. 66. 50% CVD events occur in small % of population<br />High risk<br />CVD events<br />Sue Wells PhD Auckland 2009<br />
    67. 67. But we need to improve our risk prediction<br />CVD events<br />Predicted risk<br />
    68. 68. Communicating risk<br />I give you six months or 600 miles<br />
    69. 69. CVD risk = abstract concept<br />Probability of having a symptomatic CVD event in next 5 or 10 years<br />
    70. 70. Your CVD risk is 15%<br />If you stop smoking you can go from yellow to green!<br />out of 100 people like you 15 are predicted to have a heart attack or stroke in the next 5 years<br />out of 100 people like you 85 won’t have an event in the next 5 years<br />Communicating CVD Risk- 1990s-2000s<br />
    71. 71. A problem with short-term CVD risk communication: case history<br />35 yr old Clarke Kent, smoker, BP 150/80mmHg, TC/HDL 5.7, no diabetes, sedentary, abdominal obesity<br />
    72. 72. 5-yr CVD risk is 5% = mild<br />But we know that with these risk factors longer-term risk must be high. <br />Problem – false reassurance<br />
    73. 73. Telling CVD risk story in another way<br />http://www.heartfoundation.org.nz/index.asp?pageID=2145881453<br />
    74. 74. Acknowledgements<br />National Heart Foundation<br />Enigma Publishing Ltd<br />Our team<br />Andrew Kerr, Stewart Eadie, Chris Wiltshire, Andy Biggs, Andy McLachlan, Rod Jackson<br />
    75. 75. Telling the story<br />
    76. 76. Telling the story: Relative risk<br />
    77. 77. Telling the story: Arterial Age or Heart Age<br />
    78. 78. Telling the story: long term risk <br />
    79. 79. Telling the story: Risk modification<br />
    80. 80. consumer version 2010<br />http://www.knowyournumbers.co.nz/your-heart-age-forecast.aspx<br />
    81. 81. Outline- game of 2 halves<br />Take the health statistic challenge<br />What is evidence-based practice?<br />What skills do you need?<br />The PREDICT collaboration: the use of informatics to put evidence into practice<br />Thank you!<br />

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