2. •Evidence based medicine is the trio of good science, clinical excellence, and
patient focus
•It is undertaken by the five steps of:
Asking questions
Acquiring information
Appraising the quality of evidence
Applying the results
Assessing performance
•Simple skills in focusing questions can be learnt easily
•Basic rules of appraisal can greatly improve your ability to critique the
clinical literature
•Simple maths, not complicated statistics, can help you describe the results
of scientific studies more clearly
3.
4. Quality of Health Care Services in
Pakistan & United States of America.
5. • Health Care Professionals
• Health Care Settings
• Financial aspects
• Awareness of health
• Impacts on community health.
Factors
6. • Attracts best minds from whole world.
• Career opportunities more than rest of the
world.
• Private & Public Sectors both open.
• Still areas of deficiency exist geographically as
well as per specialty.
• Immigration policies to retain.
• Continuous Medical Education programs.
• New Ideas respected.
Healthcare Professional in USA.
7. • More than 110 medical school.
• Still severe shortage of doctors and nurses.
• 90% from best medical schools emigrate to
western world, Australia, Middle east.
• Gaps are filled by Russian, Chinese and central
Asian trained doctors.
• Unsatisfied financially as well as career wise.
• Nepotism Law&Orders issue make it worse.
• Always looking for private practice.
Healthcare Professionals in Pakistan.
8. • University Hospitals.
• State hospitals.
• Community Hospitals.
• Veteran Affairs Hospitals.
• Private Hospitals.
• Diagnostic Centers.
• Research Centers.
• Specialty Institutes.
Healthcare Settings in USA
9. • Teaching Hospitals.
• District Head Quarter Hospitals.
• Tehsil Head quarter hospitals.
• Rural Health Centers.
• Basic Health Units.
• Military Hospitals.
• Private Hospitals.
Health Care Settings in Pakistan
10. • Insurance based practice.
• Private practice.
• Salary based practice.
• Share practice.
Financial Aspects in USA
11. • Government Salary.
• Private Practice.
• No Insurance.
• Share practice less liked.
Financial Aspects in Pakistan.
12. • Health Education Programs.
• Print Media
• Electronic Media.
• Social Media.
• General awareness.
• Companies imitative programs.
• Research Programs.
• Employer regulatory programs.
Awareness about health in USA
13. • No official Screening program.
• Media campaign are mostly centered on
alternative care.
• Companies conduct hidden drug trials.
• No participation by community.
• Generally low education level.
• Health is a least priority by government and
community both.
Awareness about Health in Pakistan
14. • Generally healthy community.
• Average age longer.
• Working age is longer.
• Diseases diagnosed at earlier stage.
• More productive life style.
• Independent living supported.
• Financially secured.
Impacts on Community Health in USA
15. • Generally poor health in rural communities.
• Diseases present at advanced stage.
• Financially not secured so look for
government or private support.
• Controllable infections leads to worse
outcome.
• TB is still a major burden.
• No follow up exits when treated.
Impacts on Community health in
Pakistan
16. • For Government:
• Plan with more finances for health care
professionals and healthcare setting.
• Start medical insurance schemes.
• Emphasize on health education.
• For Communities:
• To focus on personal health.
• Take part in screening programs.
• Keep on investing in future.
• Adopt Healthy Life style.
Recommendation
17. • Comparison between advanced world and
developing countries gives you to understand
the factor lacking in development phases.
• Health Care Quality Control programs should
be given more space than just provision of
health care services.
• Professional trained in health care quality
programs should keep on looking new
strategies to develop subjective & objective
tools for evaluation.
Conclusion
18. FSU College of Medicine 18
The EBM Process
“The practice of evidence-based medicine is a process of lifelong, self-
directed, problem-based learning in which caring for one's own patients
creates the need for clinically important information about diagnosis,
prognosis, therapy and other clinical and health care issues.”
(Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship
education. Am J Med. 1997 May;102(5):427-32.)
19. FSU College of Medicine 19
The EBM Process
The patient 1. Start with the patient -- a clinical problem or question
arises out of the care of the patient
The question 2. Construct a well built clinical question derived from the
case
The resource 3. Select the appropriate resource(s) and conduct a search
The evaluation 4. Appraise that evidence for its validity (closeness to the
truth) and applicability (usefulness in clinical practice)
The patient 5. Return to the patient -- integrate that evidence with
clinical expertise, patient preferences and apply it to
practice
Self-evaluation 6. Evaluate your performance with this patient
20. FSU College of Medicine 20
Constructing A Clinical Question
P
patient
I
intervention
C
comparison
O
outcome
Who? What?
Alternative
Intervention?
Outcomes
“How would I
describe a group
of patients
similar to this
particular
patient?”
”Which
treatment, test
or other
intervention?”
“Compared to what
other treatment, test,
or perhaps compared
to doing nothing”
What is the
patient oriented
outcome – better
prognosis?
Higher rate of
cure? Etc.?”
21. FSU College of Medicine 21
Examples
P I C O
Kids with acute otitis
media -2-4 y/o
Antibiotics
No treatment except
acetaminophen
for pain/fever
No pain after two
days?
Adult with
microhematuria
IVP CT scan
Diagnostic accuracy
(Predictive value or
likelihood ratio)
Adult patients <70 TIA No TIA
Rates of CVA within
90 days
Healthy adolescents
Routine
scoliosis
screen
No screening –
evaluate only if
problems
Pain, disability, need
for intervention
22. Why EBP?
• To improve care
– To bridge the gap between research & practice
– “Kill as few patients as possible” (O. London)
– A new treatment might have fewer side effects.
– A new treatment could be cheaper or less invasive
– A new treatment may be necessary in case people
develop resistance to existing therapies, etc.
• To keep knowledge and skills current (continuing
education)
• To save time to find the best information
23. How does EBP help?
A patient comes to a clinic with a fresh dog bite. It looks
clean and the nurse and patient wonder if prophylactic
antibiotics are necessary. The nurse searches PubMed and
found a meta analysis indicating that the average infection
rate for dog bites was 14% and that antibiotics halved this risk
to 7%.
• For every 100 people with dog bites, treatment with antibiotics will
save 7 from infection
• Treating 14 (NNT) people with dog bites will prevent 1 infection
• You explain these numbers to the patient along with possible
consequences and patient decides not to take antibiotics.
On a follow up visit you find out that he did not get infected.
Glasziou P, Del Mar C, Salisbury J. EBP Workbook, 2nd. ed. BMJ Books, 2007.
24. What are some Barriers for EBP?
• Overuse, underuse, misuse of evidence
• Time, effort, & skill needed
• Access to evidence
• Intimidation by senior clinicians
• Environment not supportive of EBP
• Poor decision making
25. The 5 Step EBP Process
Ask
Access
AppraiseApply
Assess
26. Health care professionals
• a person who by education, training,
certification, or licensure is qualified to and is
engaged in providing health care.
27. What kinds of clinical uncertainty
do HCP face?
• Interventions
– Therapy
– Prevention
– Targeting
– Timing
• Diagnosis
• Communicating risks and
benefits
• Referral
• Service Delivery/Organisation
One choice every 10 minutes in
acute care
28. Six challenges for health care
organizations
• 1. Design seamless, coordinated care
• 2. Make effective use of IT, including automating
patient records
• 3. Manage knowledge so that it is delivered into
patient care
• 4. Coordinate care across patient conditions,
services, and settings over time
• 5. Advance the effectiveness of teams
• 6. Incorporate measurement of care processes and
outcomes into daily practice
29. Process in creating collective organizational commitment of
•Quality improvement.
• Organizational analysis.
•Self-assessment.
•Strategic formulation of the organizational development
planning, Human resources development.
•Team work and service systems focusing on patient-
oriented mindedness.
"Hospital Accreditation"
30. What is Hospital Accreditation?
"The Hospital Accreditation"approach is a concept and
practice that yields beneficial results to patients,
customers, hospital personnel, the hospital, the Faculty
of Medicine, the society and the country as a
whole.History
In 1917, the American College of Surgeons established a
set of minimum standards for hospitals.
In 1951, the American College of Surgeons joined with
several other professional associations to form the Joint
Commission on Accreditation of Hospitals.
31. Thirty years later, this voluntary accrediting body changed its name
to the Joint Commission on Accreditation of Healthcare Organizations
to more accurately reflect its scope of health services evaluation
Inadditiontohospitals,thebodyevaluatedlong-termcarefacilitieslike,
•home health agencies,
•hospices,
•clinics,
•pharmacies,
•managed care organizations and,
•healthcarenetworks.
32. JOINT COMMISSION INTERNATIONAL ACCREDITATION
(JCIA)
*Experience in accrediting health care organizations in U.S,
the Joint Commission on Accreditation of Healthcare
Organizations initiated the development of an international
accreditation program in 1998 and was fully implemented in
late 1999.
The JCIA standards, organized according to either
Patient care functions
or
Management functions.
33. BENEFITS TO ACCREDITATION
1.BENEFITS OF PATIENTS:-
Continuity of care&Safe transport
Pain management& Focus on patient safety
Patient satisfaction is evaluated
Rights are respected and protected
Access to a quality focused organization
Credentialed and privileged medical staff
High quality of care
Understandable education and communication
34. 2. BENEFITS FOR THE STAFFS:-
Improves professional staff development.
Provides education on consensus standards.
Provides leadership for quality improvement within medicine
and nursing.
Increases satisfaction with continuous learning, good working
environment, leadership and ownership.
35. 3. BENEFITS FOR THE HOSPITAL:-
Improves care.
Stimulates continuous improvement.
Demonstrates commitment to quality care.
Raises community confidence.
Opportunity to benchmark with the best.
4. BENEFITS TO THE COMMUNITY:-
Quality revolution
Disaster preparedness
Epidemics
Access to comparative database
37. References
• Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it
isn’t. BMJ 1996;312(7023):71-2.
• [Pubmed]
• Lau AYS, Coiera E. How do clinicians search for and access biomedical literature to answer clinical
questions? Medinfo 2007;12(Pt 1):152-6.
• [Pubmed]
• Green ML, Ciampi MA, Ellis PJ. Residents’ medical information needs in clinic: are they being met?AJM 2000;109(3):218-23.
• [Pubmed]
• [URL]
• Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and
health care outcomes. Cochrane Database of Systematic Reviews: Reviews 2006 Issue 2 John Wiley & Sons Ltd, Chichester,
UK.
• [Pubmed]
• Walton RT, Harvey E, Dovey S, Freemantle N. Computerised advice on drug dosage to improve prescribing practice. Cochrane
Database of Systematic Reviews: Reviews 2001 Issue 1 John Wiley & Sons Ltd, Chichester, UK.
• [Pubmed]
• O’Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on
professional practice and health care outcomes. Cochrane Database of Systematic Reviews: Reviews 2001 Issue 1 John Wiley
& Sons Ltd, Chichester, UK.
• [Pubmed]
• Thomas L, Cullum N, McColl E, Rousseau N, Soutter J, Steen N. Guidelines in professions allied to medicine. Cochrane
Database of Systematic Reviews: Reviews 1999 Issue 1 John Wiley & Sons Ltd, Chichester, UK.
