Introduction to Healthcare in the US: The Evolution and Reform of Healthcare in the US
Audio Transcript
Slide 1
Welcome to Introduction to Healthcare in the US: The Evolution and Reform of Healthcare in the US. This is Lecture a.
The component, Introduction to Healthcare in the US, is a survey of how healthcare and public health are organized and services are delivered in the US.
Slide 2
By the end of this unit, The Evolution and Reform of Healthcare in the US, students will be able to:
- describe evidence-based medicine, clinical practice guidelines, and quality indicators in medicine;
- describe the patient-centered medical home model; and
- discuss the key issues driving healthcare reform in the US.
Slide 3
This lecture will discuss evidence-based medicine.
We will first begin with the definition of “evidence-based practice”, EBP. David Sackett [sack-eht] and his associates, in an editorial in the British Medical Journal in 1996, discussed evidence-based practice, and defined it as, “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.”
Evidence-based practice integrates individual clinical expertise with the best available external clinical evidence from systematic research, in order to provide optimal care to patients.
Slide 4
Evidence-based practice provides clinicians with the methodology so that they can make sound decisions about patient care. This method combines clinician skills, which isa combination of training and experience; patient values, which are the concerns and expectations of the patient; and evidence from research, which involves clinically relevant studies that are conducted using sound methodology; and combines them into a model methodology of practice that allows superior care to be delivered.
Slide5
One way to disseminate evidence-based best practices is to generate practice guidelines.
In 1990, the Institute of Medicine published, “Clinical Practice Guidelines: Directions for a New Program” to advise the Public Health Service on clinical practice guidelines. They defined practice guidelines as, “systematically developed statements to assist practitioners and patients making decisions about appropriate healthcare for specific clinical circumstances.
Slide6
Evidence-based practice can also be achieved by using clinical decision support. So, what is clinical decision support, or CDS?
CDS is a clinical system, application, or process that helps health professionals make clinical decisions to enhance patient care. Clinical Decision Support Systems are active knowledge systems that use two or more items of patient data to generate care-specific advice.
Slide 7
Clinical decision support systems can have a number of functions in different domains. In the administrative domain, CDS systems can help with billing, coding, referrals, or documentations. These systems can also help to manage complexity by tracking orders, referrals, and preventive care services. They can also assist with cost control measures by monitoring medication orders, and avoiding duplicate or unnecessary tests.
The classic definition of clinical decision support, however, is a system that supports clinical reasoning that promotes the use of best practices.
Slide 8
We have established some of the basic guidelines for evidence-based practice, and now we are going to look at the medical literature, to see if we can organize it, as an evidence hierarchy.
There are a number of studies that are available to clinicians on any particular subject. How does the clinician decide which study is acceptable; which study is better than another? The medical literature is ranked in a hierarchy, which helps clinicians compare studies.
Think of the hierarchy as a ladder, and the higher up the ladder of evidence a study is, the better the quality of the study. A hierarchical organization allows us to rank studies according to the validity of findings.
We need a hierarchy because it allows us to grade studies that have different methodologies. It provides a framework that can be used during the development of systematic review protocols to help determine which study design is better than the other. It is one method of ordering information according to effectiveness, appropriateness, and feasibility, which are all factors that the clinician is looking for when he or she is trying to interpret information with respect to patientcare.
Slide 9
It is not the intention of this lecture to study the designs themselves in great detail, but it is advantageous to have an idea of how the hierarchical study designs are organized.
Continuing with the hierarchy ladder analogy, there are rungs in that ladder, and if we knew what those rungs signified, it would be easier to understand what a study requires, in order for it to ascend or descend down that hierarchy of evidence.
At the bottom of the ladder, the lowest rungs signify expert opinions and physiologic studies. The major disadvantage of expert opinions is that they are opinions, and they are only as good as the experts who deliver them.
One rung higher, in the hierarchical study design, are case studies. These are systematic observations without controls. What are controls? Studies that follow proper scientific methodology, and are designed to be true experiments, have two branches: the intervention group and the control group. The intervention group iscomprised of subjects where some intervention takes place and they are subjected to a change. The control groups are a group of subjects who do not undergo the intervention.
Case studies are systematic, but they are observational studies, and they do not have true controls. One rung higher are case control studies. These are systematic studies. They do have controls, but they are defined by the outcome of interest. They are also known as retrospective studies because the outcome defines the analysis of data.
One rung higher are cohort studies. These are true experiments with controls and intervention, and they are defined by exposure to the factor and the intervention and the control group. The two cohorts are followed prospectively over time and data is then analyzed.
Then, at the highest level of the hierarchy of study designs are randomized controlled trials. In these studies there is an intervention group, and there is a control group, but both groups are randomized. The subjects, as well as the experimenters, do not know which group the subject is participating in. There is an equal probability of assignment of subjects to either the intervention group, or to the control group, and this makes the study more robust than cohort studies, case control studies, or other types of designs that are lower in the hierarchy of evidence.
Slide10
There are some common terms when discussing evidence-based practice and evidence-based medicine which we will define here.
The first is “bias.” These are inaccuracies that produce a consistently false pattern of differences between observed and true values.
The second term is “blinding.” Blinding is an attempt to eliminate bias by hiding the intervention from the patient, the clinician, and even the researchers who are interpreting the results.
The third term that is often encountered is “validity", or the extent to which a variable or intervention measures what it is actually supposed to measure.
Slide 11
There are two ways to review the medical literature. The first is an unsystematic method. The topic under discussion is searched for online, or using the tools available at a library, and some results are generated and these results are accepted as the truth.
In a systematic review, authors use a systematic method to search the medical literature for the topic under discussion. Sometimes a systematic review will use quantitative methods to summarize the result and pull data from many different studies. This is a mature analysis of the subject matter.
Systematic reviews can be conducted via journal clubs or by data mining. A good example of systematic reviews can be found in the Cochrane [kawk-rihn] Collaboration. This is a worldwide association of researchers and clinicians who create and maintain systematic reviews ofthe medical literature, and curate these reviews to keep them current and relevant.
Slide 12
Let’s recall the hierarchy of study designs or the ladder of studies. Stronger studies, such as randomized controlled trials, float toward the top of the ladder, while weaker studies based onexpert opinion, fall toward the bottom. Systematic reviews of a particular study design are considered stronger than individual studies. So for example, a systematic review of randomized control studies would be the highest rung on the ladder.
A systematic review of cohort studies would be higher on the ladder than an individual cohort study. A systematic review of case control studies would be higher than an individual case control study.
Case series and expert opinions are usually not combined in a systematic review.
Slide13
When clinicians and researchers operate under an environment of evidence-based practice, they often ask questions with respect to the medical literature in a format that has been described as “pico,”[pee-koh] or P-I-C-O where “P” stands for “patient,” “I” for “intervention,” “C” for “comparison,” and “O” for “outcomes.”
Here is an example of the PICO [pee-koh] format. A patient walks into a clinician’s office with a medical problem. The clinician feels that they can answer the patient’s questions by reviewing the literature and practicing medicine in an evidence-based fashion. They come across a question with respect to a study and they feel that they might answer that question best by applying the PICO [pee-koh] format.
The first type of question that a clinician asks is about the patient, or “P”. What are the characteristics of the population of patients being studied and the problem at hand?
The second type of question asked, upon examining the study, is about intervention, or “I”. What is the intervention or prognostic factor or exposure that is to be considered?
The third type of question is about comparison or “C”, where the clinician looks at the main alternatives that need to be compared with the intervention.
And then finally, “O” for “outcomes.” What is the measurement or improvement that is suggested by the study?
If the clinician is satisfied that these questions are answered appropriately, they may then apply that piece of evidence from the medical literature to solving the patient’s problems.
Slide 14
This concludes Lecture (a) of The Evolution and Reform of Healthcare in the US. In summary this lecture covered: definitions for EBP, practice guidelines, clinical decision support, hierarchy of evidence, and systematic reviews.
Slide 15 (Reference slide)
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Health IT Workforce CurriculumIntroduction to Healthcare and Public Health in the US1
Version 3.0/Spring 2012The Evolution and Reform of Healthcare in the US
Lecture a
This material (Comp1_Unit9a) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.