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Evidence Based Decision Making in Health Care

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Title: Evidence Based Decision Making in Health Care


1
Evidence Based Decision Making in Health Care
  • Antti Malmivaara, MD, PhD
  • Senior Medical Officer
  • Finnish Office for Health Care Technology
    Assessment, Stakes

2
(No Transcript)
3
Archie Cochrane
  • It is surely a great criticism of our profession
    that we have not organised a critical summary, by
    specialty or sub-specialty, adapted periodically,
    of all relevant randomized controlled trials

4
  • International non-profit organization that
    prepares, maintains, and disseminates systematic
    up-to-date reviews of health care interventions

5
Systematic review - definitions
  • Systematic review the application of scientific
    strategies in order to prevent bias with the
    purpose of systematically identify, critically
    assess and summarise all relevant studies on a
    specific topic
  • Meta-analyses a systematic review using
    statistical methods for combining and summarising
    the results of different studies

6
Evidence-based medicine
  • Sackett et al. EBM, Churchill Livingstone, 1997
  • Conscientious, explicit and judicious use of
    current best evidence in making decisions about
    care of individual patients
  • Integrates best external evidence with individual
    clinical expertise and patients preferences and
    expectations

7
Hierarchy of Evidence on Effectiveness
  • Meta-analysis of RCTs
  • systematic review of RCTs

Individual RCT
Observational studies patient-important outcomes
Basic research test tube, animal, human physiology
Clinical experience
8
Hierarchy of evidence
  • Hierarchy is not absolute.
  • Observational studies have allowed extremely
    strong inferences about the efficacy of insulin
    in diabetic ketoacidosis etc.
  • Much of the evidence regarding the harmful
    effects of therapies comes from observational
    studies.
  • The evidence may be extremely weak but there is
    always evidence.

9
Questions to be answered
  • Can it work?
  • Efficacy
  • Does it work?
  • Effectiveness
  • Should it be used, given other calls on a fixed
    budget?
  • Cost-effectiveness
  • Is it reaching those whom it should?
  • Availability

Development
EBM
Policy
Audit
10
What challenges do we face ?
Increasing need of health services as a result of
1. Population ageing 2. New technology Increasi
ng demand because of rising expectations Failure
of resources to grow as quickly as need and
demand
J.A.Muir Gray, Evidence Based Health Policy.
Churchill Livingstone, London 2002
11
As a consequence we have to 1. Promote
health 2. Prevent disease 3. Increase the
value obtained by healthcare resources

Muir Gray 2004
12
The value of the resources invested in healthcare
is maximised when no more benefit and no less
harm can be obtained by ALLOCATING or USING
resources in any other way
Muir Gray 2004
13

Better Allocation of Resources
Low

High Value

Value Healthcare

Healthcare
Better use of Resources
Muir Gray 2004
14
Doing the right things right
Allocating resources between or within
specialties or patient groups
Doing as much good and as little harm as possible
with any patient or group of patients
Muir Gray 2004
15
Evidence based healthcare
Making use of best current knowledge in 1.
Policy making 2. Public health 3. Health
service management
Muir Gray 2004
16
Health technology assessment (HTA)
  • Domains of HTA in the EUnetHTA program
  • Description of technology
  • Current use of technology
  • Effectiveness
  • Safety
  • Costs and economical evaluation
  • Organisational, societal/social, ethical, legal
    aspects

Finohta/ Kristian Lampe et al
17
Finohta's mission
  • To promote the use of evidence-based technology
    in the Finnish health care system in order to
    enhance the effectiveness and cost-effectiveness
    of health care.

18
Finohta's products
  • Full Health Technology Assessments (including
    Cochrane reviews)
  • Reviews on new technology (Managed Uptake of
    Medical Methods)
  • Rapid Reviews
  • Communication products
  • Impakti
  • Ohtanen

19
Examples of full HTA's by Finohta
  • Effectiveness of rehabilitation for children with
    cerebral palsy
  • Effectiveness of advanced life support in
    emergency medicine
  • Bariatric surgery effectiveness, cost's,
    organizational and ethical aspects
  • Cost effectiveness of evidence-based guidelines
    for antihypertensive interventions
  • Cost-effectiveness of glaucoma screening
  • Cost-effectiveness of drug eluting stents for
    coronary artery disease

20
Rapid implementation of new technology
Evaluation bypass due to rapid implementation
21
Managed Uptake of Medical Methods - by Finohta
al
  • Minna Kaila, MD, PhD, Pediatric Allergist, EPA
  • Adjunct Professor, University of Tampere
  • Senior Medical Officer, FinOHTA /STAKES
  • minna.kaila(at)iki.fi or (at)stakes.fi
  • mobile 358 50 5232021

22
MUMM is a joint venture of the 21 hospital
districts providing specialized care and Finnish
Office for Health Technology Assessment at
STAKES. The aim is to develop a structure for
critical appraisal and joint decisions in uptake
of new methods.
Efficacy (effectiveness) Safety
THE FIRST (May 2006) Intravenous laser therapy
for varicose veins MARS liver dialysis
Vacuum treatment of wounds Long antithrombotic
treatment with joint replacement surgery
and 64-multislice-CT in the diagnosis of coronary
disease.
THE SECOND (December 2006) Spinal Cord
Stimulation for chronic back pain Radiofrequency
ablation for snoring Vagus nerve stimulator
treatment for treatment resistant depression
Treatment of AMD with intravitreal anti- VEGF
injections.
23
Effectiveness and safety of endovenous laser
treatment. A systematic review.
  • Anders Albäck, Jukka Saarinen, Pekka Kuukasjärvi,
    Antti Malmivaara
  • Department of Vascular Surgery, Helsinki
    University Hospital
  • Department of Surgery, Tampere University
    Hospital
  • Finnish Office for Health Technology Assessment
    (FinOHTA)
  • Managed Uptake of Medical Methods
    MUMM-programme in Finland

24
The intervention
  • Thermoablation of the main trunc (great/small
    saphenous veins)
  • Adjuvant treatment for branches of these truncs
  • Ultrasound guidance
  • Local anaesthesia
  • Outpatient treatment

25
Studies included in the systematic review
26
CONCLUSIONS
  • No randomised trial has assessed the long-term
    effectiveness of endovenous laser treatment
    (ELT).
  • Postprocedural recovery seems to be favourable in
    comparison to traditional open surgery for
    saphenous vein reflux, but differences in
    treatment settings weaken the generalisability of
    the findings.
  • ELT seem to be a rather safe procedure.
  • No reliable cost-effectiveness data is presently
    available.

27
CONCLUSIONS
  • Managed up-take of ELT requires training of
    vascular surgeons, especially in the use of
    ultrasound guided method.
  • Patients should be informed of the evidence on
    the different treatment alternatives (surgery,
    laser, foam, conservative treatment), and of the
    scarcity of long follow-up data.

28
PERFECT PERFormance, Effectiveness and Cost of
Treatment episodeshttp//info.stakes.fi/perfect/E
N/index.htm
  • Research Consortium Stakes, five university
    hospitals and the Social Insurance Institution
  • Research Programme on Health Services Research -
    Terttu, Finnish Academy
  • FinWELL Tekes
  • The Finnish Innovation Fund
  • EUPHORIC-Consortium funded by the European
  • Commission

Unto Häkkinen, Chess, Stakes
29
Political Epidemiological Economic
Decision making
The values the public and politicians place on
benefits and harms of the options
Evidence
Choice Decision
The needs of the population other bids for
human and financial resources
Muir Gray 2004
30
Values
Decision
Evidence
Resources
JA Muir Gray Evidence Based Health Policy
Churchill Livingstone, London 2002
31
Knowledge is the enemy of disease
Muir Gray 2005
32
Thank you !
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