Decisions based on health economic analysis

@#Family and community practitioners sometimes will decide on what community-oriented interventions to propose and implement. The cost and effectiveness of such interventions are often debated by policy makers. A set of formal, quantitative methods for comparing alternative strategies in resource use and expected outcomes is known as health economic analysis. This article presents a tool to help family and community practitioners decide on the cost and effectiveness of such interventions.

Informing patients about disease prognosis

@#Prognosis refers to the development of possible “outcome” of disease i.e., survival in patient with cancer. Prognostic factors are characteristics of a particular patient that can be used to predict that patient’s eventual outcome i.e., patients with advanced TNM cancer stage may have lower probability of survival than those with less advance TNM cancer stage. Thus, prognosis is a prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Family physicians are often asked by patients about the probable course of their disease, they need skills on how to inform patients about this.

Risk factors that patients should avoid

@#A risk factor increases a person’s susceptibility to developing a disease. This can be a particular patient characteristic (e.g., obesity for heart disease), patient behavior (e.g., cigarette smoking for lung cancer), or a specific drug intervention (e.g., steroid intake for myopathy). Observational studies like case-control or cohort study designs are commonly used when evaluating the harmful effect of an exposure. Family and community medicine practitioners should always take the opportunity to advice patients regarding these risk factors to promote wellness and enhance primary care.

Treatment decisions based on clinical trials

@#The randomized Controlled Trial is the standard design to prove the effectiveness of drugs or other forms of interventions. In this type of clinical research, individuals are randomly assigned (randomization) to either of the two or more groups, one with the intervention the other without the intervention being tested or another intervention. When done properly, it can provide the best evidence of effectiveness

Using a systematic review and meta-analysis for clinical decision

@#A systematic review summarizes the results of a number of individual studies that address a focused clinical question. It may be accompanied by a meta-analysis, which is a quantitative method of combining the results of all these studies in order to come up with a summary statistic of the overall effect of an intervention. Single studies may be unrepresentative of the total body of evidence, that is why combining the results of several studies in a systematic review increases precision, provides better estimates of effect, and includes a greater range of patients thus facilitating better clinical decision making. This must be done in a systematic and reproducible manner.

Using a clinical practice guideline for making clinical decisions

@#Clinical practice guideline is defined as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options”. It includes recommendations that are intended to optimize patient care. They are the best source of evidence for busy clinicians and may be the most efficient type of evidence to guide decision making in family practice.

Decisions on what diagnostic tests to request

@#In Evidence-based Family Practice, requesting a diagnostic test should be based on two issues. First is whether the test is accurate and thus will significantly help in clinical decision making. Second is whether the test is appropriate and acceptable for the patient. This involves careful discussion of risks and benefits based on the physician’s knowledge and experience and the patient’s values and preferences.

Considering the probable differential diagnosis

@#Differential diagnosis is the method of limiting the possible causes of the patient’s symptoms before making a final diagnosis. For experienced clinicians, it is the process of using clinical experience alongside the patient’s symptoms and test results to prioritize the list of possibilities until the diagnosis can be identified with confidence.

Shared clinical decision making

@#Most patients want to play an active role in their own health care. There is now a movement from medical paternalism to patient-centered care in the consultation process that is based on the therapeutic alliance and negotiation between the doctor and patient, aptly named “shared decision-making” (SDM). It is a process where doctors work together with patients, including their families and caregivers, to select tests, treatments, management, or support packages, based on clinical evidence and personal informed preferences, health beliefs, and values. Successful implementation of SDM is associated with improved quality of consultations, favorable patient-reported health outcomes, and increased patient and doctor satisfaction. Patients are empowered to make proactive health decisions resulting in decreased anxiety, faster recovery, increased treatment compliance, and reduced unnecessary health care expenditure. There are multiple existing models in facilitating SDM. Two simple and easyto-follow models are the “three-talk model” and “S.H.A.R.E. approach.” The three-talk model endorsed by the NICE divides the SDM consultation into three steps, namely: team talk (explaining the need to consider treatment options as a team), option talk (describing the alternatives in more detail, and making use of patient decision aids [PDA] whenever appropriate), and decision talk (helping patients explore and form their personal preferences). On the other hand, the S.H.A.R.E. approach promoted by the Agency for Healthcare Research and Quality (AHRQ) is a five-step SDM consultation process that includes exploring and comparing the benefits, harms, and risks of each treatment option through meaningful dialogue about what matters most to patients.

Communicating health information to patients

@#In evidence-based family practice, we place great emphasis on shared decision-making with the goal of helping patients make informed decisions about their care and subsequently to improve patient health outcomes. Appropriate decision-making in family practice is affected by information delivery and patient education and interpersonal clinician-patient communication. Effective communication is essential for improved health outcomes, adherence to treatment and patient satisfaction. Informed patients are more likely to participate actively in their care, make wiser decisions, come to a common understanding with their physicians, and adhere more fully to treatment. Communicating evidence can transform a physician-dominated relationship into one that is patient-centered relationship. Techniques to improve patient communication have been associated with greater satisfaction especially when patients are involved in the decision-making process. Research about medical evidence in a particular clinical encounter has shown equally important elements: a) expertise of the provider; b) medical evidence; and c) the patient’s preferences, goals and concerns. These elements though separate, but when combined, results to a well-informed medical decision emphasizing the role of medical evidence in future communication and patient-engagement activities. Models of patient-centered communication are recommended.

Critical appraisal

@#Critical appraisal is the process of reading published research to make a judgement on its scientific value (validity), and to consider how its results can be applied in family and community practice (applicability). There are four main elements of critical appraisal in EBFP i.e., relevance, validity, results, and applicability. Some family practitioners are not so comfortable with appraisal because of their poor background in research. But we developed the guide questions for critical appraisal simple and provide advice on what and where to look for it in the published evidence.

Searching for the right evidence

@#Literature search is a systematic and well-organized search from published data to identify good quality references on a specific topic. The search can be a simple involving just a couple of sources and done within an hour or so. It can also be comprehensive and thorough where it involves multiple sources. However, in EBFP main purpose of a literature search is to obtain only a few available but relevant and high-quality evidence that can help the family practitioner make a clinical decision. The first step in making evidence-based decision is to convert the clinical problem for decision-making into a clinical question. It should be phrased in a simple sentence that is relevant and specific to the clinical problem, interesting enough to warrant searching for the answer and will likely obtain the article to answer the question. Based on the formulated clinical question discussed previously, identifying the key terms to be used for the search is the next step. The key terms are usually based on the PICO or its variants, POEM, SPICE or ECLIPSE elements in the clinical question. Since it will only be a simple search in EBFP, it is recommended to look in PubMed. PubMed is the online version of Index Medicus produced by the US National Library of Medicine (NLM). If the article is not available in PubMed, Google Scholar is another free web search engine that indexes the full text of scholarly literature across an array of publication formats and disciplines. Other advice for an efficient literature search is also discussed.

Introduction to evidence-based family practice

@#While the definition of EBM can be straightforward in other medical field, family and community medicine practitioners take on very different roles in different health systems. Despite the challenges presented, EBM is still necessary in family and community practice. Family and community medicine practitioners must be able to obtain, assess, apply and integrate new knowledge based on available evidence throughout their professional life. From the definition of EBM and the nature of family practice described previously, we propose to define “Evidence-based Family Practice as the conscientious and judicious use of the current, relevant, applicable and best available evidence in making shared clinical decisions for patient care. Such decisions must account for the capacity and setting of the family practitioner and patient preference”. The proposed steps are: 1) Framing the Clinical Problem, 2) Searching for the Evidence, 3) Critical Appraisal, 4) Informing the Patient About the Evidence, 5) Shared Decision Making, and 6) Evaluation of the Decision.