1. Introduction to Health Care and Public Health in the U.S.
Evolution of and Trends in Health Care in the U.S.
Welcome to Introduction to Health Care and Public Health in the U.S.: Evolution of and Trends in Health Care in the U.S. This is lecture a.
The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S.
Lecture a
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2. Evolution of and Trends in Health Care in the U.S. Learning Objectives
Describe the application of evidence-based medicine and clinical practice guidelines (Lecture a, b)
Discuss quality indicators in medicine (Lecture c)
Describe the patient-centered medical home and other models of care coordination (Lecture d)
The learning objectives for this unit, the Evolution of and Trends in Health Care in the U.S., are to:
Describe the application of evidence-based medicine and clinical practice guidelines;
Discuss quality indicators in medicine;
And, describe the patient-centered medical home and other models of care coordination.

3. Evidence-Based Medicine - 1
1996: David Sackett et al.
“The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.”
EBM integrates
“…individual clinical expertise with the best available external clinical evidence from systematic research.”
This lecture will discuss evidence-based medicine, or EBM. David Sackett and associates, in an editorial in the British Medical Journal in 1996, discussed EBM and defined it as, “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.”
EBM integrates “individual clinical expertise with the best available external clinical evidence from systematic research, to provide optimal care to patients.”

4. Evidence-Based Medicine - 2
Method that helps clinicians make sound decisions about patient care
Latest references (Guyatt, 2014; Guyatt, 2015)
Combines
Clinician skills
Patient values
Evidence from research
Evidence-based practice provides clinicians with a methodology they can use to make sound decisions about patient care. The most recent manuals for applying EBM are a handbook and reference authored by Guyatt et al.
EBM combines clinician skills, which are a 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; into a model methodology of practice that aims to allow superior care to be delivered.

5. Clinical Practice Guidelines
Evidence-based recommendations
1990 Institute of Medicine (IOM) Committee advised the Public Health Service
“Systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances”
One way to disseminate evidence-based best practices is to generate clinical practice guidelines.
In 1990, the Institute of Medicine, or IOM, published, “Clinical Practice Guidelines: Directions for a New Program.” They defined clinical practice guidelines as, “systematically developed statements to assist practitioners and patients making decisions about appropriate health care for specific clinical circumstances.

6. Clinical Decision Support, CDS - 1
“...a clinical system, application or process that helps health professionals make clinical decisions to enhance patient care”
“Active knowledge systems that use two or more items of patient data to generate case-specific advice”
Greenes, 2014
Evidence-based medicine can also be implemented 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. A recent reference about the state of the art in CDS is edited by Greenes et al.

7. Clinical Decision Support, CDS - 2
Some functions of decision support systems:
Administration
Management of complexity
Cost control
Decision support: Supporting clinical reasoning, promoting use of best practices
CDS systems can have a number of functions in different domains. In the administrative domain, CDS systems can help with billing, coding, referrals, or documentation. 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 promoting the use of best practices.

8. Hierarchy Of Evidence Literature is ranked in a hierarchy
Higher on the ladder of evidence = “better” quality of the study
Why have a hierarchy?
Allows grading of studies with different methodologies
Provides a framework to be used during development of systematic review protocols
Method of hierarchical ordering
Classify information according to effectiveness, appropriateness and feasibility
We have established some of the basic guidelines for evidence-based medicine, 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 trying to interpret information with respect to patient care.

9. Hierarchy of Study Designs
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 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 is comprised of subjects where some intervention takes place and they are subjected to a change. The control groups are groups 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 a higher 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. Neither the subjects, nor the experimenters, know which group subjects are 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.
9.1 Chart: The Hierarchy of Study Designs

10. Some Terms Defined
Bias: Inaccuracies that produce a false pattern of differences
Blinding: Attempt to eliminate bias by hiding the intervention
Validity: The extent to which a variable or intervention measures what it is supposed to measure
There are some common terms that are used when discussing 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. Obviously some interventions, such as surgery, cannot be blinded from the patient or clinician, but can be blinded from researchers investigating study 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.

11. Systematic Reviews - 1
Search and analysis of the medical literature is conducted systematically using specific methods
May use quantitative methods such as meta-analysis to summarize the results
The Cochrane Collaboration is an international collaboration that conducts systematic reviews
Other groups carry out systematic reviews
Many published in the medical literature
Often there are many studies on a given topic that provide evidence for clinical decisions. One method for aggregating all this evidence is to conduct a systematic review.
In a systematic review, authors systematically and exhaustively search the medical literature for the topic under discussion. Sometimes a systematic review will use quantitative methods such as meta-analysis to combine the results from many different studies as if they were a single study.
One of the most prolific producers of systematic reviews is the Cochrane Collaboration. They are a worldwide association of researchers and clinicians who create and maintain systematic reviews, with periodic updates to keep them current and relevant. There are other research groups that carry out systematic reviews, and many of them are published in medical journals.

12. Systematic Reviews - 2 9.2 Chart: Oxford EBM Hierarchy
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 on expert 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.
9.2 Chart: Oxford EBM Hierarchy

13. PICO Questions P = Patient I = Intervention C = Comparison
What are the characteristics of the patient/population/problem?
I = Intervention
What is the intervention, prognostic factor or exposure?
C = Comparison
What is the main alternative to compare with the intervention?
O = Outcomes
What is the measurement or improvement?
When clinicians and researchers seek evidence for clinical practice, they often ask questions with respect to the medical literature in a format that has been described as “pico,” or P-I-C-O where “P” stands for “patient,” “I” for “intervention,” “C” for “comparison,” and “O” for “outcomes.”
The first part of a well-structured question is about the patient, or “P”. What are the characteristics of the population of patients being studied and the problem at hand?
The second part is about intervention, or “I”. What is the intervention or prognostic factor or exposure that is to be considered?
The third part is about comparison or “C”, what are 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 intervention?

14. Evolution of and Trends in Health Care in the U.S. Summary – Lecture a
Definitions for EBM
Clinical practice guidelines
Clinical decision support
Hierarchy of evidence
Systematic reviews
This concludes lecture a of The Evolution of and Trends in Health Care in the U.S.
In summary this lecture covered: definitions of EBM, clinical practice guidelines, clinical decision support, hierarchy of evidence, and systematic reviews.

15. Evolution of and Trends in Health Care in the U. S
Evolution of and Trends in Health Care in the U.S. References – 1 – Lecture a
References
Clinical Decision Support. (n.d.). Retrieved January 31, 2017, from HIMSS website:
Evidence-Based Practice Resources. Retrieved January 31, 2017, from University of North Carolina at Chapel Hill - Health Sciences Library, Tutorials website:
Greenes, R (2014). Clinical Decision Support - The Road to Broad Adoption, 2nd Edition. Amsterdam, Netherlands, Elsevier.
Guyatt, G, Rennie, D, et al., Eds. (2014). Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, Third Edition. New York, NY, McGraw-Hill.
Guyatt, G, Rennie, D, et al., Eds. (2015). Users' Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice, Third Edition. New York, NY, McGraw-Hill.
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16. Evolution of and Trends in Health Care in the U. S
Evolution of and Trends in Health Care in the U.S. References – Lecture a
References
Sackett, D. L., Rosenberg, W. M., Muir Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996, January 13). Editorial - Evidence-Based medicine: what it is and what it isn't. BMJ, 312(71), Retrieved from
Charts, Tables, Figures
9.1 Chart: The Hierarchy of Study Designs – adapted from Oxford Center for Evidence-based Medicine - Levels of Evidence. (2009, March). Retrieved February 1, 2017, from Center for Evidence Based Medicine website:
9.2 Chart: Oxford Center for Evidence-based Medicine - Levels of Evidence . (2009, March). Retrieved December 6, 2011, from Center for Evidence Based Medicine website:
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17. Introduction to Health Care and Public Health in the U
Introduction to Health Care and Public Health in the U.S Evolution of and Trends in Health Care in the U.S. Lecture a
This material 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 90WT0001.
No Audio
Health IT Workforce Curriculum Version 4.0