1. The First International Conference for Evidence-based Healthcare

2. First International Conference on Evidence-based healthcare The Inaugural Conference of the International Society of Evidence-based Health Care India International Centre, New Delhi Workshops: 6 October 2012 (Pre-Conference workshops on topics related to EBHC) Conference: 7-8 October 2012 www.isehcon2012.com

3. Who should attend? Physicians, nurses, pharmacists, chiropractors, naturopaths, involved in the implementation of evidence including frontline healthcare professionals Educators involved in teaching and training in evidence based healthcare Speakers Kameshwar Prasad, Paul Glasziou, Gordon Guyatt, Luz Letelier, Victor Montori www.isehcon2012.com

4. The second principle of evidence-based medicine changes everything Victor M. Montori, MD, MSc Professor of Medicine KER UNIT - Mayo Clinic montori.victor@mayo.edu@vmontori

5. Disclosures Relevant Financial Relationships None Off Label Usage None Relevant Financial Relationships None Off Label Usage None

6. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

7. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

8. Confidence in the estimates of risk and benefit Bias Imprecision Inconsistency Indirectness Biased reporting

9. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

10. body of evidence Trelle et al. BMJ 2011;342:c7086

11. Our confidence in estimates of risk and benefit from the body of evidence contributes to our confidence in making decisions.

12. Appropriate care

13. Care < Need Underuse Appropriate care

14. Glasziou and Haynes ACP JC 2005

15. Care > NeedCare < Need Underuse Overuse Appropriate care

16. Geographic variation in overuse Variation in overuse by procedure (n=172) Preventive services PSA 16-36% Urinalysis 37% Follow-up colonoscopy: 61% Pap smear: 58% Korenstein D, et al. Arch Intern Med 2012: 172: 171-8 Shah ND et al. NEJM 2012

17. Sources of waste and their projected growth to 2020 Berwick, D. M. et al. JAMA 2012;307:1513-1516

18. Care > NeedCare < Need Underuse Overuse Appropriate care

19. Guidelines Every patient with diabetes is a ‘coronary heart disease risk equivalent’ Every patient with diabetes should take a statin and achieve LDL < 100 mg/dL ATP III, 2004

20. Minnesota Community Measurement

21. Guideline implications ATP III For every 1000 people treated, 150 events avoided US$ per event avoided: 139k in men, 144k in women Canada For every 1000 people treated, 153 events avoided US$ per event avoided: 148k in men, 154k in women Mason J et al PLoS ONE doi:info:doi/10.1371/journal.pone.0016170.t004

22. Weymiller et al. Arch Intern Med 2007

25. >90%<20%~50% % who opted for treatment % who should take statins based on ATP III >90%

26. The evidence alone is never sufficient to make a decision. Context and patient values, preferences and goals should be considered.

27. Encounter Research

28. Care > NeedCare < Need Underuse Overuse Appropriate care

29. Care > WantCare < Want Undertreatment Overtreatment Desirable care

30. A survey of 627 US primary care clinicians Sirovich BE et al. Arch Intern Med 2011 50% of my patients get too much care 50% of primary care docs are too aggressive 60% of specialists are too aggressive 35% practice much more aggressively than what they would like

31. Weymiller et al. Arch Intern Med 2007 Statin Choice

32. Statin Decision Aid

33. Web-based tool

34. 34 Mullan et al Arch Intern Med 2009

36. Summary of experience Age: 40-92 (avg 65) Primary care, ED, hospital, specialty care 74-90% clinicians want to use tool again Adds 2.5-3.8 minutes to consultation 60% fidelity 20% improvement in knowledge 17% improvement in patient involvement Variable clinical outcomes

37. 55 Diabetes Hypertension High cholesterol Depression Bad back Can’t sleep Obese A1c 8.2% LDL high HCTZ Beta-blocker Metformin Glipizide Neuropathy 108 kg Pain Endocrinologist Podiatrist Dietitian Dizzy Take off work Get a ride Take pills Check sugars Avoid salt, fats, carbs Exercise Check his feet 3 2 1 Numbers don’t add up Deadline is now take work home perform ! Daughter back at home 2 beautiful girls Wasted! mortgage debt insurance

38. Care > NeedCare < Need Underuse Overuse Appropriate care

39. Care > WantCare < Want Undertreatment Overtreatment Desirable care

40. Care > CanCare < Can Undertreatment Overtreatment Feasible care

41. WORKLOAD CAPACITY

42. Encounter Research NEED WANT CAN APPROPRIATE DESIRABLE FEASIBLE

43. http://shareddecisions.mayoclinic.org http://minimallydisruptivemedicine.org Need http://www.gradeworkinggroup.org Want Can

44. 7 th International Shared Decision Making Conference Lima, Perú - June 16-19 2013 www.isdm2013.org

45. Our confidence in the research contributes to our confidence in making decisions. The evidence alone is never sufficient to make a decision.

46. Want NeedCan