Evidence-Based Health Care

Cochrane Library. The Cochrane Library [44] includes The Cochrane Database of Systematic Reviews, a collection of regularly updated, systematic reviews of the effects of health care. It is maintained by contributors to the Cochrane Collaboration. Cochrane reviews are reviews mainly of randomized controlled trials. To minimize bias, evidence is included or excluded on the basis of explicit quality criteria. Data are often combined statistically, with meta-analysis, to increase the power of the findings of numerous studies, each too small to produce reliable results individually. Database of Abstracts of Reviews of Effectiveness is also included. It consists of critical assessments and structured abstracts of good systematic reviews published elsewhere. The Cochrane Controlled Trials Register with bibliographic information on controlled trials and other sources of information on the science of reviewing research and evidence-based health care are part of the Cochrane Library. It is commercially available on CD-ROM or the Internet. 

Anonymous. After lumpectomy, overall survival is similar with tamoxifen alone compared with tamoxifen plus radiotherapy in elderly women with early stage breast cancer, Evid Based Health Care 2005 9 79-80. 

Online materials to support teaching of evidence-based health care, including the Users Guides to Evidence-Based Practice, are now supported through the Centres for Health Evidence at http //www.cche.net. Table 3-4 summarizes the key elements to be... 

Cochrane (2013) Evidence-based health care and systematic reviews. The Cochrane Collaboration, http //www.cochrane.org/about-us/evidence-based-heallh-care. Accessed 11 Aug 2013... 

Geddes JR, Game D, Jenkins NE, et al. What proportion of primary psychiatric interventions are based on randomised evidence Qual Health Care 1996 5 215-217. 

Application areas for affinity-based sensors and immunosensors are specific toxic compounds or class of toxins detection. The most developed and applied recognition layer is antibody based. As the commercial success of immunoassays becomes more evident in health care, food, and environmental monitoring the demand for faster techniques will be sufficient for continued affinity sensors development. 

However, some health care providers may not prescribe an antipyretic for the patient with an elevated temperature because evidence suggests that fever activates the immune system to produce disease-fighting antibodies. The decision to treat an elevated temperature with an antipyretic is an individual one, based on the cause of the fever and the patient s physical condition. 

It is essential that, with the use of evidence-based medicine to inform decisions in health care, the processes used in program development be as transparent as possible. Information about the limited evidence and inherent uncertainty should be disclosed and available for scrutiny, even within the software itself. In fact, in an attempt to maximize transparency, some have advocated open source development and publication of interactive software models [49, 50]. Certainly, details of methodologies, sources, and other techniques employed for development of the underlying models must be acknowledged. However, the proprietary nature of many of these programs must be taken into consideration and measures put into place to ensure confidentiality. Requested publication of all NIH-sponsored research online (in PubMed) [51] within a reasonable time frame after journal acceptance will help to ensure that these data are available in the public domain in short order. 

As already outlined, health-care decision models hold little water in the sophisticated environment of evidence-based medicine. Nevertheless, two UK evaluations (Davies and Drummond, 1993 Matheson et al, 1994) do give some insight into the outcomes of using clozapine in the UK National Health Service, although model data were largely derived from the USA. 

Table 74—2 presents the recommended agents for treatment of community-acquired and complicated intraabdominal infections from the Infectious Diseases Society of America and the Surgical Infection Society.21-23 These recommendations were formulated using an evidence-based approach. Most community-acquired infections are mild to moderate, whereas health care-associated infections tend to be more severe and difficult to treat. Table 74-3 presents guidelines for treatment and alternative regimens for specific situations. These are general guidelines there are many factors that cannot be incorporated into such a table. 

Dantzer, R. (2006). Cytokine, sickness behavior, and depression. Neurol. Clin., 24(3), 441-60. Dawes, M., Davies, P., Gray, A. et al. (2005). Evidence-Based Practice A Primer for Health Care Professionals. Edinburgh Elsevier Churchill Livingstone, de Leon, J. (2006). AmpliChip CYP450 test personalized medicine has arrived in psychiatry. Expert Rev. Mol. Diagn., 6, 277-86. 

Measles component Adults bom before 1957 can be considered immune to measles. Adults bom during or after 1957 should receive >1 dose of MMR unless they have a medical contraindication, documentation of >1 dose, history of measles based on health-care provider diagnosis, or laboratory evidence of immunity. 

Currently, physicians and patients determine the demand for pharmaceuticals and employers and insurers assume the risk and cost. As the price of new health care technologies escalates, payers will design and implement strategies to share risk and cost. Defined employer contributions, increased patient cost sharing, and benefit exclusions will be used to help control utilization and cost. In this environment, value-based assessments will be crucial to the adoption of any technological innovation. It is reasonable to expect public and private coverage for new therapies if evidence is provided regarding the costs and consequences of treatment. However, social and ethical dilemmas will certainly arise as therapies whose costs exceed their benefits are debated in the public arena. 

Abstract Quality of care is complicated, especially in the elderly. For a start we need drugs with evidence for the benefits and risks in the elderly, this is currently not always the case. Thereafter we need to use the drugs in an evidence based way, which may be difficult in the complex health care system. To achieve maximum benefit for the patient (outcome) and society (health-economy) a well planned process is needed. This includes identification, prevention and resolving of the patients drug-related problems decisions and selection of treatment, communication and decisions together with the patient, risk minimisation, and communication within health care. Several of these aspects are presented in this chapter. 

As health-care professionals we need to identify and solve the problem together with the patient, and we need to do it in a rational and cost-effective way. For a practitioner this is not easy based on the rapidly expanding progress within the medical area, increasing demand from patients, and the manipulation of information from various interests in the field. First we need drugs and other treatments with documented effects (efficacy) in the elderly. Then we need to select the most appropriate drug for the individual patient. The latter is complicated and evidence-based medicine (EBM) has been suggested as the method. Finally we need to communicate with the patient and establish a partnership (concordance). 

Prevention of disease is of course very important and the individual have a responsibility for their own health in a short and long perspective. The health care system has to support the individual to make correct decision and also to further help them when disease is evident. The cornerstone to this is surgery and medication treatment. As described in Chapter 3 there are requirements for documentation of new medications when used in the elderly. However those controlled trials will always be artificial and we need more evidences and comparisons from normal clinical use based on populations and individuals. This information could be gathered continuously if the patient care supportive IT system really was supportive. 

The Cochrane Collaboration prepares Cochrane Reviews and aims to update them regularly with the latest scientific evidence. Members of the organisation (mostly volunteers) work together to provide evidence to help people make decisions about health care. Some people read the healthcare literature to find reports of randomised controlled trials others find such reports by searching electronic databases others prepare and update Cochrane Reviews based on the evidence found in these trials others work to improve the methods used in Cochrane Reviews others provide a vitally important consumer perspective and others support the people doing these tasks. The Cochrane Collaboration website provides information on a variety of ways of registering interest or becoming directly involved www.cochrane.org/docs/involve.htm involve. 

Discussions on the clinical pharmacological profiles of medicines and therapeutic options that are eurrently available based on the best scientific evidence, will be incomplete without looking into the existing health care systems and the social environment. Specifically, whether the health system can ensure the accessibility to and affordability of the needed medicines, ensure the quality of medicines in the market, and ensure the effective and safe use of those medicines ... 

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