Chandrapur Call girls 8617370543 Provides all area service COD available
Bridging Evidence Based Medicine and Patient Centered Care: The Case of Localized Prostate Cancerr
1. Bridging Patient-Centered Care and Evidence-Based Medicine
with the help of the Primary Care Provider:
桥接病人为中心的护理和循证医学与主治医生的帮助:
The Case of Localized Prostate Cancer
局限性前列腺癌的例子
Zackary Berger, MD, PhD
Division of General Internal Medicine/Berman Institute of Bioethics
Johns Hopkins School of Medicine
美国约翰霍普金斯大学一般内科院/Berman的生物伦理学学院
3. 什么是循证医学?
证据合成
医疗决策
病人的护理
Sackett, British Medical Journal, 1996: “…[t]he conscientious,
judicious and explicit use of current best evidence in making
decisions about the care of the individual patient”
4. Logic of care
护理的逻辑
Logic of decision-making
决策逻辑
T. Greenhalgh’s phrase: “Logic of decision-making versus the
logic of care” (J Primary Health Care, 2013)
5. Stewart’s global definition of patientcentered care全球病人为中心的护理
Patient’s
reason for visit
病人的理由
访问
Understanding
patient’s world
了解病人的世
界
Common ground
on problem
问题的共同点
Patientprovider
relationship
医患关系
Stewart M. BMJ. 2001 Feb 24;322(7284):444-5.
Prevention
预防
6. A complicated relationship: EBM and
patient-centered care复杂的关系
Culture 文化
EBM
Decisionmaking
医疗决策
Patientcentered care
8. Percent of Cases & 5-Year Relative Survival
by Stage at Diagnosis: Prostate Cancer in US
Distant
Cancer has metastasized
Regional
Unknown
Spread to Regional LN
Unstaged
5-Year Relative Survival
5年生存率
Localized
Confined to Primary Site
Percent of Cases by Stage
病例由百分之阶段
12/10/2013
http://seer.cancer.gov/statfacts/html/prost.ht
ml
8
9. Of those with localized prostate cancer
局限性前列腺癌患者
~90%
get treatment
接受治疗 (radiation
therapy or surgery)
~10%
active surveillance/
watchful waiting
主动监测/
观察等待
Adverse effects
不良反应
Cost
费用
Decreased adverse
effects
降低 不良反应
Decreased cost(?)
降低费用
Comparable
outcomes
10. 90% choose
Why do only 10% choose
treatment
active surveillance?
12/10/2013
10
11. What are the factors?
Leaving active
surveillance
Staying in
active
surveillance
12. Patient experience in active surveillance
主动监测的患者在方案经验
1,159 men
enrolled in
active
surveillance
program since
1995
Withdraw w/o tx (31)
Followed elsewhere
(69)
Lost to f/u (15)
Diseased (46)
August, 2013
Left with disease
reclassification
(N=311)
Those remaining
(N=584)
Without disease
reclassification
(103)
13. What factors are associated with
leaving AS?
RRR, 95% CI
Left due to progression Self-elected to leave
Age at diagnosis
40yr to <60yr
1(reference)
1(reference)
60yr to <70yr
1.02(0.63,1.63)
0.55(0.29,1.04)
70yr+
1.16(0.69,1.94)
0.16(0.06,0.42)
<4 ng/mL
1(reference)
1(reference)
4 to <10
1.79(1.25,2.58)
2.09(1.13,3.85)
10+
0.78(0.38,1.61)
0.76(0.21,2.73)
PSA at diagnosis
presents the baseline characteristics of men who remained in the active surveillance program as of August 2013 (n = 584), those who left (were treated) due to disease reclassification (n= 311), and those who left without evidence of disease reclassification (n = 103). The remaining 161 patients withdrew from the program without being treated (n = 31), are no longer in the Hopkins program but are being followed elsewhere (n = 69), were lost to follow-up (n = 15), or are deceased (n = 46). T
“It was 7 years. I figured I was pushing my luck. I figured there was a time to do it so I did it. Only, I did it closer to where I live. See, I was travelling 2 hours to the hospital, Johns Hopkins. I did that for 7 years. So I figured I got away with it for 7 years but I didn't want to push my luck anymore. That was my basic reasoning. I thought it was time to make a move, so I did. (Self-elected to leave AS)
“I would always ask something like, ‘Do you feel like this is something that needs to be done now or do I need to take care of this now?’ and he usually said ‘No, I don’t think so.’ That to me was a pretty definitive statement… The last time it was, ‘Well the numbers have changed and they’re going up… So, to me it was not a rubber stamp of ‘Yup, let’s keep in the program,’ and I promised myself that the first time I felt that I didn’t get that rubber stamp, I’d do something about it.” (Self-elected to leave AS)
“It wasn’t like I was going crazy from thinking about it, but the thoughts were there... I knew just from my study and my research on my path, look, just because those biopsies are not showing the cancer cells and so forth, in all probability it's in there. It's just that the biopsies are not picking the heat up… it was in my mind, maybe not constantly, but it was there often enough – to the point where, you know what, enough is enough.” (Self-elected to leave AS)
“Well, I guess the word ‘cancer’ scares me. I had a good friend who died with prostate cancer, and he was fairly young.” (Self-elected to leave AS)