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  • Delfini Click: Screening & Diagnostic Studies
    the nodule is benign involves risk The United States Preventive Service Task Force s USPSTF 2004 review of spiral CT scanning for lung cancer reported the risks of screening overall mortality rates for lung biopsy using thoracotomy and tissue resection range from 1 3 to 11 6 and morbidity rates from 8 8 to 44 with higher rates usually being associated with greater amounts of tissue resection 4 Additionally there is a potential risk of CT screening because of the radiation There may be harms which show up much later to chest organs and tissues including damage to the heart muscle or coronary arteries from the CT radiation A more recent article provides a very negative perspective on the value of CT screening for lung cancer Based on a comparison of the predicted with the observed number of new lung cancer cases lung cancer resections advanced lung cancer cases and deaths from lung cancer Bach et al 5 suggest that annual CT screening does not result in a decline in the number of advanced cancers detected or death from lung cancer but does result in a 10 fold increase in lung cancer surgeries resulting from screening The implication is that there will be huge increases in surgical operations and harms might well outweigh benefits from CT screening The authors cite US postoperative mortality rates for lung cancer surgery as averaging about 5 and the frequency of serious complications ranging from 20 to 44 They conclude that Until more conclusive data are available asymptomatic individuals should not be screened outside of clinical research studies that have a reasonable likelihood of further clarifying the potential benefits and risks Criteria for Screening Tests and Spiral CT Frame and Carlson developed criteria for a screening test in 1975 6 Similar criteria are now used by many health care organizations and by the USPSTF Let s compare the evidence for spiral CT as a screening test with these criteria FRAME AND CARLSON CRITERIA FOR EVALUATION A SCREENING TEST 1 The disease must have a significant effect on quality or quantity of life Yes Lung cancer is the major cause of cancer deaths in the U S 2 Acceptable methods of treatment must be available No No valid RCTs have demonstrated improved outcomes morbidity or mortality with screening RCTs which may answer this question may be available in 2009 3 The disease must have an asymptomatic period during which detection and treatment significantly reduce morbidity and or mortality No This appears to be a major issue RCT outcome data demonstrating improved outcomes with CT screening are needed In the past multiple studies of chest X ray screening for lung cancer reported detection of increased numbers of small early stage lung cancers but mortality was not reduced by the screening and the chest X ray screening was for the most part abandoned Lead time length and overdiagnosis bias described above were probably present in those studies 4 Treatment in the asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptoms appear No RCTs have shown this See number 3 above 5 Tests must be available at a reasonable cost to detect the condition in the asymptomatic period No Tests are expensive and not reliable for detecting early lung cancer that will benefit from surgery or other treatment at the detection time There is no currently available high quality science to tell us how many false positive and false negative tests will occur with screening Because of lead length overdiagnosis and volunteer biases along with lack of RCTs showing improved outcomes with screening it is not known if detecting asymptomatic lung cancer improves meaningful clinical outcomes Cost considerations must also include further testing that will result from positive screening CTs e g serial imaging thoracotomy lung resection with significant costs of the resulting morbidity and mortality 6 The incidence of the condition must be sufficient to justify the cost of screening Although the cost is high the incidence is so high that if screening and treatment were shown to be effective cost may not be a significant barrier In addition to these criteria the screening test itself must be validated with attention to sensitivity specificity accuracy and precision CT screening appears to have high rates of false positive findings as noted above Until valid studies comparing screening to no screening with low dose CT scans are available we will lack valid information on sensitivity specificity predictive values accuracy and precision and thus will be unable to predict outcomes for patients at risk The Bottom Line What Should We Tell Patients Let s go back to our case study What should we advise our patient about spiral CT screening There are two take home messages for patients 1 Stop smoking or don t start It is the best way to prevent dying from lung cancer 2 The science is insufficient to assure you that any screening test is going to find lung cancer that will with treatment clearly result in greater benefits than harms A positive result of screening may represent a non lethal nodule false positive test that will require more tests or an operation on your chest Chest surgery for positive findings has significant risks and unproven benefits There is also the possibility that you will be falsely reassured if you have a negative result A negative CT scan is no guarantee that you are protected from lung cancer That s why knowledgeable groups do not recommend screening for lung cancer For example The US Preventive Services Task Force states Evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography chest x ray sputum cytology or a combination of these tests 2004 The American College of Chest Physicians recommends against the use of low dose CT chest radiographs or sputum cytology for lung cancer screening including smokers or others at high risk except in the context of a clinical trial 2007

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  • Delfini Click: Scondary Studies
    being misgraded high it s their high ground you want to head for c If you are in agreement over which you have audited reach a high quality grade do a face validity check of the number of studies getting high marks Since probably over 80 of the medical literature achieves a Delfini Grade U for uncertain validity and or usefulness there are likely to be very few studies that are worthy of inclusion in any review And then let us pray for a quality source we can all trust Click here to share this page If you are at an entry URL title copy URL then click share button to paste into body text of your message Review of Cochrane Groups Assessment of Bias in Studies 05 08 08 The Cochrane Collaboration publishes systematic reviews developed by various groups and after peer review are edited by Cochrane Review Groups who use their own assessment recommendations as well as those published by the Cochrane Handbook of Systematic Reviews of Interventions An important study from the Nordic Cochrane Centre has examined how the different Cochrane review groups currently recommend assessment and handling of the risk of bias in studies evaluated for inclusion in systematic reviews The authors focus on the use of study components versus numerical scales and suggest possible improvements 1 as there is significant variation in the quality of approaches by Cochrane groups Some key points from the study are presented below Background It is important in developing systematic reviews to evaluate for bias each study being considered for inclusion in the review There are four major areas of bias that should be considered selection bias performance bias attrition bias and assessment bias Anything that leads away from truth is a bias excepting for chance effects The reason for this assessment is that biased studies are likely to result in unreliable estimates of effect ie misleading results Unreliable conclusions then lead to inaccurate predictions of outcomes of benefits and harms for users Assessing studies for bias has generally been done by Cochrane groups using two different approaches namely Component Approach meaning assessing the study components for bias Evaluating the methodological areas of each study for bias e g details of randomization blinding similarity of care experiences except for the intervention being studied handling of drop outs methods for calculating outcomes This approach is supported by empirical evidence Scale Approach meaning assessing the study by assigning an overall quality score This requires providing numerical values to validity threats The Jadad scale is an example of this approach 2 The use of scales is not well supported by empirical research For example Jüni et al 3 used 25 existing scales to identify high quality trials and found that the effect estimates and conclusions of the same meta analysis varied substantially with the scale used The Cochrane Collaboration advises against use of scales for assessing studies Methods The authors from the Nordic Cochrane Centre examined the instructions to authors of the 50 Cochrane Review Groups that focus on clinical interventions for recommendations on methodological quality assessment of studies Results The following table summarizes the main findings COMPONENT APPROACH SCALE APPROACH Groups recommending a component approach 41 50 82 Groups recommending a scale approach 9 50 19 23 groups had their own checklists ranging from 4 to 23 items 5 groups recommend Jadad Areas Recommended for Assessment by Component Group Areas Recommended for Assessment by Scale Group Sequence Generation 26 63 9 100 Concealment of allocation 41 100 2 22 Blinding of patients 33 80 9 100 Blinding of caregivers 32 78 1 11 Blinding of outcome assessors 39 95 9 100 Follow up 38 93 9 100 Intention to treat analysis 20 49 1 11 Recommendations for using quality assessments of individual studies in reviews by Component Group Recommendations for using quality assessments of individual studies in reviews by Scale Group Analytical Approach e g sensitivity analysis to test if including only trials of higher methodological quality changes the effect estimates 20 49 8 89 Descriptive Approach 1 2 0 0 No information 20 49 1 11 Recommendations for Type of Analysis by Component Group Recommendations for Type of Analysis by Scale Group Sensitivity analysis 17 85 7 88 Threshold 4 20 3 38 Subgroup analysis 4 20 3 38 Cumulative analysis 1 5 2 25 Weights 1 5 1 13 Meta regression 0 0 1 13 Authors Conclusions Cochrane Reviews are undertaken by authors with different levels of methodological training and following Cochrane Review Groups guidelines for assessing bias can be problematic if the guidelines are not in accordance with the empirical research on bias Despite advising against scales the Cochrane Handbook actually recommends a ranking scale The scale distinguishes between low risk of bias all criteria met moderate risk of bias one or more criteria partly met and high risk of bias one or more criteria not met However the Cochrane Handbook does not specify the criteria to be used Instead it states that the criteria used should be few and address substantive threats to the validity of the study results The Jadad scale consists of three items and up to two points are given for randomization two for double blinding and one for description of withdrawals and dropouts An overall score between zero and five is assigned where three is commonly regarded as adequate trial quality The Jadad scale is problematic for a variety of reasons we agree and present some of our observations below Also studies have shown low interrater agreement particularly for withdrawals and dropouts where kappa values below zero have been reported which is an agreement that is worse than that expected by chance The Cochrane Handbook recommends analyzing all data according to the intention to treat principle using different methods without specifying what those methods should be The Handbook should give clearer recommendations to ensure a more homogeneous methodology The authors list multiple errors made by the various Cochrane groups for example the grading system recommended by the Back Group has five levels of evidence and was developed using a consensus method Consistent findings among multiple low quality non randomized studies are considered to be the same level of evidence as one high quality randomized trial which is not in accordance with findings from empirical studies or with the Cochrane Handbook The four level grading system used by the Musculoskeletal Group is also based on consensus and is also highly problematic The system is based on arbitrary cut points such as sample size above 50 and more than 80 follow up which are not based on empirical evidence The only difference between platinum and gold evidence is that there needs to be two randomized trials for platinum and one for gold which is not reasonable as for example the platinum trials could involve 60 patients each and the gold trial 500 patients Silver level can be either a randomized trial with a head to head comparison of agents or a high quality case control study which is not supported by empirical research and bronze level can be a high quality case series without controls or expert opinion Delfini Comment on the Jadad Scale We have long had issues with the Jadad Scale Points can be awarded merely for reporting rather than giving appropriate attention to methodological quality For randomization the scale addresses explicitly the sequence generation but not concealment of allocation of the sequence The scale does not address intention to treat analysis among many other considerations Therefore randomized trials with an appropriate randomization sequence but with no concealment of allocation with large numbers of dropouts that are well described using only a per protocol analysis and having myriad other biases such as differences between groups may be scored as of the highest methodological quality five points After years of doing critical appraisals involving thousands of studies we feel confident in stating that no scale can be developed that is sufficient to evaluate studies Instead an understanding of critical appraisal concepts combined with critical and clinical thinking is required Delfini Approach to Secondary Studies As to use of systematic reviews Delfini frequently starts evidence based reviews and quality improvement projects by checking Cochrane for recent systematic reviews We have over the years noted a great deal of variation in the quality of the reviews and have reported this to Cochrane This report from the Cochrane Nordic Centre is further evidence that we should keep doing what we have been doing auditing Cochrane reviews to be sure that the included studies are of high quality and not just accepting the results and conclusions of all reviews as valid because they come from a most trusted source This is how we approach use of systematic reviews The critical appraisal process for secondary studies includes a number of elements including a review of the systematic search methods employed and an assessment of whether the secondary source includes only valid and clinically useful primary sources To assess the latter the source is reviewed to attempt to determine whether critical appraisal of the content from included studies was performed along with an attempt to assess the skill level of the appraisers and the robustness of their review One or two of included primary studies considered to be of the highest quality are critically appraised for validity and usefulness as an audit by Delfini If these studies pass the audit one or two included primary studies of the lowest quality are critically appraised as well If these lower quality studies also pass it is assumed that the authors have employed good critical appraisal techniques If the source passes an audit for validity and usefulness the source s efficacy and safety conclusions are used in the Delfini evidence synthesis and new research published following the date of the source s search strategy is sought If the source does not pass the audit for validity and usefulness but has utilized a sound search strategy and sound criteria for excluding efficacy studies lacking relevance validity or for other problems all the primary studies selected for inclusion by the source are critically appraised and valid useful studies form the basis of the Delfini review which will then be updated with any new valid and clinically useful primary studies published since the date of the secondary source s search We applaude the Nordic Cochrane Group for their efforts in helping to improve an important resource References 1 Lundh A Gotzsche PC Recommendations by Cochrane Review Groups for assessment of the risk of bias in studies BMC Med Res Methodol 2008 Apr 21 8 1 22 Epub ahead of print PMID 18426565 2 Jadad AR Moore RA Carroll D Jenkinson C Reynolds DJ Gavaghan DJ McQuay HJ Assessing the quality of reports of randomized clinical trials is blinding necessary Control Clin Trials 1996 Feb 17 1 1 12 PMID 8721797 3 Jüni P Witschi A Bloch R Egger M The hazards of scoring the quality of clinical trials for metaanalysis JAMA 1999 282 1054 60 PMID 10493204 Click here to share this page If you are at an entry URL title copy URL then click share button to paste into body text of your message Bell s Palsy Update 02 11 08 12 03 2010 for instructional slides to demonstrate how to perform a conservative intention to treat ITT analysis Note This is actually a primary studies issue but is stored here for historical reasons as our Bell s Palsy journey began with a narrative review Things have changed It now appears that early treatment with prednisone most likely does benefit patients with Bell s Palsy In the past we were critical of narrative reviews published in the BMJ and the NEJM because as had been nicely pointed out by a Cochrane review there were no high quality RCTs demonstrating improved outcomes with steroids in the treatment of acute Bell s Palsy See our letters in the boxes below Sullivan et al N Engl J Med 2007 357 1598 607 PMID 17942873 have now presented probably valid and clinically useful data to change our conclusions about the use of steroids in Bell s Palsy In a 4 arm 9 month study comparing 1 prednisolone placebo versus 2 acyclovir placebo versus 3 prednisolone acyclovir versus 4 2 placebo capsules the investigators report rates of complete recovery of 94 4 for patients who received prednisolone and 81 6 for those who did not a difference of 12 8 percentage points 95 CI 7 2 to 18 4 P 0 001 They concluded that in patients with Bell s palsy early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months Critical Appraisal of the Sullivan Study We critically appraised this study and found the following threats to validity Would have preferred more details of randomization No mention of co interventions or allowed disallowed concommitnant Rx 7 patients assigned to prednisolone received the wrong drug 3 patients assigned to placebo received the wrong drug In the prednisolone placebo group the loss to follow up was 11 138 7 9 in the double placebo group the loss was 19 141 13 5 For the acyclovir prednisolone group the drop out rate was 10 124 8 and for the acyclovir placebo the dropout was 15 123 12 Total loss 55 526 10 5 True ITT analysis not done and an adequate sensitivity analysis was not done by the authors Therefore we redid the analysis using the following assumptions No Predisolone Group We applied the percent recovered rate in the no prednisolone group control event rate to those missing or who discontinued which agreed with statistics on the natural history of the condition excepting those who sought active treatment who were counted as treatment failures Prednisolone Group We failed all who were missing and those who sought active treatment Our reanalysis yielded a statistically significant difference between those subjects receiving prednisolone and those who did not at a p value of 0 0487 Comment Because of author s analysis reported efficacy results are likely to be inflated but the evidence suggests that prednisolone is likely to be an effective agent for adults with acute onset of Bell s palsy when administered within 72 hours of onset Because of loss to follow up some uncertainty remains Grade B U Possible to uncertain usefulness The evidence might be sufficient to use in making health care decisions however there remains sufficient uncertainty that the evidence cannot fully reach a Grade B and the uncertainty is not great enough to fully warrant a Grade U Study quality is such that it appears likely that the evidence is sufficient to use in making health care decisions however there are some study issues that raise continued uncertainty Health care decision makers should be fully informed of the evidence quality 12 03 2010 See the story in pictures PDF of our instructional slid es on Intention to Treat Recalculation of Sullivan 2007 PMID 17942873 Prednisolone for Treatment of Bell s Palsy Click here to share this page If you are at an entry URL title copy URL then click share button to paste into body text of your message Delfini Letter to BMJ Corticosteriods are Not Proven for Treatment of Bell s Palsy Or are they See update here The cover feature of the September 4 2004 BMJ is about improving outcomes in Bell s palsy Yet they publish an invalid study Holland JN Weiner GM Recent developments in Bell s palsy BMJ 2004 329 553 557 PMID 15345630 4 September Full Text Despite a good Cochrane review that exposes some fatal flaws in prior research the above reference review not only includes this flawed study but excludes a valid one Here is our response to BMJ reprinted below Corticosteroids are Not Proven for Treatment of Bell s Palsy Editor Holland and Eisner support the use of corticosteroids for treatment of moderate to severe facial palsy based on two systematic reviews 1 2 We believe that such a conclusion is not justified by the medical evidence presented by the authors and that the two systematic reviews are fatally flawed In the Ramsey review three studies met the authors criteria for validity 3 4 5 but in Ramsey s analysis the study by May et al 3 a valid study was excluded because it was an outlier i e the results were not consistent with the other two studies included in the review Excluding a study on the basis of results rather than methodology is inappropriate Results from non valid studies should not be utilized in decision making May et al reported that corticosteroids resulted in poorer facial recovery than placebo It should be noted that the quality index score of the excluded May study was better than one of the studies included in Ramsey s review If the May et al study is not excluded the results do not support the authors conclusion of benefit from corticosteroid treatment It should also be noted that a Cochrane systematic review 6 included the May study as a valid study but excluded the Austin study because 29 percent of subjects in the Austin study were lost to follow up Cochrane also excluded the Shafshak study because it was a non randomized study As pointed out by the Cochrane group the Grogan practice parameter is probably invalid because Grogan included the Shafshak and Austin studies and that if these two trials were excluded from the pooled estimate the results were no longer in favor of steroids for the treatment of Bell s palsy Grogan PM Gronseth GS Practice parameter steroids acyclovir and surgery for Bell s palsy an evidence based review report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 2001 56 830 6 Ramsey MJ DerSimonian R Holtel MR Burgess LP Corticosteroid treatment for idiopathic facial nerve paralysis a meta analysis Laryngoscope 2000 110 335 41 May M Wette R Hardin WB Jr Sullivan

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  • Delfini Click: EBM Humor
    you Paul Happy Day all Sheri http electroncafe wordpress com 2011 05 04 scientific process rage Click here to share this page If you are at an entry URL title copy URL then click share button to paste into body text of your message Chrismas 2009 Evidence based Merriment Professional Matters 12 7 09 Issue http www bmj com cgi content full 339 dec07 1 b5098 Click here to share this page If you are at an entry URL title copy URL then click share button to paste into body text of your message Festive Medical Myths 12 24 08 Hoorah for the BMJ Always something fun and thought provoking for the holidays To access copy the following into an internet search engine http www bmj com cgi content full 337 dec17 2 a2769 ijkey 851a958851868b998f2533557846e624a72e2558 Click here to share this page If you are at an entry URL title copy URL then click share button to paste into body text of your message EBM Secret Truths Uncovered In the annual holiday issue of BMJ there is a dramatic find the uncovering of our secret EBM movement Cult Did you all know that There are 10 secret commandments e g Commandment 4 Thou shalt neither publish nor read any case reports Commandment 9 Mandatory retirement is required for all clinical experts within 10 days of their being declared experts EBMers can be recognized by their socks at least the Brit ones Many many more EBM secrets Sheri is now very excited to learn that she is a cult priestess Explains the sometimes wild jewelry If you would like some more holiday EBM and mirth go to http bmj com cgi content full 325 7378 1496 Thanks to Dr Ted Ganiats for the find and happy 2003 from i Delfini Click

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  • Delfini-KPHI: CKD QI Project and Clinical Guideline
    cardiovascular disease or obesity are the least likely to benefit from CKD screening The full review is available from AHRQ at http www effectivehealthcare ahrq gov index cfm search for guides reviews and reports pageaction displayproduct productid 809 PCem EN Update 01 01 2007 Chronic Kidney Disease CKD Guideline Outcomes We were pleased to learn that our Kaiser Permanente Chronic Kidney Disease Guideline Team in Hawaii is seeing improved referral rates and clinical outcomes in patients with CKD Key elements in the success include A great team with great leaders A 1 pager with actionable information for clinician An electronic system that allows Nephrologists to quickly access medical records to analyze cases and create messages with suggestions for management to primary care physicians Outcomes from 6 5 05 to 10 30 06 include Identification and greater attention to adults not yet on dialysis with a GFR under 60 ml min Protein quantification by Upr cr microalbum cr or 24 hour urine protein 2005 26 8 2006 37 2 Project Outline Phase I Identify Team Leaders from Medical Education and the EBM Working Group solicited interest among clinical staff and identified Nephrology as the pilot group With Delfini s guidance a multidisciplinary team was formed including nephrologists nutrition primary care pharmacy and an EBM working group leader Phase II Select Project Delfini provided advice and training in successful project selection Chronic kidney disease management by primary care providers and guidance on referral to nephrology was identified as an area in which there was a gap between current and optimal care The team agreed upon development and implementation of a clinical practice guideline as their EBM clinical improvement project Phase III Develop Project Outline Existing guidelines were reviewed for applicability validity appropriateness and currency Focus statements straw algorithm and key statements were drafted to help frame project scope Team members received training in effective searching of the medical literature critical appraisal for validity and usefulness of primary and secondary sources measures of outcomes intention to treat analysis project rescue and evidence grading The training was hugely successful and was met with great enthusiasm by both members and leadership Members reported feeling psyched and motivated Leadership expressed gratitude that Delfini was helping the group to create a workable map for both real life problem solving and providing on the job EBM training Phase IV Obtain Evaluate Synthesize Evidence Phase V Create Clinical Recommendations Potentially useful evidence was obtained through a systematic search and appraisal process Following evidence evaluation the best available valid and useful evidence was identified and prepared for evidence synthesis In an on site working session and following the working session team members reviewed discussed made decisions about and created Draft Evidence Synthesis Delfini Secondary Studies Cochrane Clinical Evidence Review Team Primary Studies Included and Excluded Studies Summary Tables Team Listing of K DOQI Guidelines seed guideline Statements Voted on by Team Members Team Draft Straw Clinical Recommendations Delfini Draft Evidence Tagging Statements Delfini Draft Algorithm Team modified algorithm created by Delfini Phase VI Assess Impacts of Practice Change Formal impact assessment was not done Phase VII Create information Decision Action Aids Following training in information engagement communication strategies decision making visual display of information and tool construction team members will select content communication vehicles and communication formats to convey guideline information and they will develop tools to facilitate clinical change and to provide guidance on clinical care and referral Phase VIII Implement Guideline The following implementation strategies have been used and additional strategies will be added as necessary depending upon performance measurements Approved by KP Hawaii Quality Council Jan 2006 All Hawaii KP physicians notified of guidelines via e mail in January 2006 Guidelines have been posted on the Kaiser intranet Clinician Education is being conducted through CME and other educational initiatives Family Practice Grand Rounds Honolulu May 2006 Family Practice Grand Rounds Maui July 2007 Regional Dietitians Meeting August 2006 Internal Medicine Grand Rounds Sept 2006 Presentation of the guideline at an evidence based CME conference conducted Nov 6 9 2006 in Maui Patient Care Material Chronic Kidney Disease Checklist Anemia Management Service renal clinical pharmacists Health connect integration referral criteria are now listed on the electronic nephrology referral form Decision support in Panel Support Tool The use of administrative and clinical databases to create a registry used by the guideline leaders Basically this consists of pro actively emailing or phoning primary care physicians to assist with care Phase IX Implement Measurement Reporting Plan Outcomes As of 2 15 07 for additional outcomes also see Update 7 8 09 Decrease in rate of late referrals Increase in Arterio venous fistula AVF rate Increase in outpatient inpatient starts Decrease ESRD rate Decrease ESRD prevalence Increase in urine protein testing Adults not yet on dialysis with a GFR under 60 ml min within the last 2 yrs 2005 26 8 2006 37 2 Measures being considered Number of patients with up c over 1 and GFR less than 60 ml min on ACEI or ARB Number of patients with GFR under 60 ml min with blood pressure under 130 80 Anemia management service referrals from PCPs Phase X Continuous Improvement Strategies and techniques for keeping guideline content and tools up to date will be applied by the team leaders Published in BMJ Quality Improvement Report The role of specialists in managing the health of populations with chronic illness the example of chronic kidney disease Article Key Points Update 7 8 09 BMJ Lee BJ Forbes K Quality Improvement Report The role of specialists in managing the health of populations with chronic illness the example of chronic kidney disease BMJ 2009 339 b2395 Introduction The Lee 2009 BMJ article summarizes some of the key elements of the Kaiser Permanente Hawaii KPHI Nephrology EBM Guideline Project The KPHI Chronic Kidney Disease Guideline Workgroup which was formed in January 2005 see Web Documentation for details with the goal of assisting with the management of stable chronic kidney disease CKD As described in the Lee

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  • Evidence Based Health Care Quality Help: Little EBM Test
    want a tiny taste test of your EBM knowledge Take a quick sampling by clicking on our Traveling Dolphin Rmmmm Forest Photo Courtesy Saharadesertfox Return to delfini org 2002 2013 Delfini Group LLC All Rights Reserved Worldwide Use of this

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  • Delfini Systematic Review: OA Knee
    LIST QUALITATIVE SYSTEMATIC REVIEW Delfini conducted a qualitative systematic review which is being utilized by the Washington State s Health Technology Assessment Program HTA and is available online Delfini Qualitative Systematic Review Arthroscopic Lavage Debridement For Osteoarthritis of the Knee HTA is an innovative program that determines if health services used by state government are safe and effective and was showcased in the New England Journal of Medicine where it was reported that the state estimated their first year cost savings to be 1 8 million dollars for a procedure that has good evidence that it is ineffective The primary goals of HTA are to make Health care safer by relying on scientific evidence and a committee of practicing clinicians Coverage decisions of state agencies more consistent State purchased health care more cost effective by paying for medical tools and procedures that are proven to work Coverage decision process more open and inclusive by sharing information holding public meetings and publishing decision criteria and outcomes HTA is leading the state effort to use evidence based medicine to make health policy and coverage decisions that result in safer health care The program acts as a resource to five participating agencies by sorting through a flood of information about selected medical technologies and producing reports that analyze the information and assess the quality of evidence The program also provides transparency and consistency to industry stakeholders through publishing of criteria inviting comments holding open public meetings and contracting for independent reports Finally coverage decisions are made by the Health Technology Clinical Committee HTCC an independent committee of health practitioners who review evidence on these medical devices procedures and test to ensure they are safe work as promoted and provide value Read the Seattle Times news report on the Washington State Health Technology Assessment

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  • Delfini-KPHI:BP QI Project and Clinical Guideline
    leader Phase II Select Project The team selected low risk hypertension HTN as the population to focus on an area with a large gap between current and optimal care Phase III Develop Project Outline Focus statement 4 9 2007 The Kaiser Permanente Hawaii EBM Hypertension HTN Quality Improvement Team will help establish guidelines based on the Kaiser Permanente Care Management Institute CMI recommendations to help improve hypertension care to Hawaii s population The use of the guidelines will help improve management and clinical outcomes of hypertension through local innovations The focus will be initially on clinical implementation of guidelines on low risk hypertensive patients Key issues Focus on improved hypertension control 1 Improve blood pressure technique to insure accurate blood pressure readings 2 Improve clinic workflow 3 Establish a work flow that can reduce unnecessary medical assistant MA Registered Nurse RN physician visits 4 Develop an in reach and outreach process targeting HTN patients not at goal 5 Update providers with HTN guidelines 6 Reduction in the over treatment of HTN 7 Create HTN handouts for clinicians staff and patients 8 Need to improve overall outcomes with large scale NNT rates for strokes and MI Key Questions Clinical Questions Addressed in this QI Project 1 What is the appropriate technique for taking blood pressure measurements 2 How can we improve clinic workflow 3 Are the staff and physicians appropriately trained in blood pressure techniques 4 What system is in place to insure accountability and training 5 Are there appropriate monitors available in the clinic 6 What are the new EBM HTN guidelines available via Kaiser Permanente National CMI team and can we apply them to Hawaii Kaiser Permanente s population 7 Are the handouts currently in the system updated and uniform If not will the team work on editing and creating new ones 8 Are group classes available for patients to have HTN education sessions 9 What role can Panel Support Service PSS play in this initiative 10 What role can How Are We Doing HAWD program play in this initiative Phase IV Obtain Evaluate Synthesize Evidence Training was provided by Delfini in critical appraisal of all sources including guidelines and other secondary sources evidence synthesis creating clinical recommendations impact assessment creating decision support implementation and measurement Existing guidelines were reviewed for applicability validity appropriateness and currency Phase V Create Clinical Recommendations KP CMI Hypertension guidelines were reviewed and accepted as the basis for management of hypertension Phase VI Assess Impacts of Practice Change Before implementation KP HI Region wide control of HTN was at 50 as of July 2009 the rate was approximately 70 control unofficial HTN control rate will be available in August 2009 Phase VII Create information Decision Action Aids Hawaii Kaiser Permanente Region Hypertension Playbook was developed This playbook included 1 Project Focus Statement 2 Updated CMI HTN Guidelines 3 Blood pressure reading technique standardization process a Poster demonstrating appropriate technique to be placed by work up stations b Video created demonstrating appropriate technique for staff

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  • Delfini Systematic Review: MRI Breast
    Systematic Review Breast MRI In Diagnosis and Treatment of Cancer in Women at High Risk The aim of the review was to systematically review critically appraise and analyze research evidence regarding the accuracy efficacy effectiveness and safety of MRI in the detection of breast cancer in women with a recent diagnosis of breast cancer and in women at high for breast cancer because of other risk factors such as a positive family history or known genetic mutations HTA is an innovative program that determines if health services used by state government are safe and effective and was showcased in the New England Journal of Medicine where it was reported that the state estimated their first year cost savings to be 1 8 million dollars for a procedure that has good evidence that it is ineffective The primary goals of HTA are to make Health care safer by relying on scientific evidence and a committee of practicing clinicians Coverage decisions of state agencies more consistent State purchased health care more cost effective by paying for medical tools and procedures that are proven to work Coverage decision process more open and inclusive by sharing information holding public meetings and publishing decision criteria and outcomes HTA is leading the state effort to use evidence based medicine to make health policy and coverage decisions that result in safer health care The program acts as a resource to five participating agencies by sorting through a flood of information about selected medical technologies and producing reports that analyze the information and assess the quality of evidence The program also provides transparency and consistency to industry stakeholders through publishing of criteria inviting comments holding open public meetings and contracting for independent reports Finally coverage decisions are made by the Health Technology Clinical Committee HTCC an independent committee

    Original URL path: http://www.delfini.org/Showcase_Publication_WashingtonStateHTA_MRIBreast.htm (2016-02-01)
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