Problematization

CRITICAL PROBLEMATIZATION: TRANSFORMING INFORMATION INTO KNOWLEDGE Suzana Alves da Silva PROCEP: Teaching and Research Center of Pro-Cardiaco

suzana.silva@procardiaco.com.br

quarta-feira, 11 de agosto de 2010

Problematization It is the act of knowing in concrete situations It is the reflection on the content of an act itself in order to act better within the framework of reality It requires: Critical reasoning of reality Attitude towards the transformation of this reality

quarta-feira, 11 de agosto de 2010

Evidence-Based Medicine “The integration of best research evidence with clinical expertise and patient values and circumstances�

David Sackett, 1992

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Model for Clinical Decision Expertise

Patients

Evidence Haynes. ACP J Club 1996.

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Model for Clinical Decision Circumstances

Patients

Evidence Haynes. ACP J Club 2002.

quarta-feira, 11 de agosto de 2010

Model for Clinical Decision Circumstances

Expertise Patients

Evidence Haynes. ACP J Club 2002.

quarta-feira, 11 de agosto de 2010

Scientifically Informed Medical Practice and Learning - SIMPLE Model “Knowledge does not extend from those who consider they know to those who consider they do not know. Knowledge is built in the relationship between human beings and perfects it self in the critical problematization of these relations.�

Paulo Freire

Suzana Silva, Sicily Conference, Italy 2009 | JECP 2010 quarta-feira, 11 de agosto de 2010

Scientifically Informed Medical Practice and Learning - SIMPLE Model Cri

tic

al P

rob lem ati

zat ion

“Knowledge does not extend from those who consider they know to those who consider they do not know. Knowledge is built in the relationship between human beings and perfects it self in the critical problematization of these relations.�

Paulo Freire

Suzana Silva, Sicily Conference, Italy 2009 | JECP 2010 quarta-feira, 11 de agosto de 2010

Scientifically Informed Medical Practice and Learning - SIMPLE Model Cri

tic

al P

rob lem ati

zat ion

Cli nic al A

cti

on

“Knowledge does not extend from those who consider they know to those who consider they do not know. Knowledge is built in the relationship between human beings and perfects it self in the critical problematization of these relations.�

Paulo Freire

Suzana Silva, Sicily Conference, Italy 2009 | JECP 2010 quarta-feira, 11 de agosto de 2010

Scientifically Informed Medical Practice and Learning - SIMPLE Model Cri

tic

al P

rob lem ati

zat ion

Cli nic al A

cti

Sci e

nti

fic

Evi den

ce

on

“Knowledge does not extend from those who consider they know to those who consider they do not know. Knowledge is built in the relationship between human beings and perfects it self in the critical problematization of these relations.�

Paulo Freire

Suzana Silva, Sicily Conference, Italy 2009 | JECP 2010 quarta-feira, 11 de agosto de 2010

EBCP is ... “The systematic extension of EBM into the fabric of clinical actions arising from patient-practitioner relationships.�

Peter Wyer

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“The process of problematization implies a critical return to action. It starts from action and returns to it�

Paulo Freire. Pedagogy of the Oppressed. 1974

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Research and Practice David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.

g kin

< 20%

Ma

al nic Cli

All the rest

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cis ion

De

Observational Studies

f n I

n o i t a m r o

Randomized Controlled Trials

> 80%

Logarithmic Transformation â&#x20AC;&#x153;Things must be as simple as possible, but not any simplerâ&#x20AC;?

.... .... .. .

Einstein

Therapeutic Interventions

Systematic Reviews Randomized Controlled Trials

Suzana Silva, EBCP Newsletter, McMaster University 2008 quarta-feira, 11 de agosto de 2010

Logarithmic Transformation â&#x20AC;&#x153;Things must be as simple as possible, but not any simplerâ&#x20AC;?

Einstein

Critical Problematization

Suzana Silva, EBCP Newsletter, McMaster University 2008 quarta-feira, 11 de agosto de 2010

Logarithmic Transformation â&#x20AC;&#x153;Things must be as simple as possible, but not any simplerâ&#x20AC;?

Einstein

Therapy Diagnosis Prognosis Harm

Suzana Silva, EBCP Newsletter, McMaster University 2008 quarta-feira, 11 de agosto de 2010

Logarithmic Transformation â&#x20AC;&#x153;Things must be as simple as possible, but not any simplerâ&#x20AC;?

Einstein

Therapy Diagnosis Prognosis Harm

Suzana Silva, EBCP Newsletter, McMaster University 2008 quarta-feira, 11 de agosto de 2010

The Epistemological Crisis XVII

XVIII

IX

XX

Knowledge is gained from experience.

Theory of Tabula Rasa and Posteriori Reasoning.

The concept of Weak and Strong Verification

Theory is considered true if it works in practice

Socio-Cultural context.

Tacit knowledge

Silva and Wyer, Where is the wisdom? II, JECP 2009 quarta-feira, 11 de agosto de 2010

The Epistemological Crisis XVII

XVIII

IX

XX

Knowledge is gained from experience.

Theory of Tabula Rasa and Posteriori Reasoning.

The concept of Weak and Strong Verification

Theory is considered true if it works in practice

Socio-Cultural context.

Tacit knowledge

Silva and Wyer, Where is the wisdom? II, JECP 2009 quarta-feira, 11 de agosto de 2010

The Epistemological Crisis XVII

XVIII

IX

XX

Knowledge is gained from experience.

Theory of Tabula Rasa and Posteriori Reasoning.

The concept of Weak and Strong Verification

Theory is considered true if it works in practice

Socio-Cultural context.

Tacit knowledge

Silva and Wyer, Where is the wisdom? II, JECP 2009 quarta-feira, 11 de agosto de 2010

id Ev

n tio ca sifi s as ne Cl li d de or Gui

Basic Science

xf

Clinical Research

O

en JA ce M H A ie 19 ra 92 rch y

Integration of Knowledge

Clinical Expertise

Silva and Wyer, Where is the wisdom? II, JECP 2009 quarta-feira, 11 de agosto de 2010

id Ev

n tio ca sifi s as ne Cl li d de or Gui

Basic Science

xf

Clinical Research

O

en JA ce M H A ie 19 ra 92 rch y

Integration of Knowledge

Clinical Knowledge â&#x20AC;&#x153;Problematizationâ&#x20AC;? - Constructivism

Positivism

E quarta-feira, 11 de agosto de 2010

xi pl e

Information

Co m

Pos-Positivism - Pragmatism

ty

Scientific Knowledge

s i p

i

H l a 09 c i 0 g o P2 l o C m JE e t

y h c r a r e

Clinical Expertise

Silva and Wyer, Where is the wisdom? II, JECP 2009

id Ev

Clinical Expertise Clinical Knowledge â&#x20AC;&#x153;Problematizationâ&#x20AC;? - Constructivism

Positivism

E

xi pl e

Information

Co m

Pos-Positivism - Pragmatism

ty

Scientific Knowledge

s i p

i

H l a 09 c i 0 g o P2 l o C m JE e t

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Wisdom quarta-feira, 11 de agosto de 2010

n tio ca sifi s as ne Cl li d de or Gui

Basic Science

xf

Clinical Research

O

en JA ce M H A ie 19 ra 92 rch y

Integration of Knowledge

Silva and Wyer, Where is the wisdom? II, JECP 2009

Evidence Assimilation What does it mean?

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Evidence Assimilation Action Patient-Practitioner Relationship and Practice Circumstances

i l o P

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Patient-Practitioner Relationship and Practice Circumstances

Evidence Assimilation Action

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Patient-Practitioner Relationship and Practice Circumstances

Silva, Charon, Wyer. JECP 2010. In press. quarta-feira, 11 de agosto de 2010

A

C

T

Problem

Action

Choices

Targets

Utility Therapeutic Interventions Diagnostic Interventions Prognostic Interventions

Performance Diagnosis Prognosis

Frequency Diagnosis Prognosis

Patient-Practitioner Relationship and Practice Circumstances

P

Revised Share consideration of Estimate

Revised Share consideration of Estimate Share considerati on of

X

Estimate

Silva, Charon, Wyer. JECP 2010. In press. quarta-feira, 11 de agosto de 2010

A

C

T

Problem

Action

Choices

Targets

Utility Therapeutic Interventions Diagnostic Interventions Prognostic Interventions

Performance Diagnosis Prognosis

Frequency Diagnosis Prognosis

Patient-Practitioner Relationship and Practice Circumstances

P

Revised Share consideration of Estimate

Revised Share consideration of Estimate Share considerati on of

X

Estimate

Silva, Charon, Wyer. JECP 2010. In press. quarta-feira, 11 de agosto de 2010

A

C

T

Problem

Action

Choices

Targets

Utility Therapeutic Interventions Diagnostic Interventions Prognostic Interventions

Performance Diagnosis Prognosis

Frequency Diagnosis Prognosis

Patient-Practitioner Relationship and Practice Circumstances

P

Revised Share consideration of Estimate

Revised Share consideration of Estimate Share considerati on of

X

Estimate

Silva, Charon, Wyer. JECP 2010. In press. quarta-feira, 11 de agosto de 2010

A

C

T

Problem

Action

Choices

Targets

Utility Therapeutic Interventions Diagnostic Interventions Prognostic Interventions

Performance Diagnosis Prognosis

Frequency Diagnosis Prognosis

Patient-Practitioner Relationship and Practice Circumstances

P

Revised Share consideration of Estimate

Revised Share consideration of Estimate Share considerati on of

X

Estimate

Silva, Charon, Wyer. JECP 2010. In press. quarta-feira, 11 de agosto de 2010

A

C

T

Problem

Action

Choices

Targets

Utility Therapeutic Interventions Diagnostic Interventions Prognostic Interventions

Performance Diagnosis Prognosis

Frequency Diagnosis Prognosis

Patient-Practitioner Relationship and Practice Circumstances

P

Revised Share consideration of Estimate

Revised Share consideration of Estimate Share considerati on of

X

Estimate

Silva, Charon, Wyer. JECP 2010. In press. quarta-feira, 11 de agosto de 2010

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

original article

Prognosis Utility

Disclosure of APOE Genotype for Risk of Alzheimer’s Disease Robert C. Green, M.D., M.P.H., J. Scott Roberts, Ph.D., L. Adrienne Cupples, Ph.D., Norman R. Relkin, M.D., Ph.D., Peter J. Whitehouse, M.D., Ph.D., Tamsen Brown, M.S., Susan LaRusse Eckert, M.S., Melissa Butson, Sc.M., A. Dessa Sadovnick, Ph.D., Kimberly A. Quaid, Ph.D., Clara Chen, M.H.S., Robert Cook-Deegan, M.D., and Lindsay A. Farrer, Ph.D., for the REVEAL Study Group*

Persons with high levels of emotional A bs t r ac t distress before undergoing genetic testing were more likely to have emotional The apolipoprotein E (APOE) genotype provides information on the risk of Alzheimer’s disease, but the genotyping of patients and their family members has been discourdifficulties after disclosure. aged. We examined the effect of genotype disclosure in a prospective, randomized, Background

controlled trial.

Methods

We randomly assigned 162 asymptomatic adults who had a parent with Alzheimer’s disease to receive the results of their own APOE genotyping (disclosure group) or not to receive results (nondisclosure group). We measured symptoms of anxiety, quarta-feira, 11 desuch agosto de 2010

From Boston University School of Medicine (R.C.G., T.B., L.A.F.), Boston University School of Public Health (R.C.G., L.A.C., C.C., L.A.F.), and Harvard Medical School Genetics Training Program (R.C.G.) — all in Boston; the University of Michigan School of Public Health, Ann Arbor (J.S.R.); Weill Cornell Medical College, New York (N.R.R.); Case Western Reserve University School of Medicine, Cleveland (P.J.W., M.B.); Columbia University School of Medicine, New York

Diagnostic Test Utility

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Diagnostic Test Utility

Heart failure therapy guided by N-terminal BNP did not improve overall clinical outcomes or quality of life compared with symptom-guided treatment. quarta-feira, 11 de agosto de 2010

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What is the accuracy of BNP test for establishing or excluding CHF in patients admitted in the emergency room with non specific dyspnea? quarta-feira, 11 de agosto de 2010

Assimilating Information Into Policy and Practice

I am going to give examples that pertain to practice in the level of System and Individual Care. The third dimension is Policy and will be delt with by Holger who will discuss the interplay of value issues and scientific evidence within the GRADE system quarta-feira, 11 de agosto de 2010

Early Goal Direct Therapy Recommendation to monitor ScvO2 to guide treatment of severe sepsis in the emergency room Guides therapy and enables early intervention Convenient, accurate and easyto-use Continuous ScvO2 monitoring is also available with integrated Oligon antimicrobialâ&#x20AC; â&#x20AC; material

Rivers 2001 quarta-feira, 11 de agosto de 2010

Cartesian Reasoning Linear system: one thing leads to another

RenĂŠ Descartes

â&#x20AC;˘Should Pre-Sep catheter be

available in the emergency room and used to guide therapy in patients with sepsis?

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The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis* Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008

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The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis* Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008

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Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Scan Identify Assessment Implement Monitor

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Scan

What is the actual effectiveness of care?

Identify Assessment Implement Monitor

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Scan

What is the actual effectiveness of care?

Identify

What should be done that is not been done?

Assessment Implement Monitor

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Scan

What is the actual effectiveness of care?

Identify

What should be done that is not been done?

Assessment

What are the barriers?

Implement Monitor

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Scan

What is the actual effectiveness of care?

Identify

What should be done that is not been done?

Assessment

What are the barriers?

Implement

What are the strategies to modify it?

Monitor

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Scan

What is the actual effectiveness of care?

Identify

What should be done that is not been done?

Assessment

What are the barriers?

Implement

What are the strategies to modify it?

Monitor

What are the outcomes?

quarta-feira, 11 de agosto de 2010

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Scan

What is the actual effectiveness of care?

Identify

What should be done that is not been done?

Assessment

What are the barriers?

Implement

What are the strategies to modify it?

Monitor

What are the outcomes?

quarta-feira, 11 de agosto de 2010

Evidence Need

Constructivist Reasoning Theory of complexity: several things may lead to other several

Evidence Assimilation in the Level of Health Care Steps

Problematization

Evidence Need

Scan

What is the actual effectiveness of care?

... what is the expected mortality...?

Identify

What should be done that is not been done?

Catheter? ATB? Fluids?

Assessment

What are the barriers?

Number of personnel needed? etc

Implement

What are the strategies to modify it?

Does this strategy modify behavior?

Monitor

What are the outcomes?

What are the main important outcomes?

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Medicine of complexity Evidence Assimilation in Individual Care

â&#x20AC;&#x153;I woke up with palpitations and chest pressure this morning. It lasted for about 10 minutes. I just want to get it checked out, thatâ&#x20AC;&#x2122;s all.â&#x20AC;?

This is how a 31 year old construction worker, who has come to the emergency department during lunch break describes his problem. His physical exam, EKG and initial lab test including cardiac markers are normal. His dad had a heart attack in his sixties. He has no other risk factor besides being a smoker.

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Chest Pain Unit Cartesian Reasoning

• Low risk patient • Follow the algorithm for low risk chest pain

which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram

• Non-invasive test for stratification: GATEDSPECT Cintigraphy or Treadmill Test

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Cartesian Reasoning

• Low risk patient

+ • Follow the algorithm for low risk chest pain

which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram

• Non-invasive test for stratification: GATEDSPECT Cintigraphy or Treadmill Test

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Cartesian Reasoning

• Low risk patient

+ • Follow the algorithm for low risk chest pain

which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram

+ • Non-invasive test for stratification: GATEDSPECT Cintigraphy or Treadmill Test

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Cartesian Reasoning

• Low risk patient

+ • Follow the algorithm for low risk chest pain

which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram

+ • Non-invasive test for stratification: GATEDSPECT Cintigraphy or Treadmill Test

=

$$$$$$ - Low Patient Satisfaction Overwhelming

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning Patient Priorities

quarta-feira, 11 de agosto de 2010

Practitioner Priorities

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

quarta-feira, 11 de agosto de 2010

Practitioner Priorities

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

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Practitioner Priorities

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

quarta-feira, 11 de agosto de 2010

Practitioner Priorities

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

quarta-feira, 11 de agosto de 2010

Practitioner Priorities

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

quarta-feira, 11 de agosto de 2010

Practitioner Priorities What is this patient pre-test probability for ACS?

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

quarta-feira, 11 de agosto de 2010

Practitioner Priorities What is this patient pre-test probability for ACS? Diagnosis Frequency

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

quarta-feira, 11 de agosto de 2010

Practitioner Priorities What is this patient pre-test probability for ACS? Diagnosis Frequency

Will the algorithm for low risk chest pain help me out excluding ACS for this patient?

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

quarta-feira, 11 de agosto de 2010

Practitioner Priorities What is this patient pre-test probability for ACS? Diagnosis Frequency

Will the algorithm for low risk chest pain help me out excluding ACS for this patient?

Diagnosis Performance

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

Practitioner Priorities What is this patient pre-test probability for ACS? Diagnosis Frequency

Will the algorithm for low risk chest pain help me out excluding ACS for this patient?

Diagnosis Performance

If this patient in fact has ACS what will be the probability of a bad outcome in the next few days?

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning Patient Priorities Am I having a Heart Attack?

Diagnosis Frequency

If I come back to work what is the probability of something bad happening?

Prognosis Frequency

Practitioner Priorities What is this patient pre-test probability for ACS? Diagnosis Frequency

Will the algorithm for low risk chest pain help me out excluding ACS for this patient?

Diagnosis Performance

If this patient in fact has ACS what will be the probability of a bad outcome in the next few days?

Prognosis Frequency

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning Patient Priorities

Practitioner Priorities

Pre-Test Probability of ACS

1%

Probability of a Bad Outcome if the patient has ACS

0,1% Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006. quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning Patient Priorities

Practitioner Priorities

Pre-Test Probability of ACS

1%

Within 1 month

Probability of a Bad Outcome if the patient has ACS

1 out of 10.000 Will have a heart attack

0,1% Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006. quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning Patient Priorities

Practitioner Priorities

Pre-Test Probability of ACS

1%

Within 1 month

Probability of a Bad Outcome if the patient has ACS

0,1%

1 out of 10.000 Will have a heart attack

100% of patients > 40 y/o 3% with multiple risk factors Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning

gPriorities Practitioner n i th r e his h t t o d Pre-Test Probability of ACS ny hin a e e r b ? e n n i h t o a s p I g t n s 1% i e go ch Within 1 month

Patient Priorities

Probability of a Bad Outcome if the patient has ACS

0,1%

1 out of 10.000 Will have a heart attack

100% of patients > 40 y/o 3% with multiple risk factors Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning

Is this patient adherent gPriorities Patient n i d will follow the Practitioner anPriorities th r e s i h ? on ati nd t me h om rec t o d y Pre-Test Probability of ACS n n i a h e e r b ? e n n i h t o a s p I g t n s 1% i e go ch Within 1 month

Probability of a Bad Outcome if the patient has ACS

0,1%

1 out of 10.000 Will have a heart attack

100% of patients > 40 y/o 3% with multiple risk factors Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning

Is this patient adherent gPriorities Patient n i d will follow the Practitioner anPriorities th r e s i h ? on ati nd t me h om rec t o d y Pre-Test Probability of ACS n n i a h e e r b ? e n n i h t o a s p I g t n s 1% i e go ch Within 1 month it s I ? e v i l e h 1 out of s e s I o d ? l e a r t i p s o Whe h e10.000 with h t o t Probability of a Bad Outcome g n i v i close l e n o y if the patient has ACS n a have a heart attack e r e Will h t him?

0,1%

100% of patients > 40 y/o 3% with multiple risk factors Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006.

quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning

Is this patient adherent gPriorities Patient n i d will follow the Practitioner anPriorities th r e s i h ? on ati nd t me h om rec t o d y Pre-Test Probability of ACS n n i a h e e r b ? e n n i h t o a s p I g t n s 1% i e go ch Within 1 month it s I ? e v i l e h e 1 out of s e s I o d m ? l e a r t o st Whe i p s c o h o e e 10.000 t h t h t t i o t w s e Probability of a Bad Outcome g n i bl stres w? close v i l a e n o o e y if the patient has ACS t n n a have a heart attack b ien e r e e Will h m t him? li l h utpat k fro W o wee n 100% of patients > 40 y/o 0,1% a 1 to hin 3% with multiple risk factors t i w Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006. quarta-feira, 11 de agosto de 2010

Chest Pain Unit Constructivist Reasoning

Is this patient adherent gPriorities Patient n i d will follow the Practitioner anPriorities th r e s i h ? on ati nd t me h om rec t o d y Probability of ACS n n i WPre-Test a h ill a e e r b ? e n n i h test n outp t o a s p I g a ben t t n s i 1% i e e n efit go ch this t stress Within 1 month pati ent? it s I ? e v i l e h e 1 out of s e s I o d m ? l e a r t o st Whe i p s c o h o e e 10.000 t h t h t t i o t w s e Probability of a Bad Outcome g n i bl stres w? close v i l a e n o o e y if the patient has ACS t n n a have a heart attack b ien e r e e Will h m t him? li l h utpat k fro W o wee n 100% of patients > 40 y/o 0,1% a 1 to hin 3% with multiple risk factors t i w Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006. quarta-feira, 11 de agosto de 2010

Patient’s Opinion

Based on ESCAPE Trial, Goodacre et al. BMJ 2007.

“It’s not a heart attack (or a what-you-call-it), see you later.”

“But it is something, you know, there is something going on” Patients rarely knew to whom they had been talking, either by name or designation Lack of information was a main concern Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008 quarta-feira, 11 de agosto de 2010

Where is the Wisdom? â&#x20AC;&#x153;Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?â&#x20AC;?

TS Eliot. The Rock.

Acknowledgement to Peter Wyer David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005.

Wyer, Silva. Where is the Wisdom I. JECP 2009.

Sival, Wyer. Where is the Wisdom II. JECP 2009.

quarta-feira, 11 de agosto de 2010

The cases presented here were used only for didactic purposes and should not be used as a prescription or reference for practice.

suzana.silva@procardiaco.com.br quarta-feira, 11 de agosto de 2010

Thank You! Gracias!

The cases presented here were used only for didactic purposes and should not be used as a prescription or reference for practice.

Danke!

Merci! ありがとう

Obrigada! suzana.silva@procardiaco.com.br quarta-feira, 11 de agosto de 2010