Bridging Evidence Based Medicine and Patient Centered Care: The Case of Localized Prostate Cancerr
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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
- 2. MIND THE GAP Evidence-Based Medicine 循证医学 12/10/2013 Patient-Cent Care 病人为中心的 2
- 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
- 7. Bridging EBM and patientcentered care: a case study 12/10/2013 7
- 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
- 14. What patient experiences influence their decision-making? 12/10/2013 14
- 15. I wonder if I should get treatment for my prostate cancer Personal criteria Clinical criteria Time (+/- progression)
- 16. I wonder if I should get treatment for my prostate cancer Ambiguous expression? Personal criteria Clinical criteria
- 17. I wonder if I should get treatment for my prostate cancer Cancer-related uncertainty
- 18. I wonder if I should get treatment for my prostate cancer Time (+/- progression)
- 19. Demographic targeting might be hard
- 20. Assuaging patients’ anxieties, concerns Including families Including partners
- 21. Further work Partnership in discussing options Partnership throughout course of chronic illness 12/10/2013 21
- 22. WARNING: SPECULATION! 建议 Perhaps primary care providers should be more involved in all cancers? 初级保健 医生应该 参在癌病 人护理
- 23. Acknowledgments • • • • • • • Bal Carter Craig Pollack Jonathan Yeh Tricia Landis Fred Brancati Jeanne Clark Bimal Ashar 12/10/2013 23
Notas del editor
- 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)