Outline of presentation 1) Key messages 2) HFA 3) Thoughtful physicians: Difficult Questions 4) EBM 5) Measurement Iterative Loop 6) COPCORD / WHO / ILAR

Outline of presentation

1) Key messages

2) HFA

3) Thoughtful physicians: Difficult Questions

4) EBM

5) Measurement Iterative Loop

6) COPCORD / WHO / ILAR Studies

7) In conclusion ……

•Listen•Listen•Listen

listen & generate

hypothesescross examine to gather

data for hypothesis testingtest

hypothesesis one of the hypotheses

valid?

TAKE ACTION

The cyclic process of differential diagnosis

NO

YES

How do I select the appropriate diagnostic test?

1) Diagnostic tests RARELY reveal a patient’s true state with certainty.

2) Test selection should be restricted to those

diagnostic tests whose results could change

physician’s mind as to what should be done

for a patient.

3) Physicians often start treatment despite

uncertainty about true state of patient.

Number of diagnostic hypotheses remaining during

The steps of evaluating a symptom

0

5

10

15

c h ie f c o mp la in t h isto ry p h ysic a l e xa m te sts

Number of diagnoses to be considered

chief complaint

history

physical exam tests

Equal chance of occurring or not occurring

Certain not to occur

Probability of disease - 1

0 0.5 1.0

Certain to occur

Posterior Probability

Prior Probability


0 0.5 1.0

P[disease] = 0.06


0 0.5 1.0

EBM: Essential Steps & Flowchart1) Convert information needs into answerable

questions

2) Track down, with maximum efficiency, the best evidence with which to answer them (from the clinical examination, the diagnostic laboratory, the published literature, or other sources)

3) Critically appraise that evidence performance for its validity (closeness to the truth) & usefulness (clinical applicability)

4) Apply the results of this appraisal in clinical practice

5) Evaluate performance

Best Evidence

Clinical knowledge, experience,

skills, guts, flair

Patient Preferences

Fig : Flowchart of evidence-based medicine (adapted from Jenicek7)

Diagnosis, Therapy, Prognosis

Performance

Clinical aphorisms

1) If you hear hoofbeats, think of horses, not zebras

2) Rare manifestations of common diseases are

often more likely than common manifestations of rare diseases

3) If a test is unlikely to change the management of the patient, don’t do the test

4) If a test result surprises you, repeat the test

before taking action

5) The first priority in differential diagnosis is to

think about the diseases you can’t afford to miss


1) Key messages

2) HFA


4) EBM




Burden of Illness (Assessment)

Etiology or Causation

Community Effectiveness

Efficiency

Synthesis & Implementation

of Program

Monitoring & Reassessment

Policy Process

Measurement Iterative Loop

Diagnosis

Therapy

Prognosis

Relevance of population based studies

* Prevalence

* Incidence

* Risk factors

* Protective factors

* Knowledge, Attitude, Practice & Behavior

Relevance of population based studies - 1

Prevalence = No. of affected persons present in

the population at a specific time

--------------------------------------------- No. of persons in the

population at that time

Implication : - Useful measure of burden of disease - Age/gender prevalence- Valuable for planning health services & allocating resources (M)- Spectrum of disease seen (mild /moderate

/severe)


Incidence : No. of new cases that occur during a specific period of time

-----------------------------------------population at risk of

developing the disease

Implication :

Helpful in exploring the relationship of an exposure & the risk of disease e.g. sore throat & RF Rheumatic fever –

“licks the joint and bites the heart”


Risk factors :

Factors associated with occurrence ofdisease – most likely to be present

prior tothe onset of disease

Implication :

Risk factors – potential causal implications

eg. Hypertension & heart disease


Protective factors :

Those which appear to have an inverse association with the presence or

developmentof disease

Implication :

For potential treatment or even prevention of

disorders eg. Low fat diet & atherosclerosis


Knowledge, Attitude, Practice, & Behavior

(KAPB) Studies: Assess the knowledge,attitude, practice & behavior of a

particular disease in the population

Implication:

- Health behavior- Treatment seeking behavior- Compliance of treatment


1) Key messages

2) HFA


4) EBM




The Bhigwan (India) COPCORD Study: Publications

- The Bhigwan (India) COPCORD : Methodology & First Information ReportA Chopra, J Patil, V Billampelly, J Relwani, HS TandaleAPLAR Journal of Rheumatoloty, September 1997

- Prevalence of Rheumatic diseases in a Rural Population in Western India: A WHO-ILAR COPCORD Study

A Chopra, J Patil, V Billampelly, J Relwani, HS Tandale J Assoc Physicians India, February 2001

- Pain & disability, perceptions & beliefs of a Rural Indian Population : A WHO-ILAR COPCORD study

A Chopra, M Saluja, J Patil, HS Tandale The Journal of Rheumatology, 2002

The Bhigwan (India) COPCORD : Methodology & First Information

Report - 1

Study objective : Well stated

Study population : Characteristics well defined &

compared with national level (generalizability)

Study team : COPCORD team & good representation of local resources (manpower)

Study design : Cross-sectional community based study

Chopra et al. APLAR Journal of Rheumatology

September 1997

The Bhigwan (India) COPCORD : Methodology & First Information

Report - 2

Study instruments :

Standardized COPCORD questionnaires

- Questions translated to local language

- Validated on 50 referral patients (General population) Chopra et al. APLAR Journal of Rheumatology September 1997

The Bhigwan (India) COPCORD : Methodology & first information report

- 3

Survey teams : Trained Community Health Workers

COPCORD Medical Team : One rheumatologist, one

orthopedic surgeons, one rural doctor, two rheumatology research associates

Data collection :

- House to house daily visits- Daily operations were supervised - Due care was taken to look at the NON

respondents- Results well presented

Chopra et al. APLAR Journal of Rheumatology September 1997

Prevalence of Rheumatic diseases in a Rural Population in Western India: A WHO-ILAR COPCORD Study - 1

- Prevalence data from 1st rural Indian COPCORD survey in Bhigwan

- Cross-sectional survey : n = 6034

- Significant rural spectrum of rheumatic-musculoskeletal symptoms/diseases (RMSD)

Chopra et al. JAPI 2001

Prevalence of Rheumatic diseases in a Rural Population in Western India: A WHO-ILAR COPCORD Study - 2

Chopra et al. JAPI 2001

Conditions Prevalence Remarks Rheumatoid arthritis 0.5 %

(95% CI 0.3-0.7)Highest ever reported from an Asian Rural COPCORD study

Osteoarthritis 5.8% -Inflammatory arthritis 0.9% -Soft tissue rheumatism – general

3.2% -

Soft tissue rheumatism - regional

2.3 % -

Pain & disability, perceptions & beliefs of a Rural Indian Population :

A WHO-ILAR COPCORD study

- < 25% of patients perceive that they have severe problem which influences their work ability & personal life

- 21% did not perceive a need to see a doctor

Implications :

- Health seeking behavior - Treatment & Compliance- Cost & quality of life implications

Chopra et al. The Journal of Rheumatology 2002


1) Key messages

2) HFA


4) EBM




Burden of Illness (Assessment)

Etiology or Causation

Community Effectiveness

Efficiency

Synthesis & Implementation

of Program

Monitoring & Reassessment

Policy Process

Measurement Iterative Loop

Diagnosis

Therapy

Prognosis

RecoveryDeath

Incidence

Relationship between incidence & prevalence

Prevalence

In conclusion …..

1) Key messages

2) HFA


4) EBM




Inferior doctors treated the patient’s

disease,

Mediocre doctors treat the patient as a

person,

Superior doctors treat the community as a

whole.

- Huang Lee,

2600 BC

Documents

Outline of presentation 1) Key messages 2) HFA 3) Thoughtful physicians: Difficult Questions 4) EBM 5) Measurement Iterative Loop 6) COPCORD / WHO / ILAR