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2014/10/22
1
1
2014-1022
privacy) autonomyDNR
tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
3C2A BPS
ContinuousContinuous CommitmentCommitment ConsiderationConsideration MutualaccountabilityMutualaccountability RespectRespect
2014/10/22
2
patienteducation,selfcare
communicationwithpatients,partnerships,health promotion and
evidencebasedmodels
PatientcenteredcarePatientfocusedcarePatientfocusedmedicine
healthpromotion,and
physicalcare(3C2A,HolisticMedicine).thethreeCsofpatientfocusedcarecommunication,continuityofcare,andconcordance (findingcommonground)
TransforMED plan of evolving family medicine practice toward the newtoward the new model in operation
Patient centered medical homes
symptoms History
signs
clinical impression tentative diagnosis
clinical impression
final diagnosis
p tentative diagnosis
the practice of family medicine
Focused Keypoints RedFlag YesorNo
2014/10/22
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the practice of family medicine
General KeypointsRedFlags Focused Keypoints RedFlag
Whathappen?YesorNo
privacy) autonomyNR
tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
What is family med specialized about?
Family doctor is specialized in You
ContinuousContinuous
3C2AContinuousComprehensiveCoordinated
Costeffective
Cost effectiveConvenience
AccessibleAccountable
AvailableAffordable
3C2AContinuousComprehensiveCoordinatedCosteffective
CME Re-certificationCost effectiveConvenience
AccessibleAccountableAvailableAffordable
2014/10/22
4
privacy) autonomyDNR
tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
GoogleFacebook
guidelines ABFP preventive
http://www.uspreventiveservicestaskforce.org/Page/BasicOneColumn/28
Cancer societyPul med,CV CV
NutritionSalt
privacy) autonomyDNR
tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
2014/10/22
5
Categories of recommendations Level A: Good scientific evidence suggests that the benefits of the clinical
service substantially outweighs the potential risks. Clinicians should discuss the service with eligible patients.
Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.
Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service but the balance between benefits and risks areprovided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.
Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.
evidence based medicineRanking the quality of evidence
The UK National Health Service Level A:
Consistent Randomised Controlled Clinical Trial, cohort study, all or none , clinical decision rule validated in different populations.
Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study; or extrapolations from level A studies.
Level C: Case-series study or extrapolations from level B studies.
Level D:Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.
Grade of Recommendation
Level of Evidence
Therapy
[A] 1a Systemic review of RCTs
1b Single RCT
1c All-or-none
[B] 2a Systemic review of cohort studies
2b Cohort st d or poor RCT
BP measurement vaccination Lung cancer 4
2b Cohort study or poor RCT
2c Outcomes research
3a Systemic review of case-control studies
3b Case-control study
[C] 4 Case series
[D] 5 Expert opinion, physiology, bench research
Coumadin for Af
Anti-arrhythmia
Categories of recommendations Level A: Good scientific evidence suggests that the benefits of the clinical
service substantially outweighs the potential risks. Clinicians should discuss the service with eligible patients.
Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.
Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service but the balance between benefits and risks areprovided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.
Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.
CXR cardiac cathEEG EKG tumor markersMuscle relaxant
LASIK Glucosamin Antioxidant
US Preventive Services Task Force Systems to stratify evidence by quality have been developed, such as this
one by the U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments or screening:
Level I: Evidence obtained from at least one properly designed randomized controlled trial.
Level II 1: Evidence obtained from well designed controlled trials without
evidence based medicineRanking the quality of evidence
Level II-1: Evidence obtained from well-designed controlled trials without randomization.
Level II-2: Evidence obtained from well-designed cohort or case-controlanalytic studies, preferably from more than one center or research group.
Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
2014/10/22
6
http://consumer.fda.gov.tw/Food/InfoHealthFood.aspx?nodeID=162#
A00000000000
-
3 (2007)
245 221 24
2014/10/22
7
2014/10/22
8
2014/10/22
9
13 (1) (2) (3) (4) (5) (6) (7) ( ) (8)
1 2
3 4
5 6
7 8
(8) (9) (10) (11) (12) (13) 102
2007 7
8 9
10120078
(functional foods) 1984 (Foods for Specified Health Use, FOSHU)
vs 19911995 6,299 1996
(Foods with Health Claims FHC) 2001 4 (Foods with Health Claims, FHC) 2001-4
(1) (FOSHU) (2) (Foods with Nutrient Function Claims, FNFC)
(Nutrition Labeling and Education Act, NLEA)
1990
(Dietary Supplement Health and Education Act, DSHEA)
1994
(Food and Drug Administration, FDA)
2014/10/22
10
DSHEA
Gelcap (Liquid)
(1) (2) (3) (Herb or other botanical)
(4) (4) (5) (6)
(7)
(Health claim) 14 (1) Calcium and osteoporosis(2) Dietary lipids (fat) and cancer(3) Dietary saturated fat and cholesterol and risk coronary heart disease(4) Dietary noncariogenic carbohydrate sweeteners and dental caries(5) Fiber-containing grain products, fruits, and vegetables and cancer(6) Folic acid and neural tube defects(7) Fruits and vegetables and cancer(8) Fruits vegetables and grain products that contain fiber particularly(8) Fruits, vegetables, and grain products that contain fiber, particularly
soluble fiber, and risk of coronary heart disease(9) Sodium and hypertensionDietary sugar alcohol and dental caries(10) Soluble fiber from certain foods and risk of coronary heart disease(11) Soy Protein and risk of coronary heart disease(12) Stanols /sterols and risk of coronary heart disease(13) Whole grain foods and coronary heart disease and certain cancers(14) Potassium and the risk of high blood pressure and stroke
(FDA/CFSAN, 2006)
FDA (Preapproval system)
DSHEA
(Notification) 75 FDAFDA75 FDAFDA FDA 90
FDA FDA 180
DSHEA 1. (1) (Health claim)
(2) (Structure/Function claim) (Drug claim)
1. (disclaimer)(1) FDA
(This statement has not been evaluated by the FDA.)(2)
(This productis not intended to diagnose, treat, cure or prevent any disease.)
2007 22-27
Wholefood
2014/10/22
11
privacy) autonomy DNR
tumor markers, tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
privacy) autonomyDNR
tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
AIDS
64
DNR
privacy) autonomy DNR
tumor markers, tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
lead time bias
66
2014/10/22
12
HPVB B
1226
1055
1.
2.
3.
4.80%
5.
6.
7.55
5565
privacy) autonomy DNR
tumor markers, tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
2014/10/22
13
privacy) autonomy DNR
tumor markers, tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
STDHPV
74
HPV
privacy) autonomy DNR
tumor markers, tumor markers, low dose chest CT, MRI let the patient talk, I know how to listen
END
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