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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

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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

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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

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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

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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.

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http://consumer.fda.gov.tw/Food/InfoHealthFood.aspx?nodeID=162#

A00000000000

-

3 (2007)

245 221 24

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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)

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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

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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

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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

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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