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
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Evidence-Based Medicine
循证医学
Patient-Centered
Care
病人为中心的护理
MIND THE GAP
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”
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)
Logic of care 护理的逻辑
Stewart’s global definition of patient-centered care全球病人为中心的护理
Understanding patient’s world 了解病人的世
界
Patient’s reason for visit
病人的理由
访问
Common ground on problem
问题的共同点
Prevention
预防
Patient-provider
relationship
医患关系
Stewart M. BMJ. 2001 Feb 24;322(7284):444-5.
A complicated relationship: EBM and
patient-centered care复杂的关系
EBM
Patient-centered care Decision-
making
医疗决策
Culture 文化
Bridging EBM and patient-
centered care: a case study
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Percent of Cases & 5-Year Relative Survival by Stage at Diagnosis: Prostate Cancer in US
12/10/2013http://seer.cancer.gov/statfacts/html/prost.ht
ml8
Localized
Confined to Primary Site
Regional
Spread to Regional LN
Distant
Cancer has metastasized
Unknown
Unstaged
Percent of Cases by Stage
病例由百分之阶段
5-Year Relative Survival
5年生存率
~10%
~90%
Of those with localized prostate cancer
局限性前列腺癌患者
get treatment
接受治疗 (radiation
therapy or surgery)
Adverse effects
不良反应
Cost
费用
active surveillance/
watchful waiting
主动监测/
观察等待
Decreased adverse
effects
降低 不良反应
Decreased cost(?)
降低费用
Comparable
outcomes
90% choose
treatment
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Why do only 10% choose
active surveillance?
Leaving active surveillance
Staying in active
surveillance
What are the factors?
Patient experience in active surveillance 主动监测的患者在方案经验
Those remaining (N=584)
Without disease reclassification
(103)
Left with disease reclassification
(N=311)
Withdraw w/o tx (31)Followed elsewhere
(69)Lost to f/u (15)Diseased (46)
1,159 men enrolled in
active surveillance
program since 1995
August, 2013
What factors are associated with leaving AS?
RRR, 95% CI
Left due to progression Self-elected to leaveAge 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)
PSA at diagnosis
<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)
What patient experiences
influence their decision-making?
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I wonder if I should get treatment for my prostate cancer
Clinical criteriaPersonal criteria
Time (+/- progression)
I wonder if I should get treatment for my prostate cancer
Clinical criteriaPersonal criteria
Ambiguous expression?
I wonder if I should get treatment for my prostate cancer
Cancer-related uncertainty
I wonder if I should get treatment for my prostate cancer
Time (+/- progression)
Demographic targeting might be hard
Assuaging patients’ anxieties, concerns
Including partners
Including families
Further work
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Partnership in
discussing options
Partnership
throughout course
of chronic illness
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
Acknowledgments
• Bal Carter
• Craig Pollack
• Jonathan Yeh
• Tricia Landis
• Fred Brancati
• Jeanne Clark
• Bimal Ashar
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