Está en la página 1de 13

2014/10/22

2014-1022


privacy) autonomy
DNR

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

3C2A BPS

Continuous

Commitment

Consideration

Mutualaccountability
Respect

2014/10/22

patienteducation,selfcare

Patientfocusedcare
Patientfocusedmedicine

evidencebasedmodels

Patientcenteredcare

communicationwithpatients,

partnerships,

health promotion and


healthpromotion,and
physicalcare(3C2A,HolisticMedicine).

thethreeCsofpatientfocusedcare
communication,
continuityofcare,and
concordance (findingcommonground)

TransforMED plan of
evolving family
medicine practice
toward the new
model in operation

symptoms
History

clinical impression
tentative diagnosis

signs

clinical impression
p
tentative diagnosis

Patient centered
medical homes
final diagnosis

the practice of family medicine

Focused Keypoints RedFlag


YesorNo

2014/10/22

the practice of family medicine

General KeypointsRedFlags
Focused Keypoints RedFlag
Whathappen?YesorNo


privacy) autonomy
NR

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

What is family med specialized


about?

Continuous

Family doctor is specialized in You

3C2A
Continuous
Comprehensive
Coordinated
Cost effective
Costeffective
Convenience

Accessible
Accountable
Available
Affordable

3C2A
Continuous
Comprehensive
Coordinated
Cost effective
Costeffective
Convenience

Accessible
Accountable
Available
Affordable

CME

Re-certification

2014/10/22


privacy) autonomy
DNR

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

http://www.uspreventiveservicestaskforce.org/Page/BasicOneColumn/28
Cancer society
Pul med,
CV CV

Nutrition
Salt

Google
Facebook

guidelines ABFP preventive


privacy) autonomy
DNR

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

2014/10/22

evidence based medicine

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,
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.

Ranking 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 Therapy
Evidence

[A]

1a

Systemic review of RCTs

BP measurement
vaccination

1b

Single RCT

Lung cancer 4

1c

All-or-none

[B]

2a

Systemic review of cohort


studies

2b
2c

Cohort study
st d or poor RCT

3a

Systemic review of casecontrol studies

3b

Case-control study

Coumadin for Af

Outcomes research

[C]

Anti-arrhythmia

Case series

[D]

Expert opinion, physiology,


bench research

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,
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.
LASIK Glucosamin Antioxidant

CXR cardiac cath


EEG EKG tumor markers
Muscle relaxant

evidence based medicine


Ranking the quality of evidence

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:
II 1: Evidence obtained from well-designed
well designed controlled trials without
randomization.
Level II-2: Evidence obtained from well-designed cohort or case-control
analytic 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

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

A00000
000000
-

3 (2007)

245

221

24

2014/10/22

2014/10/22

2014/10/22

6
7

101

20078

13
(1)
(2)
(3)
(4)
(5)
(6)
(7) ( )
(8)
(9)
(10)
(11)
(12)
(13)
102
2007 7

(functional foods)
1984
(Foods for Specified Health Use, FOSHU)
vs
19911995 6,299
1996
(Foods with Health Claims
Claims, FHC) 2001-4
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

DSHEA

Gelcap (Liquid)


(1)
(2)
(3) (Herb or other botanical)
(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
Fruits, vegetables,
vegetables and grain products that contain fiber,
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 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 product
is not intended to diagnose, treat, cure or prevent any disease.)



2007 22-27


Wholefood

10

2014/10/22


privacy) autonomy

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

DNR


privacy) autonomy
DNR

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

AIDS

DNR

64


privacy) autonomy

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

DNR

lead time bias

66

11

2014/10/22

HPV
B
B

1.

1226

2.

1055

4.

80%

5.

6.

7.55

55
65

3.


privacy) autonomy

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

DNR

12

2014/10/22


privacy) autonomy

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

DNR

STD
HPV
HPV

74


privacy) autonomy

tumor markers,
low dose chest CT, MRI

let the patient talk, I know how to listen

END
DNR

13