Public Health: Why Blog ?

About Blogging

Hits
Type "blog" into Google and you get over 150 million hits. "Blogging" gets more than 9 million. "Weblog" gets you 40 plus million while "web log" gives you in excess of 20 million.

In the Dictionary
According to Wired magazine “Bloggers had a great year.” they go on to say that Merriam-Webster, the dictionary publisher, declared "blog" – a word- "noun (short for Weblog) (1999) : a website that contains an online personal journal with reflections, comments and often hyperlinks provided.

So What is blogging?
Ask Bruce! Will tell you along with a bit on why to blog and the history of blogging. http://www.bbc.co.uk/webwise/askbruce/articles/browse/blogging_1.shtml
More on what blogging and its history here http://www.tokyoshoes.com/blogclass/
For A Practical Guide to Blogging see Greg Knollenberg http://www.writerswrite.com/journal/jul02/gak16.htm

Please be careful
You could loose your job.-This wired article talks about posting content that your employer does not agree with. http://www.wired.com/news/culture/0,1284,65912,00.html
Listen to the guy who worked for Waterstone’s (UK booksellers) and got sacked because of his blog- "It is a big personal blow to me to lose my job and it also has grave implications beyond that - for anybody who works for any company and blogs, which is thousands of people." The story posted in the Guardian Newspaper in the UK is an interesting read and a cautionary tale. (Blogger sacked for sounding off. Waterstone's says bookseller brought firm into disrepute.) http://www.guardian.co.uk/online/weblogs/story/0,14024,1388466,00.html

Public Health and Blogging

Public Health Blogs
This one is actually called Public Health Weblog http://depts.washington.edu/hswork/phblog/phblog_0904.html
The Behaviour and Health Blog at Johns Hopkins University is definitely worth a visit. http://bhblog.jhsph.edu/
The Public Health Press http://publichealthpress.blogspot.com/

Here are some functions blogs can fulfill according to Effect Measure:(http://effectmeasure.blogspot.com/- this site seems concentrate on the spread of viruses- influenza in particular- however there many other posts of interest to public health practioners)

Filter information from the web and elsewhere pertinent to our point of view and of use and interest to the public health community;
Provide context for that information;
Provide alternate points of view (challenging the conventional wisdom or the unspoken assumptions that get in the way of finding "out of the box" solutions);
Encourage argument, examination and evaluation of important issues for the purpose of fashioning a coherent point of view that can be framed and efficiently and effectively communicated;
Accrue an audience specifically interested and attuned to that point of view, which may be small, but if coordinated can exert significant influence and leadership.

If you want to try your hand at blogging you can start at Blogger
(it's free!):http://www.blogger.com/

Health and Stuff

My other blog Health and Stuff is still up and running. http://welleconhealth.blogspot.com/
Well still up. Have to decide about the running. I have transferred, edited and republished most of the postings here. But there are still a couple- Health vs rights of workers, Evidence-Based Healthcare links and a bit on Quackery that I have left and the one here on HTA generalisablity is a shorter version (minus list of articles found, included and excluded)

I hope that Wellecon 2 will be a worthwhile read on topics of public health, health economics and primary care.

Complexity and Healthcare. Part Won.

Complexity quotes and links.
What Is Complexity?
http://www.prototista.org/E-Zine/WhatisComplexity.htm
According to Jim Begun- Complexity science is a way health-care professionals are looking at their systems for understanding and improvement. Complexity Science encourages healthcare leaders to work with, rather than against, overwhelming complexity by focusing on relationship building, organizational values and culture, and widespread participation, rather than tight integration, formalization, and centralizeddecision-making. The leader serves the organization by making sense of a complex world, rather than providing neat answers that promise success. JIM BEGUN, PH.D Introduction to the Basic Concepts of Complexity Science http://www.codynamics.net/intro.htm

Some more excerpts on what it is all about: Complexity views all groups of living creatures, including people in organizations, as complex adaptive systems.
A system is a group of two or more parts which interact to function as a whole. Complex groups of living things and their behaviors are complicated. Adaptive living systems constantly adapt to their changing environments.
Feedback Impacts Systems. This occurs in two forms: balancing, which keeps the system stable by limiting change (like a thermostat), and reinforcing, which intensifies the change or activity.)Emergence
Complex living systems exhibit behaviors and characteristics that are different from the behaviors and characteristics of the parts or members.
Self-Organization
People naturally recognize their interdependence and work together to accomplish shared goals or tasks. They do not always have to be told what to do.
Powerful Attractors
As a complex system adapts to its environment, a preferred state or way of doing things is discovered, and the whole system converges on that pattern.

BMJ has several articles by paul plsekhttp://bmj.bmjjournals.com/searchall/all

Plsek PE, Wilson T. Complexity, leadership, and management in healthcare organisations.BMJ. 2001 Sep 29;323(7315):746-9.Plsek PE, Greenhalgh T.Complexity science: The challenge of complexity in health care.BMJ. 2001 Sep 15;323(7313):625-8.

New England Complex Systems Institute COMPLEX SYSTEMS IN SCIENCE AND SOCIETY:Healthcare/Medical System ( there are some interesting papers on this site)http://necsi.org/cxworld/healthcare.html

Plexus Institute uses complexity theory to improve healthcare http://www.plexusinstitute.com/

Complexity Science and Analysis of Health Care Delivery Systems http://order.ph.utexas.edu/McDaniel.pdf

Evidence Based Health Services: An Introduction to Complexity Thinking www.liv.ac.uk/ccr/conferences/Oct1_NHScomplex_conf.pdf

Leadership and Transformation Require a Taste for Complexity http://www.physiciancareerventures.com/physician_leader_complexity.htm

Conference on Complexity and Health Care The Robert Wood Johnson Foundation http://www.rwjf.org/reports/grr/032705s.htm

Book- COMPLEXITY AND HEALTHCARE an introduction. Edited by Kieran Sweeney and Frances Griffiths http://www.radcliffe-oxford.com/books/bookdetail.asp?ISBN=1+85775+559+6

Complexity. Part True.

Considering the Whole.
What does the deterioration of thatch roofs by moth larvae after house spraying in the course of a malaria eradication program(me) have to do with complexity.
The story is everywhere. I did not believe it was true. Spent a while looking for a legitimate source. Still not sure even though I have found what must be considered legitimate sources. It is called different names in different places but the core of the story endures.

The fact that the details are so similar, almost identical, in the accounts made me think that it may not be a true story but rather an urban legend. It could have happened. Right so what is this about? Some of us may have heard of “Operation Cat Drop” It is presented as happening in the 1950’s in Borneo. Cats, Geckos, Catapillers, Rats and Parachutes are involved.
http://www.strange-loops.com/scicatdrop.html

Forty years ago malaria was the scourge of the Dayak people of Borneo. In response, the World Health Organization (WHO) sprayed DDT to kill the malaria-carrying mosquitoes. The mosquitoes died, but so too did parasitic wasps that had controlled thatch-eating caterpillars; roofs collapsed. Other DDT-poisoned insects were eaten by geckos, which were eaten by cats. When the cats died, the rats flourished, and the Dayak people were suddenly faced with outbreaks of typhus and plague. In response, WHO parachuted 14,000 cats into Borneo. That is the metropolis version http://www.metropolismag.com/html/content_0498/ap98man.htm

The story is everywhere. Except any WHO or health related sites. It is referred to in reminding us to consider the effects of what we do and to remember that there may be unintended consequences of even small actions. whole systems, complexity and all that.
I was concerned that because the versions that I was seeing were very similar and mostly from websites of individuals that it was an urban legend. is it true? Did it actually happen? The times magazine archive link suggests so. Is it a parable? Honestly I don’t think so. I found this but no abstract available. Deterioration of thatch roofs by moth larvae after house spraying in the course of a malaria eradication programme in North Borneo. Bull World Health Organ. 1963; 28:136-7. I have not yet been able to get my hands on the article to see exactly what is says. What I do know is that it is a reminder of the interconnectedness of things. Of the complexity of living things and systems. http://www.time.com/time/archive/preview/0,10987,901002,00.html

Prostate Cancer Screening

Prostate Cancer and Screening: An Update
December 19th 2004

Phillips, Erwin Arthur MBBS, MPH
This document sets out the answer the following questions:

What do we know about prostate cancer?•

When does it make sense to screen?•

What do we tell patients?•

Prostate Cancer is a significant cause of mortality and morbidity worldwide- we only need turn to the US prostate cancer lobby to learn that in the USA:
"Prostate cancer is diagnosed every 2 1/4 minutes, over 232,000 new cases are expected in 2005. It is the most commonly diagnosed cancer in America among men.
An estimated 30,350 American men will lose their lives to prostate cancer this year alone, one death every 18 minutes. That's more new cases than any other form of cancer.
Prostate cancer incidence rates increased 192 percent between 1973 and 1992." National Prostate Cancer Coalition website

Risk Factors include:
•High animal fat and protein
•Family History•Ethnicity

Clinical Features:
Most often asymptomatic Lower urinary tract symptoms (BPH) Frequent urination, especially at night Inability to urinate Trouble starting or holding back urination A weak or interrupted flow of urine Painful or burning urination Blood in the urine or semen Painful ejaculation Frequent pain in the lower back, hips, or upper thighs

Diagnosis is by:
•Digital Rectal Examination (DRE)
•Prostate Specific Antigen (PSA)
•Transrectal ultrasound with or without Biopsy (TRUS)

Other than the size of the prostate and the age of the person PSA may be raised by the following:Urinary Tract Infections, ejaculation or vigorous exercise in the past 48 hours, biopsy of the prostate in the past 6 weeks and DRE in the past 48 hours

Treatment of Prostate CancerConsidering grade and stage, age and health, values and feelings (about benefits and harms of each option. )
•Radical Prostatectomy •Radical Radiotherapy•Conservative Management

Prevention (this is controversial)•Diet (lowfat)•Exercise ??•Screening(this is very controversial)•High Intensity Focused Ultrasound (experimental)

Lets talk a little bit more about screeningIn 1968 Wilson and Junger came up with some guidelines to help those making decisions about implemeting screening programmes. While 1968 is a very long time ago not much has changed. The guidelines continue to be valuable. This is what they said:The condition is an important health problem Its natural history is well understood It is recognisable at an early stage Treatment is better at an early stageA suitable test exists An acceptable test exists Adequate facilities exist to cope with abnormalities detected Screening is done at repeated intervals when the onset is insidious The chance of harm is less than the chance of benefit The cost is balanced against benefit

Guidelines
The reality is that there is alot of controversy about the benefits of screening for prostate cancer. (That is looking for illness in people who do not have symptoms) If we for example look at the following organisations' positions on prostate cancer screening(PCS) you would find acknowledged that the info supporting its benefits is very limited if not non-existant. Interestingly enough Cancer Societies and Urologists continue to push prostate cancer screening. Hopefully this has nothing to do with the fact that they have financial incentive to do so and instead is explained by their inability to understand the published information on the subject. Most puplic health agencies acknowledge that "Since current evidence is insufficient to determine whether the potential benefits of prostate cancer screening is beneficial." (http://www.cdc.gov/cancer/prostate/prostate.htm)
Some other bodies that have opinions and make recomendations about PCS:

American Cancer Society http://caonline.amcancersoc.org/cgi/content/full/53/1/27#SEC6U.S.

Preventive Services Task Force http://www.ahcpr.gov/clinic/uspstf/uspsprca.htm

US Centers for Disease Control http://www.cdc.gov/cancer/prostate/prostate.htm

UK NHS Screening http://www.cancerscreening.nhs.uk/

Australia http://www7.health.gov.au/pubs/ahtac/prostate.htm

University of California Irvine http://www.ucihealth.com/news/UCI%20Health/prostate.htm

Canada http://www.prostatecancer.ca/english/living/screening.html

Recommendations

In theory PCS may help. There is not solid evidence that it does. There is evidence that it may cause harms. We need to communicate this effectively to the public as opposed to saying it is a cure-all or a complete waste of time. Several large studies are underway with preliminary results due out in soon (2006?) and definitive results in the next few years (?2015). For now we need to clearly explaining the risks and potential benefits.•PSA+ DRE may be offered annually from age 50•Informed decision (pros and cons)•High risk from 45•Greater risk from 40

References
•Nelson, W. G. et al Mechanisms of Disease: Prostate Cancer, New England Journal of Medicine 2003:339;366-81

•Mazhar, D and Waxman J Review:Prostate Cancer, Postgraduate Medical Journal 2002; 78,590-595•Kakehi, Y. Watchful waiting as a treatment option for localised prostate cancer in the PSA era, Review Article, Japanese Journal of Clinical Oncology 2003; 33(1) 1-5

•Sabichi, A L et al, Frontiers in Cancer prevention Research, Cancer Research 63, 5649-5655, September 2003

•Selly S et al, Diagnosis Management and Screening of Early Localised Prostate Cancer Health Technology Assessment 1997, Vol 1; No 2
National Prostate Cancer Coalition http://www.pcacoalition.org/

Further Reading (prostate)

•Watson E, Jenkins L, Bukach C Austoker J. The PSA test and prostate cancer: Information for primary care. NHS Cancer Screening Programmes, Sheffield 2002

•Tudiver F,et al What influences family physicians’ cancer screening decisions when practice guidelines are unclear or conflicting? The Journal of Family Practice, September 2002 Vol 51, No 9

•Summary of Evidence Last Modified: 10/20/2004 National Cancer Institute- www. Cancer.gov (see prostate cancer, prevention, screening, treatment and levels of evidence)

•Prostate Cancer Screening Australian Health Technology Advisory Committee Report http://www7.health.gov.au/pubs/ahtac/prostate.htm

•Russell Harris, MD, MPH and Kathleen N. Lohr, PhD Screening for Prostate Cancer: An Update of the Evidence for the U.S. Preventive Services Task Force, Annals of Internal Medicine 3 December 2002 Volume 137 Issue 11 Pages 917-929Further Reading (Screening)

•NHS (UK) Screening Programme. http://www.cancerscreening.nhs.uk/

•Sennfalt K, Sandblom G, Carlsson P, Varenhorst E,Costs and Effects of Prostate Cancer Screening in Sweden: A 15-year follow-up of a randomized trial Scandinavian Journal of Urology & Nephrology. 38(4):291-298, 2004.Guide to Clinical Preventive Services http://www.ahrq.gov/clinic/cps3dix.htm

•Greenhalgh T, How to read a paper: Papers that report diagnostic or screening tests BMJ 1997;315:540-543

Further information (Screening)

the NHS Screening Specialist Library http://libraries.nelh.nhs.uk/screening/

MP Petticrew et al, False-negative results in screening programmes: systematic review of impact and implications Health Technology Assessment 2000; Vol. 4: No. 5 http://www.ncchta.org/execsumm/summ405.htm

Screening to Improve Health in New Zealand: Criteria to assess screening programmes http://www.nhc.govt.nz/publications/ScreeningCriteria.pdf

The Urological Society of Australasia (a very good discussion of the issues) http://www.urosoc.org.au/info/screeningprostate.html

Prostate Cancer Screening. Summary of the review prepared by the Australian Health Technology Advisory Committee http://www7.health.gov.au/pubs/ahtac/prostate.htm


American Geriatric Society. Position Paper. Health Screening Decisions for Older Adults. AGS Ethics Committee http://www.americangeriatrics.org/products/positionpapers/stopscreening.shtml
Chronic Disease Teaching Tools - Disease Screening Chronic Disease Teaching Tools - Disease Screening


Feel free to contact me at:e.arthurphillips@gmail.com

Violence Guideline Proposed Layout

Suggested Layout:

Following OHSA guidelines for preventing workplace violence against healthcare.. workers

Proposed title: Guidelines for the Prevention of Violence in Primary Healthcare

Acknowledgements

Introduction
Purpose and scope of document
Violence definition
Extent of the problem- international and local context
Risk factors for workplace violence in healthcare (primary care?) settings

Overview of guidelines
Strategies for preventing violence
(Medical Management of the acutely aggressive patient ect- other guidelines Safe working- transport, money, office layout, lighting)
Strategies for dealing with violence during and after and event
Recording incidents/ monitoring/ assessing violence prevention programmes
Violence Survey?

Violence prevention programmes
Management commitment and employee involvement- Worksite analysis- Hazard Prevention and control- Safety and Health Training- Record keeping and Programme Evaluation

Conclusions

Recommendations

Appendices

References
U.S. Department of Labor, Occupational Safety and Health Administration
Guidelines for Preventing Workplace Violence for Health Care &
Social Service Workers OSHA 3148-01R, 2004

UN ECLAC/CDCC Data Collection System for Domestic Violence 2002

ILO/ICN/WHO/PSI Workplace Violence in the Health Sector: Country Case Studies Research Instruments: Survey Questionnaire 2003

World Report on Violence, A comprehensive approach to preventing violence at work?? (full reference)

Naish J et, al Brief Encounters of aggression and violence in primary care: a team approach to coping strategies, Family Practice 2002

Bradford J, Violence in an Emergency Department: A survey of Healthcare Workers in the Accident and Emergency Department of the Queen Elizabeth Hospital, Barbados, DM thesis, UWI, 2003

NHS Zero Tolerance
Stopping the violence against NHS Staff- we don’t have to take this! http://www.nhs.uk/zerotolerance/intro.htm

Runyan C W, Zakocs R C, Zwerling C. Administrative and behavioral interventions for workplace violence prevention. American Journal of Preventive Medicine, 2000;18(4 Supplement):116-127.

Guidelines for the management of imminent violence
http://www.rcpsych.ac.uk/publications/guidelines/violence_full_h.htm
Clinical Resource and Audit Group, Scotland (CRAG) (1996) Good Practice Statement on the Prevention and Management of Aggression

Kerr, I.B. & Taylor, D. (1997) Disturbed or violent behaviour: principles of treatment. Journal of Psychopharmacology, 11, 271-277.
Royal College of Psychiatrists (1996) Assessment and Clinical Management of Risk of Harm to Other People.

Ministry of Health, New Zealand (1994) Guidelines for Reducing Violence in Mental Health Services

CURRENT INTELLIGENCE BULLETIN 57, Violence in the workplace, Risk Factors and Prevention Strategies, National Institute for Occupational Safety and Health, Division of Safety Research, July 1996
A full copy of the "ASSE 2004 Workplace Violence Survey & White Paper" which also includes a list of resources can be found on the ASSE web site by going to http://www.asse.org and to ASSE News. Or request a copy by contacting ASSE directly at customerservice@asse.org .

International Labour Office Code of practice on workplace violence in services sectors and measures to combat this phenomenon Meeting of Experts to Develop a Code of Practice on Violence and Stress at Work in Services: A Threat to Productivity and Decent Work (8-15 October 2003) Geneva (This document covers hazard identification, risk assessment, prevention and control, training, management and mitigation of the impact, and care and support for workers affected by on-the-job violence. It is intended as a reference tool to help the parties design workplace policies and plans of action as well as national laws, policies and programs.) http://www.ilo.org/public/english/dialogue/sector/techmeet/mevsws03/mevsws-cp.pdf

Additional Resources for developing programmes or accessing training / advice.

NHS zero tolerance zone
http://www.nhs.uk/zerotolerance/
This is the home page of the NHS Zero Tolerance campaign and includes the materials developed by the NHS Executive in collaboration with a series of partners, which aims to help health service managers work locally with organisations such as the police and the Crown Prosecution Service to prevent violence against staff. The NHS zero tolerance zone is a nationwide campaign to tackle violence against staff working in the NHS initiated by the Secretary of State for Health. There is information and advice on how to deal effectively with violent incidents, examples of good practice, preventing violence and how the criminal justice system deals with violent incidents.

A safer place to work : protecting NHS hospital and ambulance staff from violence and aggression (accessible at: http://www.nao.gov.uk/publications/nao_reports/02-03/0203527.pdf)
'A safer place to work : protecting NHS hospital and ambulance staff from violence and aggression' is published by the National Audit Office, (NAO) (March 2003). This report examines the extent and impact of violence and aggression within the NHS - "National Health Service
(NHS) staff have the right to expect a safe and secure workplace and NHS organisations have a legal and ethical duty to do their utmost to prevent staff from being assaulted or abused in the course of their work." The report is 54 pages long and is in PDF, requiring Adobe Acrobat software to view it.

American Medical Association: violence prevention
(Accessible at http://www.ama-assn.org/ama/pub/category/3242.html)
The American Medical Association (AMA) violence prevention Web site is "part of the growing violence-prevention movement that is coming together as a collective voice to take a firm stand against violence." This site provides information on the AMA's violence- related policies and reports, as well as its activities and projects. A listing of violence-related diagnostic and treatment guidelines published by the AMA is provided and there are links to other Web sites on violence prevention.

Royal College of Psychiatrists' clinical practice guidelines : management of imminent violence
A clinical practice guideline from the Royal College of Psychiatrists, on the management of imminent violence. The guidelines aim to support mental health services, and are based on a systematic review of the evidence. The guideline covers good practice in the clinical environment, anticipating and preventing violence, medication in the context of violence, and short term prediction of violence. Published on the web by the Centre for Evidence Based Mental Health, Oxford University Department of Psychiatry.

BMA : violence at work : the experience of UK doctors
http://www.bma.org.uk/ap.nsf/Content/violence
"This report "Violence at work: the experience of UK doctors" was produced by the Health Policy and Economic Research Unit of the British Medical Association (BMA) in October 2003. It presents the findings from a national survey of 3000 doctors on the incidence and impact of violence in the workplace. Its The aim of the study was to "explore the incidence of violence against doctors in an attempt to understand better the extent of such incidences and the impact such violence has on the lives of doctors." Recommendations for future practice cover reporting violent incidents and action, interventions, and training for all healthcare staff on methods of restraint, communication, managing aggression and personal safety. A summary of the report is available here, and the full-text document is in PDF, which requires Adobe Acrobat Reader. "

http://www.knowledge.com/Top/Society/Issues/Violence_and_Abuse/Workplace
http://www.workplaceviolence911.com/docs/20040623.htm
http://www.cdc.gov/niosh/conferences/work-violence/

Violence Prevention in a Primary Health Care Setting

Violence in Primary Healthcare and its Prevention
Violence in the workplace is an important issue as can be seen by the occupational health and safety, labour and other health-related information on the topic. Also the issue seems to be receiving increasing attention, possibly in part due to the increase in litigation following incidents in the workplace. In the healthcare setting it is clear that violence or the threat of violence is perceived to be a significant issue by staff in most if not all contexts. A lot of the work that has been done on the issue of violence on healthcare providers has dealt with Accident and Emergency Department and Psychiatric services. However there seems to be acknowledgement that Community-Based workers are also at significant risk. My interest in this is that I work in primary care where, anecdotally, there is significant concern about violence. We were actually asked to put together guidlines for the prevention of violence in primary care. The challenge however is to respond to a problem for which I am aware of no organised, reliable local information. To find out what the current reality and perceptions are we will need to organise a survey, get info from police and from clinic records. There will also likely be benefit from pushing for a formal system for recording incidents of violence and aggression. We are going to need to find out what the literature says around violence in primary healthcare and its' prevention. The following are that we would have to consider topics for searching for information on: Violence in Healthcare, Violence in the workplace, Violence in the healthcare setting of this country (unlikely to find much but heard that there was a MSc thesis done by Accident and Emergency trainee), Violence in the Polyclinics, Violence Prevention strategies, Assessing the Extent and Impact of Violence in the Polyclinic/Workplace, Violence Management/Response, The Violent Patient.

Not wanting to reinvent the wheel- a fair amount of info can be taken from various source that have done reviews and have programmes/ guidelines in place:

NHS Zero Tolerance Website http://www.nhs.uk/zerotolerance/dealing/index.htm,

New South Wales in Australia Taskforce on Prevention and Management of Violence in the Health Workplace http://www.health.nsw.gov.au/communications/campaigns/antiviolence.html

The International Labour Organisation, http://www.ilo.org/public/english/dialogue/sector/techmeet/mevsws03/mevsws-cp.pdfFrom In the The USA, Occupational Safety and Health Administration Website, Violence in Healthcare Module http://www.osha.gov/SLTC/etools/hospital/hazards/workplaceviolence/viol.html

IN addition they have produced- Guidelines forPreventing WorkplaceViolence for Health Care & Social Service Workers U.S. Department of LaborOccupational Safety and Health Administration 2004

BMA : violence at work : the experience of UK doctors http://www.bma.org.uk/ap.nsf/Content/violence
Royal College of Psychiatrists' clinical practice guidelines : management of imminent violence http://www.psychiatry.ox.ac.uk/cebmh/guidelines/violence/violence_full.html

Seems like folks from the following should be on board at some stage:Epi/psyche/legal/security(police)/occupational health/labour unionThe issue is definitely within the perview of the Ministry of Health although I am not sure under which stragetic goals it best fits. The other things that increase these thoughts becoming action taken by the powers that be include: If a large number of persons perceive that the problem exists or there is a significant increase in the numbers that do so, If people perceive the problem to be very severe or of significantly increasing severity. An epi collegue has agreed to help with the survey. So the first thing is to get the information from the survey (we are looking for survey instruments that can be adapted), get info records of clinics, from police records and to call for formal systems for documenting incidents, looking at current violence prevention and documentation systems where they exist and looking at existing or potential hazards. Not much about prevention yet as we need to assess what is happening before moving on to that aspect.

Evidence-Based Healthcare: a quick and dirty guide

Evidence-Based Healthcare
by E. A. Phillips, BSc, MBBS, MPH e.arthurphillps@gmail.com

What is Evidence- based Healthcare, Evidence-based Primary Care, Evidence-based Medicine, Evidence-Based...?

The process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. It's about integrating individual clinical expertise and the best external evidence. Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Despite differing definitions, its central tenet remains the appropriate integration of relevant best practice (usually based on published research findings when available) into clinical practice. Obviously this is not a new process — we have always tried to combine ir clinical expertise, patients' values and the best available evidence.History of evidence based… in four lines. A group of doctors who wanted to improve patient care, and base their practices on the best evidence. (Wanting to base practice on best evidence sounds strange- isn’t practice based on the best evidence? Estimates of what is evidence based range from 10% to 80%). Interest in the subject has certainly increased as we have gone from one Medline citation in 1992 to more than 13 000 in 2004.

Does it work?

Since we are talking about evidence we must ask if Evidence-based... results in better health outcomes. Um Ah. Hmm. This is a little embarassing. The reality is that it seems reasonable that it should but we really don't know.•An intensive 3 day course on evidence based medicine for doctors from various backgrounds and training level led to a clinically meaningful improvement of knowledge and skills (Fritsche et al 2002)•Evidence-based medicine makes good sense in theory and while there is no good evidence that it improves patient outcomes (very difficult to arrange a good study of this- ethics contamination ect) it is clear that patients that receive effective interventions do better than those that do not. (Straus 2000)•The context- Why do we need?.. Do we need evidence based healthcare?•daily need for information to answer clinically important questions•traditional information sources are no longer adequate•clinicians’ up-to-date knowledge decreases over time as increasing amounts of new knowledge is published in increasing numbers of journals•time demands of clinical work and sifting through the volume of published information make it difficult to find and assimilate new knowledge.

What do I need to practice EBM?

Right. So supposing you were interested in practicing evidence based.. in a formal way- what would you need to do?(The following is from Phillips and Sladek 2004) Attitudes. Consider alternatives to your practice. Be willing to challenge existing practices. Contemplete unanswered questions as they arise. Commit to life-long learning acknowledging that new research knowledge may change current understandings. Knowledge. Know what the "best-evidence" would look like to answer your question (research methodologies, strengths, weaknesses, potential biases. Know where to search for answers (databases). Know how to assess the quality of published information for its validity and relevance (critical appraisal) Skills. Be able to decide which question(s) you need to pursue in the published literature. Be able to frame a question so that is answerable. Be able to search databases effectively (searching skills). The original definition of Evidence-based Healthcare (Sackett et al) (1) is distinctly process-orientated, and has probably been the most commonly expressed in the literature. They identified five essential steps: (i) asking an answerable question; (ii) finding the best evidence to answer that question; (iii) critically appraising that evidence; (iv) integrating it with expertise and the patient’s individual requirements; and then (v) evaluating effectiveness of the search for the evidence as well as the outcomes of the application of the evidence.

Doing versus Using

Should you attempt to do the formal Evidence-based thing yourself? All those skills. Formulating a question. Looking for an answer. Assessing the answer. Applying the answer. Assessing the process. Is there an alternative? Are the skills of searching for, assessing research necessary? Time, effort, understanding….
"it is difficult to picture the general practitioner, medical registrar, or even less the tyro casualty officer, asking the patient to wait while he or she boots the computer and searches the medical literature, starting with a couple of systematic reviews and delving into an article published in Revista Médica Española, for example, only to do the same during the next consultation and, possibly, repeating the process next week, as an important new contribution may have appeared.” Ivan Moseley 2001
Alternative: to access and use secondary sources of pre-assessed evidence Finding the best evidence Advantages and disadvantages of the following: colleagues, experts, textbooks, journals, internet. Question – problem- how would you describe a group of patients similar to yours? Intervention which main intervention am I considering? Comparison- what is the main alternative?. Outcome- what do I hope to accomplish? Is there an up to date systematic review?

Criticism of Evidence-based...

Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom.The difficulty with which the approach can be applied by busy doctors, especially those in primary care. Shortage of coherent, consistent scientific evidence. Difficulties in applying evidence to the care of individual patients. Barriers to the practice of high-quality medicine (funds and other resources). The need to develop new skills (epidemiology, economics, qualitative research)Limited time and resources (time, access to information resources ect)

References

Evidence based medicine: what it is and what it isn't BMJ 1996;312:71-72 (13 January)

Editorial•What is evidence-based practice? Progress in Palliative Care, 1 February 2004, vol. 12, no. 1, pp. 6-9(4)

Ruth M. Sladek and Paddy A. Phillips•Seven Alternatives to Evidence-Based Medicine. The Oncologist, Vol. 6, No. 4, 390-391, August 2001.

David Isaacs, Dominic Fitzgerald•Effect of an Evidence-based Medicine Seminar on Participants' Interpretations of Clinical Trials A Pilot Study Academic Medicine (2000) 75: 1212-1214.

Philip Schoenfeld, David Cruess and Walter Peterson•Evidence-based medicine: a commentary on common criticisms CMAJ • October 3, 2000; 163 (7) Sharon E. Straus and Finlay A. McAlister

Further Reading

Arri Coomarasamy, Khalid S Khan, What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review, BMJ 2004;329:1017 (30 October), doi:10.1136/bmj.329.7473.1017

Trisha Greenhalgh How to read a paper: Assessing the methodological quality of published papers BMJ, Aug 1997; 315: 305 - 308. Trisha Greenhalgh How to read a paper : getting your bearings (deciding what the paper is about) BMJ, Jul 1997; 315: 243 - 246. Trisha Greenhalgh How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses) BMJ, Sep 1997; 315: 672 - 675.(actually the entire greenhalgh series- diagnostic tests, cost studies, statistics intro I+II, drug trials ect)

EBM Resources

Databases: Best Evidence Clinical Evidence, Cochrane Library, DARE, OVID EBMRJournals: ACP Journal Club, Bandolier, Evidence Based Cardiovascular Medicine /Dentistry /Eye Care /Healthcare/ Medicine/ Mental Health/ NursingEBM Online. Evidence-Based Medicine (http://ebm.bmjjournals.com/) The same editorial team produces both EBM and ACP Journal Club using the same procedures, but the intended audience of each journal is different. The first is intended for use in Europe by generalists while the second one is intended for use in North America by internists.Florida State University (medical informatics programme) has a web page called Evidence-Based Medicine Resources http://med.fsu.edu/informatics/EBM.asp

Books

How to Read a Paper by Trisha Greenhalgh is based on her BMJ articles has received excellent reviews. It costs about $20 USD

Evidence Based Medicine--How to Practice and Teach EBM David L Sackett et al

What is Health Technology Assessment

The first in a series on the topic of HTA in which we will look at the following questions. What is Health Technology Assessment? What are the issues with HTA as it relates to developing countries? What determines whether a HTA report is generalisable?

Technology assessment in health care is a multidisciplinary field of policy analysis. It studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology. (INHTA. 2002) ‘Technology’ is not necessarily referring to expensive pieces of equipment.Technology is the practical application of scientific knowledge. (Szczepura 1996) Initially Health Technology meant “drugs, equipment and medical devices, medical and surgical procedures along with the organisation and support systems” needed for their use in looking after patients. The term now includes all technologies in personal health care (of ill and healthy) and makes explicit the knowledge and skills needed for the use of those technologies. (PAHO 1998)
Most health care technologies can be thought of as belonging to one of the following categories: drugs, devices or equipment, medical and surgical procedures, support systems, and organisational and managerial systems. (Goodman 1998)Is Health Technology Assessment Research?Although there is occasionally the need to commission research to support the HTA process generally it does not seek to generate new knowledge or new solutions and therefore is not research (PAHO 1998)

Purpose of HTA

According Banta the goal of technology assessment is to provide policy makers with information on policy alternatives (Banta and Luce, 1993). Stevens and Milne are more specific in saying that the purpose of HTA is to help services that have an impact on health meet the objectives of the decision makers. (Stevens 2001). There are several ways that HTA can be used to support decisions including: Advising a regulatory body about whether to allow commercial use of a drug, device or other technology. Assisting health care financiers and providers in determining which technologies should be funded and / if how much they should pay. Providing useful information for patients, clinicians and health care providers on appropriate use of various health interventions. Guiding managers of health care institutions in their acquisition and management of health technologiesAdvising health officials contemplating public health programmes (Goodman 1998)

Do we need HTA?

It is becoming more and more apparent that not all health interventions make large contributions to health at reasonable cost but rather many new technologies make minimal impact on health at vast cost. (Gray 2001, Pencheon 2001, Panerai 1989)To control costs without negatively affecting health we have to make a concerted effort to obtain reliable and relevant information. Some of the major reasons cited for the interest and increase in use of HTA are: The acknowledgement that there are variations in clinical practice that is not entirely accounted for by clinical/ epidemiological, uncertainty, acceptability and diversity. Significant uncertainty about the real impact on health of many widely used health technologies.The fact that new interventions are being introduced more rapidly that in the past along with pressure from industry to adopt them. (Szcepura, 1996) Over the past few years we have seen significant world-wide increases in resource implications of providing health care (attributed to various factors: ageing population, business savvy of drug and medical device manufacturers among others) combined with an awareness of the limitations of resources. (PAHO 1998) It is also useful to bear in mind that the aims of individual patients, groups of patients with the same problem and the elected representatives may be in conflict. This is likely to be so because: each individual or group of individuals with a common health problem will tend to try to maximise the allocation of resources to their problems, while the representative of the public at large will be expected to allocate resources in ways that are transparent and that maximise equity of access. (Gray 2001)

Types of HTA

One of the issues with HTA is that it is despite the fact that it was originally intended for assessments to be comprehensive this is seldom done. These “partial” technology assessments tend to look at impacts that are of particular interest and their scope is influenced by resource constraints. (Goodman 1998) It is generally accepted that there are three perspectives from with a HTA can be done. The orientations are not always distinct; they may overlap and complement each other. It is suggested that a good HTA should contain elements of all three. (Goodman 1998, Szczepura 1996) Technology-Oriented Assessments are intended to determine the characteristics or impacts of a particular technology. Problem-Oriented Assessments are intended to assess how best to manage a particular type of problem for which there are alternative and/or complementary technologies as possible solutions Project-oriented Assessments focus on the need for or use of an intervention in a institution, programme or other designated project.

What do we assess in HTA?

Where as the traditional technology assessment may have focused on the social impact, health technology assessments zero in on safety, cost and effectiveness. This is so because of the fact that healthcare technologies tend to be insulated from the rules of the market economy. Typically products in other areas survive only as they are competitive in terms of price and performance. In health care it tends to be the health care professional or institution that determines what is provided (PAHO 1989) The following characteristics have been taken from Goodman’s discussion of the Properties and Impacts assessed in HTA. (Goodman 1998)Technical qualities- these include performance, conformity with design specifications, reliability, ease of use and related measures. Clinical safety- this is a judgement of the acceptability of risk in specific clinical situations. Efficacy and /or effectiveness- how well the technology will contribute to the improvement of patient health outcomes in idealised study settings (efficacy) and in everyday practice (effectiveness) Economic attributes or impacts- microeconomic attributes include costs, prices, charges and payment levels accompanying individual technologies they may also include comparison of resource use and benefits for alternative technologies. The macroeconomic concerns involve the impacts of technologies on national or state wide health care costs, effects on the spending between different health programmes or between health and other areas, or the impact on the delivery mechanisms for health care.Social, legal, ethical and/ or political impacts. Some technologies as a direct result of their being used in life threatening situations, being reproduction related or the need to allocate scarce resource intensive technologies. (Szczepura 1996, Goodman 1998)

References

Banta, H. D Luce, B. Health Care Technology and its Assessment: An International Perspective, Oxford University Press, Oxford, 1993Drummond, M. et al Methods for the Economic Evaluation of Health Care Programmes, 2nd ed. Oxford University Press, London, 1997

Gold, M. Et al (eds.) Cost- Effectiveness in Health and in Medicine . Oxford University Press, New York, 1996

Goodman, C., TA 101 Introduction to Health Care Technology Assessment, National Library of Medicine, 1998Available from national library medicine: http://www.nlm.nih.gov/nichsr/outreach.html#ta101 (Accessed: 4/12/02)

Muir Grey, J. Evidence-based health care. How to make policy and management decisions. 2 ed. Harcourt publishers, London, 2001

Stevens, A. and Miline, R. Evaluating Health Care Technologies. Chapter 5.3 p 300-308 in Pencheon et al ed. Oxford Handbook of Public Health Practice, Oxford University Press, Oxford, 2001

Szczepura, A and Kankaanpaa (eds.) Assessment of Health Care Technologies: Case Studies, Key Concepts and Strategic Issues, John Wiley and Sons limited, West Sussex, 1996

Resources

International Journal of Technology Assessment in Health

Web Resources

Center for Reviews and Dissemination- Health Technology Assessment (HTA) Database http://www.york.ac.uk/inst/crd/htahp.htm

The NHS Health Technology Assessment Programme http://www.ncchta.org/HowToOrderHTAMonos.htm

Canadian Coordinating Office for Health Technology Assessment http://www.ccohta.ca/entry_e.html

Health Technology on the Web www.ahfmr.ab.ca/hta/hta-publications/ infopapers/Internet_sources_of_information.pdf

The University of Birmingham in the UK offers a MSc in HTA http://www.bham.ac.uk/PublicHealth/htamasters/

INTERNATIONAL MASTER'S PROGRAM IN HTA & Management? Offered by universities of McGill, Montreal and Ottawa in Canada , Barcelona in Italy and Cattolica del Sacro Cuore in Italyhttp://www.hta-master.com/en/intro.html

HTA in developing countries- Caribbean Perspective

It is apparent that developed countries engage in health technology assessments as means of informing decisions about programmes with major implications. One can see evidence for this in the membership of the International Network of Agencies for Heath Technology Assessment (INAHTA: http://www.inahta.org/inahta_web/index.asp) Some of those who accept that the use of HTA is of potential benefit have argued that HTA is not relevant to developing countries. (Attinger 1988) They suggest that this is so because HTA developed in response to the needs of developed countries and therefore may not be suitable for looking at the types of issues in the ways that may be appropriate to developing countries. They add that there may be the danger that if HTA is incorrectly applied to developing countries technologies would be adopted that work well in first world countries but for various reasons will not be of benefit in the third world. (PAHO 1989) There are some further challenges that may face developing countries wishing to engage in HTA.
Resource Limitation
Among the challenges facing developing countries is the issue of resource limitation. By this we refer to the relative and or absolute shortage of financial, human and other resources. These shortages may manifest themselves in terms of technical and administrative personnel, lack of infrastructure. In many third world countries the financial resources available are actually shrinking. (PAHO 1989). In terms of human resources a few issues need to be highlighted. Because of the relatively small sizes of some developing countries human resources can be particularly difficult. The cost of training health professionals can be quite steep. Some of the countries have experienced “brain drain” as many of their highly qualified nationals seek to better themselves financially in developed countries. Fortunately even is such regions there may be universities which provide for training areas of relevance to HTA such as public health, health economics and other clinical and allied heath disciplines. (PAHO 1997) This may be supported by investigations such as one into the possibility of Trinidad and Tobago (a developing country in the Caribbean) conducting Health Technology Assessment. That report suggested that the basic skills and expertise for HTA were available in the wider Caribbean region. (Banken 2001)
Morbidity patterns
Many of the health problems faced by the populations of the less-developed regions of the world are quite different from those in the more-developed ones due to eradication or significant reduction. In one situation (developing country) the technologies may be focusing on saving life at minimal cost while the other (developed country) may be aimed at making life more comfortable but adding very little if anything to the length. One of the implications of this is that technologies that are assessed in the developed world may be in fact of minimal relevance to the underdeveloped world. (PAHO 1989)Several developing countries have been seeing shifts in their illness profiles towards those of developed countries. ) To the extent that the illnesses that afflict the developing jurisdictions are similar to those of the developed world there may be a similarity in the interventions that should be considered in remedying them.
Cultural diversity
There is interaction between culture and the value system, resulting from this culture may affect the effectiveness of any particular. Culture affects the perception of health and disease and the acceptability of different forms of health interventions. This can be particularly seen in the case of technologies that require participation, such as education. (PAHO 1989) There are varying cultures in the Caribbean both within different states and within states as a result of the patterns of migration to the islands. In the two main groups in terms of numbers are those of East Indian ancestry and those of African ancestry. Differences still remain despite years of living together and intermarrying. As may be seen in religious affiliation and festivals. (PAHO 1998) Political systemsIt is suggested that because fewer of the developing countries are democracies it is less likely that there is a social force that keeps the leadership in check by open discussion of decisions and their implications. This is one of the reasons why the potential impact of a health technology assessment should be ascertained before deciding to conduct it. (PAHO 1989) All of the countries of the English-speaking Caribbean are democracies in terms of espousing the parliamentary system and the holding of periodic competitive, free and fair elections. In addition freedom of speech and freedom of the press contribute to a situation in which the leaders are required to justify their plans and actions. It is therefore likely that HTAs conducted or adopted will have significant positive impact. (PAHO 1998) Healthcare system structuresWhether the health care system is centrally controlled or not may affect the implications of doing HTA. There may be more potential for HTA findings to have wide reaching impacts in systems that are centrally controlled as opposed to situations where responsibility is fragmented. (PAHO 1998)Availability of information and dataIn many developing countries there is a severe lack of appropriate accurate timely local information. This contributes to making it particularly difficult to do any local HTA of value. (Paho 1998) Technological capacityAlthough some of the larger developing countries have produced some of their own health technologies a significant portion of the technologies used are imported from developed countries. The ability of these countries to create local solutions to local health challenges will be affected by, existing capacity, raw materials and expertise in all aspects of technology development. (Paho 1989) There is likely to be a range of abilities of developing countries to generate their own interventions. It is likely that in developing countries there needs to be dependence on developed countries for a significant amount of technology. Social technologies. This refers to ‘soft’ technologies such as capability in the following: information management capability, administration, and organisation in addition to legislation and regulation. It may be particularly important to put social technologies in developing countries through there is the possibility of them being more politically sensitive than “hard” technologies. (PAHO 1989) There is likely to be a range of capacities in the soft technologies. This may be an area in which countries may benefit from the assistance of international development agencies.

References
Attinger, E and Panerai, R. Transferability of Health Technology Assessment with particular emphasis on developing countries. International Journal of Technology Assessment in Health Care (INJTAHC) 4 (1988) 545-554
Banken, R. Consultancy on Health Technology Assessment. Final Report, November, 2001. Ministry of Health Trinidad and Tobago
Pan American Health Organisation (PAHO), Developing Health Technology Assessment in Latin America and the Caribbean, PAHO Division of Health Systems and Services Development, Washington, 1998 Online Resources
HTA 101 INTRODUCTION TO HEALTH TECHNOLOGY ASSESSMENTwww.nlm.nih.gov/nichsr/hta101/hta101.pdf
Etext on Health Technology Assessment (HTA) Information Resources compiled & edited by Leigh-Ann Topfer and Ione Auston http://www.nlm.nih.gov/nichsr/ehta/
National Coordinating Centre for Health Technology Assessment http://www.ncchta.org/Catalan Agency for Health Tecnology Assessment and Research http://www.aatrm.net/html/en/Du8/index.html
A special edition of reprints from the International Journel of Technology Assessment in Health Care with particular relevance to developing countries. http://www.mtppi.org/reports.php?repid=045Directory of Health Technology Assessment Organizations Worldwide published by Medical Technology & Practice Patterns Institute and WHO Washington, DC, 1998 http://165.158.1.110/english/hsp/hsptec3.htm
Technology assessment and transfer for district health systemshttp://www.who.int/health-services-delivery/performance/accreditation/20000629a.htm
November 25, 2004 Health Technology Assessment: Bridging Global Evidence to Local Issues: 3rd Asian Regional HTA Conference http://www.philhealth.gov.ph/qa/htaconference2004/
Maylaisia’s HTA programmehttp://www.moh.gov.my/Medical/HTA/overview.htm
1st HTA Workshop for Latin America Mexico City November 20 - 21, 2004www. aetmis.gouv.qc.ca/fr/publications/ congres/Abstract%20F-02A.pdfInternational Society of Technology Assessment in Health Care www.istahc.net
International Network of Agencies for Health Technology Assessment www.inahta.org

Generalisability of HTA Reports

The following information was gathered from a review of the literature conducted in 2003 on generalisability of effectiveness, cost effectiveness, full economic evaluations; multinational clinical trials, economic evaluations, international cost comparisons and papers on methodology among others. Healthcare has become more effective and more ambitious and in many cases significantly more expensive.There has been an increased awareness of the fact that resources are limited and that there should be a responsibility to make sure that they are well used. In order to ensure we make the best use of the resources we need to evaluate health interventions.B ecause of the abundance of health impacting interventions available it is likely to be challenging for all except the most wealthy contexts to do all of their own assessments. This is likely to be a particular challenge for developing countries. As a result it may be important to be able to have a way of transferring, adapting or reinterpreting the findings of health technology assessments done by developed countries in developing countries. There aught to be a simple way of adapting HTAs from one country to another. Or at least assessing which HTA's are transferable. Several factors were found in guidelines of the generalisability of HTAs. The most important of these were detailed reporting of unit prices and discount rates; and reporting costs and resources separately; clear information on what was done; similarity between study and target population (in terms of definitions; costs; perspective; patient characteristics and preferences common or;) minimal sensitivity of result to reasonable change in key parameters and standard method. Therefore it may be useful to have guidelines based on these as a means of assessing the best available evidence on whether HTAs are generalisable. Further work needs to be done to determine the special issues that may be of relevance when generalising from developed to developing countries.Michael Drummond's book (Oxford University Press 2001)Economic Evaluation in Health Care: Merging Theory with Practice has a chapter on transferablity of economic evaluation results. Assessing Generalisability by Location in Trial-Based. Cost-Effectiveness Analysis: the Use of Multilevel Models. Andrea Manca Scupher and othershttp://www.herc.ox.ac.uk/DEEM/Bristol/Manca.pdf See page 61 in the GUIDELINES FOR ECONOMIC EVALUATION OF PHARMACEUTICALS: CANADA 2nd Edition November 1997 http://www.farmacoeconomia.com/articulos/canada.pdf I find this to be a very facinating subject and am certainly interested in hearing your coments.