Context Material Method Results Discussion and conclusion Using Knowledge Modelling to Measure How Clinical Practice could Actually Be Evidence-Based: a Preliminary Analysis with Arterial Hypertension Management eroussi a , Jacques Bouaud b , Denk´ e a , Brigitte S´ e L. Denk´ Hector Falcoff c Jacques Julien d , a AP-HP, Tenon, D´ epartement de Sant´ e Publique & UFR de M´ edecine, Universit´ e Paris 6 & APREC, Paris, France & LIM&Bio, Bobigny, France b AP-HP, DSI, STIM & INSERM, UMR S 872, eq. 20, Paris, France c SFTG, Paris, France; Universit´ e Paris 5, Facult´ e de M´ edecine, D´ epartement de M´ edecine G´ en´ erale, Paris, France. d AP-HP, HEGP, Service de M´ edecine Vasculaire et Hypertension Art´ erielle, Paris, France. S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 1/20
Context Material Method Results Discussion and conclusion Medical practice and medical knowledge Continuous publication of medical knowledge Observed variability of medical practice Differences between state of the art and practice Suboptimal healthcare quality - Medical errors The paradigm of evidence-based medicine “[...] the explicit, judicious, and conscientious use of current best evidence from health care research in decisions about the care of individuals and populations.” 1 1[Sackett et al. Evidence based medicine: what it is and what it isn’t. Br Med J 1996;312(7023):71-2] S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 2/20
Context Material Method Results Discussion and conclusion Clinical practice guidelines Clinical practice guidelines (CPGs) Promotion of professional best practices in health care Health professional societies or national agencies Systematic reviews of publications Publication as textual documents “catalog” of recommendations: prototypical situations with corresponding recommended actions Recommendation strength Recommendation with grade: A, B, or C ➠ supported by scientific evidence Recommendation without explicit grade ➠ supported by consensus within CPG working groups Implementing guidelines: so what? Almost no impact of textual dissemination Existence of knowledge “gaps” S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 3/20
Context Material Method Results Discussion and conclusion Guideline-based clinical decision support systems Guideline-based clinical decision support systems (CDSSs) CPGs are the knowledge resource Computerized model of CPG content Patient-centered recommendations at decision time (Some) evidence of impact on practice Modeling the knowledge base of a CDSS Knowledge engineering approach From explicit textual statements to a formalized representation Often requires interpretation assumptions S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 4/20
Context Material Method Results Discussion and conclusion The guiding mode of ASTI (ASTI-GM) ASTI project (Computerized Support for Therapeutic Strategy) A prototype guideline-based CDSS Therapeutic prescribing in primary care AHT, dyslipidemia, diabetes, smoking cessation, AF Patient follow up, order critiquing, guiding module ASTI guiding mode Knowledge base as a decision tree A nosological repository of patient profiles with associated therapeutic recommendations Systematic modelling Exhaustive coverage through a completion step Combination of different knowledge sources Synthesis and conflict resolution with an expert ➠ Output might not be explicitly supported by CPGs S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 5/20
Context Material Method Results Discussion and conclusion Problem statement and objectives What is the evidence status of the recommendations issued by ASTI-GM? Which recommendations correspond to evidence-based statements, to consensus-based statements in the CPGs, or are not explicitly supported by the CPGs? Which ones are used in practice? How clinical practice could actually be evidence-based? S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 6/20
Context Material Method Results Discussion and conclusion Problem statement and objectives What is the evidence status of the recommendations issued by ASTI-GM? Which recommendations correspond to evidence-based statements, to consensus-based statements in the CPGs, or are not explicitly supported by the CPGs? Which ones are used in practice? How clinical practice could actually be evidence-based? Objectives 1 Characterize the evidence status of a recommendation in ASTI-GM KB 2 Analyze the status theoretical distribution in the KB 3 Analyze the status distribution on a patient sample S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 6/20
Context Material Method Results Discussion and conclusion Modelling AHT management French AHT management CPGs (2005) AHT management principles Identification of the clinical situation (comorbidities, risk factors) Identification of the current treatment wrt recommended treatment plan [T1, T1+T2, T1+T2+T3] ➠ In case of inefficiency, add drug ➠ In case of contraindication, substitute drug Modelling principes 2 Atomisation, deabstraction, and desambiguisation steps Knowledge completion step: Implicit criteria Implicit situations Contribution of implicit medical knowledge 2Shiffman et al. Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation. J Am Med Inform Assoc 2004, 11(5);418-426. S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 7/20
Decision tree Coronary disease yes no Antecedent of stroke yes no Clinical ATCD of stroke Renal disease level � diabetes yes no � elderly Diabetes yes no � bitherapy Microalbuminury � CI to ACEi yes no � prior tt by ARBs + TDs Ederly � ARBs + TDs + CCBs + yes no statin + aspirin + Health meas. Current treatment yes no Treatement type mono quadri and more bi tri Therapeutic CI to ACEi level yes no Prior tt by ARBs + TDs yes no Efficient treatment no ARBs + TDs + CCBs + statin + aspirin + HM
Non explicitly supported recommendation
Context Material Method Results Discussion and conclusion Data collections 1 Extended KB of ASTI-GM Path in the decision tree = a conjunction of decision criteria + therapeutic recommendations ➠ 44,571 theoretical patient profiles 2 A data sample of actual hypertensive patient Extracted from a GP medical practice (March 2007) Selection of hypertensive patients Selection of orders posterior to December 2005 with antihypertensive drugs Collection of patient data at decision date ➠ 435 actual patient profiles S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 10/20
Context Material Method Results Discussion and conclusion Evidence status definition Assumption: The status of a recommendation can be characterized from the criteria of its patient profile Definition: A profile P has the evidence status of the recommendation it supports, or is eligible for 3 evidence status: Evidence-Based (EB): explicit statement with grade (A, B, C) Consensus-Based (CB): explicit statement without grade Non-Supported (NS): no explicit statement in the CPGs 3 variable categories reusing ASTI-GM modelling Clinical criteria: 9 comorbities (elderly, antecedent of stroke, myocardial infarction, stable angina, ischemic cardiac failure, diabetes, microalbuminury, renal disease, left ventricle hypertrophy) Current level of drug association (no treatment, mono-, bi-, tri-therapy...) Drug contraindications (CI to ACE i or BB) S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 11/20
Context Material Method Results Discussion and conclusion EB profiles P is “clinically EB” ( EB cl ) if there exists at most one comorbidity among elderly, antecedent of stroke, MI, stable angina, ischemic cardiac failure, (diabetes ∧ microalbuminury) for which explicit EBM statements are provided in CPGs. P is “therapeutically EB” ( EB th ) when treatment is initialized ( no current treatment ), for which evidence exists. P is “EB with respect to contraindications” ( EB ci ) if there are no contraindications (except in the case of ischemic cardiac failure where a graded recommendation exists when ACE i are contraindicated). EB ( P ) = EB cl ( P ) ∧ EB th ( P ) ∧ EB ci ( P ) S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 12/20
Context Material Method Results Discussion and conclusion CB profiles P is “clinically CB” ( CB cl ) in some contexts explicitly described in CPGs and for which consensus-based advices are provided: renal disease alone, left ventricle hypertrophy alone, (renal disease ∧ diabetes), (myocardial infarction ∧ ischemic cardiac failure) . P is “therapeutically CB” ( CB th ) when the current treatment level is at most a bitherapy since these CPGs recommend up to tritherapies. P is “CB with respect to contraindications” ( CB ci ) only for CI to ACE i (except when explicitly mentionned with grade) CB ( P ) = ¬ EB ( P ) ∧ ( CB cl ( P ) ∨ EB cl ( P )) ∧ ( CB th ( P ) ∨ EB th ( P )) ∧ ( CB ci ( P ) ∨ EB ci ( P )) S´ eroussi, Bouaud, Denk´ e, Julien, Falcoff MIE 2009, Sarajevo, BH 13/20
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