Lesson 1.1: Health care bases

What is healthcare?

Healthcare comprises the services and activities aimed at promoting, protecting, and restoring health

What does healthcare include?

• Clinical practice: direct individualized patient care: prevention diagnosis, treatment and follow up

• Health promotion: education education and interventions aimed at improving healthy habits and behaviours

• Population-based prevention: screening programmes, vaccination, and pother interventions targeting groups or population

• Public health and epidemiological surveillance: monitoring and control of diseases and health risks affecting the population

• Healthcare management and coordination: organization of the resources and services rewuired to provide care

How is the healthcare system made up?

Institutions, Healthcare professionals, resscources and services

What are the possible Organizations of healthcare systems?

Public, private or mixed models, depending on how the healthcare is financed and provided

Comparison of the different healthcare systems

What are the levels of healthcare?

Primary care: First point of contact with healthcare system. Includes health promotion diagnosis and treatment of common condition, follow-up and coordination of care

Secondary care: specialist care, usually following refferal from primary care. (Cardiology, dermatology, oral and maxillofacial surgery)

Tertiary care: Highly specialized and complex care requiring advanced ressources and technology (organ transplantation, complex neurosurgery, specialized oncology)

What level of healthcare is dental care?

Much of dental care can be considered primary care, while more complex cases are refered to specialist levels of care.

What is evidence-based medicine?

Conscientous, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Who established the evdience-based medicine?

McMaster University team led by physicians David Sackett and Gordon Guyatt.

What does evidence-based medicine integrate and what is the goal?

1. The best evidence

2. The clinical experience

3. The patients values

To ensure that everyday medical practice is based on scientific evidence rather than assumptions or beliefs.

Which model turns a specific clinical problem into an evidence-based?

Five step model (5 A ´s) to tun a specific clinical problem into an evidence-based clinical decision.

What are the steps of the 5 step model?

1. Ask

2. Acquire

3. Appraise

4. Apply

5. Assess

What does the 5 step model do?

Describes the process followed by the healthcare professional, from the moment a clinical question arises to evaluating whether the decision made was effective.

Step 1

Ask

Turn the need for information into a clear and focused clinical question based on given clinical problem (regarding prevention, diagnosis, prognosis, treatment).

• In patients with lung cancer, does radiotherapy provide better outcomes than chemotherapy alone?

Step 2

Acquire - Search for Information

Search literature for relevant and appropriate original research articles to answer the clinical question (best available evidence).

Searching for evidence is part of continuous learning process, as scientific knowledge is constantly evolving.

Relying solely knowledge acquired during training or on clinical experience may lead to outdated clinical practice.

A high number of paper with scientist and clinical relevance is not a proof for reliability if the amount of total papers is very high.

Step 3

Appraise - Critical appraise

Determine whether the evidence found is valid, relevant and appliable to the clinical problem before using it to make a decision.

Is it valid? -> Is rhe study well designed? is there a risk of bias?

What are the results? -> What is the magnitude and precision of the effect?

Is it applicable? -> Are the results relevant to my patient or clinical problem?

Step 4

Apply

It consists of integrating the best available evidence with clinical expertise and the patients characteristics, needs and preferences to make a clinical decision.

Step 5

Assess - Evaluation of outcomes

Review the process and perform a critical self assessment to identify errors and improve the process iteratively.

• Determine whether the results were satisfactory in clinical practice

• Reassess our own actions

• Explore alternatives

What are the Bioethics principles?

• Non maleficience: Obligates to protect patient from potential harms of medicine

• Beneficence: Moral obligation to seek the patients well being while respecting their preferences

• Patients autonomy: Respect for the patients decisions

• Justice: Commits to the fair and equitable distribution of healthcare ressources

What is the informed consent and what does it include?

Procedure that ensures the subject voluntarily expresses:

• Their intention to participate in the intervention and/or research

• After understanding the information provided

• Study objectives, benefits, discomforts, potential risks and alternative, their rights

How is the procedure?

Communication with the patient: Information -> decision -> signing the document

What does the informed consent base on?

A fully informed patient can participate in choices about his health care

• Legal and ethical right the patient has to direct what happens to his body

• And from ethical duty of the physician to involve patient in his healthcare

What is the content of the informed consent?

• Nature of decision/procedure

• Reasonable alternatives to the proposed intervention

• Relevant risks, benefits, and uncertainties related to each alternative

• Assessment of patient understanding

• Acceptance of the intervention by the patient

How much information is considered as adequate?

• Reasonable physician standard: what would a typical physician say about this intervention?

• Reasonable patient standard: What would the average patient need to know in order to be an informed participant in the decision?

• Subjective standard: What would this patient know and understand in order to make an informed decision?

What kind of interventions require informed consent?

• Surgery

• Anesthesia

• Other invasive procedures