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3 . Clancy CM et al Evidence based decision making:global evidence local decision Health affairs Clancy CM et al, Evidence-based decision making:global evidence, local decision. Health affairs. 2005;24:151 Muir Gray, University of Oxford. Evidence-based decision-making is an essential element in the provision of health care for the 21 st Century.

5 J. Bruce Moseley, M.D. etc A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. New Engl J Med. 2002:347: # Harrison s Principles of Internal Medicine 15th Ed (2001)

8 A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee J. Bruce Moseley, M.D. New Engl J Med.

11 Corticosteroids prior to preterm delivery Reviewer: Crowley P January 1996

17 Statement on Issues to Be Considered Before New Surgical Technology is Applied to the Care of Patients t by the American College of Surgeons 1.? 2.? 3.? 4. -?

19 Halfway Technology

20 High Technology

22 The Way for Best Decision i Making Governing Rule Philosophy Information Value Affordability: Reality Decision Making Method

23 Governing Rule

25 Governing Rule European Countries: focus on safety, effectiveness and cost-effectiveness USA: CMS for Medicare: Reasonable and necessary -Social security Act, Title XVIII,section 1862(a)(1)(A) BCBSA: Medically necessary - 5 criteria Kaiser Permanente: Kaiser Permanente: Medically appropriate

26 Medically necessary

27 medically necessary/medical necessity

28 Blue Cross and Blue Shield Association medically necessary; 5 criteria

30 the Decreasing Variation in Medical Necessity Decision Making Sara Singer, et al. Center for Health Policy, Stanford University. it August, 1999

31 Effective ;? benefits / potential harmful effects. Health outcomes;? Scientific evidence; ; ( ) ; health outcomes? ;. the Decreasing Variation in Medical Necessity Decision Making Sara Singer, et al. Center for Health Policy, Stanford University. August, 1999

32 ; (scientific evidence) ; the Decreasing Variation in Medical Necessity Decision Making Sara Singer, et al. Center for Health Policy, Stanford University. August, 1999

33 State Law Regulation of Medical Necessity S R b t l C t f H lth S i R h d P li D t t f H lth P li Sara Rosenbaum et al. Center for Health Services Research and Policy, Department of Health Policy, The George Washington University School of Public Health and Health Services. MEDICAL NECESSITY IN PRIVATE HEALTH PLANS. 2003

34 Massachusetts defines medical necessity as health care services that are consistent with generally accepted principles of professional medical practice. Mass. Ann. Laws ch. 176O (1) (2001).

35 Hawaii defines medical necessity if it is recommended by the treating physician or treating licensed health care provider, is approved by the health h plan s medical director or physician i designee, and is: (1) For the purpose of treating a medical condition; (2) The most appropriate delivery or level of service, considering potential benefits and harms to the patient; (3) Known to be effective in improving health outcomes; provided that: (A) Effectiveness is determined d first by scientific evidence; (B) If no scientific evidence exists, then by professional standards of care; and (C) If no professional standards of care exist or if they exist but are outdated or contradictory, then by expert opinion;and (4) Cost-effective for the medical condition being treated compared to alternative health interventions, including no intervention. For the purposes of this paragraph, cost-effective shall not necessarily mean lowest price. HRS 432E-1.4 (2000) (IRO Statute) This Hawaii s definition, enacted in 2000, is virtually identical to the prototype definition proposed in 1999 by Singer et al.

40 Value

42 Value

43 Committee - Decision Making Process

46 Carolyn M. et al Evidence-based decision making. Health Affairs. 2005;24:151

48 P Knipschild. Systematic Reviews: Some examples BMJ 1994;309:

55 Data, Information, Knowledge, and Wisdom

57 Classification of content t of the human mind and Medicine

58 CARDIAC RESYNCHRONIZATION THERAPY

59 Data

60 Information

63 Knowledge

77 National Emphysema Treatment Trial (NETT)

79 CED

80 UK Decision Making Process Published evidence HEALTHCARE PROFESSIONAL GROUPS PATIENT GROUPS; GENERAL PUBLIC SOCIAL VALUE JUDGEMENTS Review of POLICY NHS; Evidence MAKING PUBLIC SECTOR Unpublished evidence??? ACADEMIA INDUSTRY Academic group or professional collaborating centre Standing independent advisory committee or ad hoc expert group

94 $100,000/QALY $20,000/QALY

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101 FEED BACK

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DBPIA-NURIMEDIA

DBPIA-NURIMEDIA 27(2), 2007, 96-121 S ij k i POP j a i SEXR j i AGER j i BEDDAT j ij i j S ij S ij POP j SEXR j AGER j BEDDAT j k i a i i i L ij = S ij - S ij ---------- S ij S ij = k i POP j a i SEXR j i AGER j i BEDDAT