Mulaz Bustani Regenstrief Conference Slides

Selecting An Intervention In A Complex Adaptive Health Care System & Evaluating Its Impact Malaz Boustani, MD, MPH Indianapolis Discovery Network for Dementia Indiana University center for Aging Research Regenstrief Institute, Inc www.indydiscoverynetwork.com

The US Health Care System Report Card ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Boustani, 2007; IOM, 2001, Westfall, 2007; Faison et al, 2003;

Independent Agent E Other Local CASs Stress Feedback Independent Agent D Independent Agent C Independent Agent B Independent Agent A Changing Environment Connection The health care CAS Emergent Performance

Complex Adaptive Health Care System ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Holden, 2005; Litaker et al. 2006 Feb.

Complex Adaptive Health Care System ,[object Object],[object Object],[object Object],[object Object],Holden, 2005; Litaker et al. 2006 Feb.

The Paradox of CAS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Holden, 2005; Litaker et al. 2006 Feb; Stoebel et al, 2005.

The Paradox of CAS ,[object Object],[object Object],Holden, 2005; Litaker et al. 2006 Feb; Stoebel et al, 2005.

How Can I Assess CAUSALITY? Can I Predict? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],How Can I Assess CAUSALITY? Can I Predict?

The 9 Principles of Selecting a Change in a Complex Health Care System ,[object Object],[object Object],[object Object],[object Object],[object Object],Paul E Plsek. 1997.

The 9 Principles of Selecting a Change in a Complex Health Care System ,[object Object],[object Object],[object Object],[object Object],Paul E Plsek. 1997.

Reflective Adaptive Process ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Stroebel et al.2005.

The RAP Principles ,[object Object],[object Object],[object Object],[object Object],[object Object],McDaniel et al, 2003; Stroebel et al.2005; Boustani et al 2007.

Evaluation of Interventions in CAS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Evaluating the Impact of the Selected Interventions

Methodological Quality “ Extent to which a study’s design, conduct, and analysis has minimized selection, measurement , and confounding biases” West et al, 2002

The “Safeguards” Evidence ,[object Object],[object Object],[object Object],[object Object],[object Object],Guyatt et al, 1993; West et al, 2002

The Hierarchical Strength of Evidence in Treatment Decisions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Guyatt et al, 1993; West et al, 2002

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Proposed Evaluation Process

Applying N-OF-1 RCT in CAS ,[object Object],[object Object],[object Object],[object Object]

N-OF-1 RCT in CAS 0----------1------------2-----------3-----------4----------5-----------6------------7-----------8-------------9-----------10------------11------------12 Time Outcome Data Outcome Data Outcome Data Outcome Data Outcome Data Outcome Data Outcome Data R to Int R to Int R to Int R to UC R to UC R to UC

Issues of –OF-1 RCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Guyatt et al, 1986; Price & Evans, 2002

Issues of –OF-1 RCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Guyatt et al, 1986; Price & Evans, 2002

The Requirement for N-of-1 RCT: ,[object Object],[object Object],[object Object],[object Object],Guyatt et al, 1986; Price & Evans, 2002

The Science of CAS ,[object Object],[object Object]

The Science of CAS ,[object Object],[object Object],[object Object],[object Object]

Mulaz Bustani Regenstrief Conference Slides

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