View
150
Download
2
Category
Preview:
Citation preview
Sumandeep Vidyapeeth_20151
Dr Monali ShahProfessor, Dept of Periodontology
Steps Of Evidence Based Decision Making And Concept Of Critical Appraisal
Sumandeep Vidyapeeth_20152
Evidence based health careEvidence based practice in health
care industry is relatively new philosophy of clinical practice and a life long learning, which emphasizes a systematic and rigorous assessment of evidence for use in decision making in health care.
Sumandeep Vidyapeeth_20153
1. 2. 3. 4. of Evidence Based Practice 0NE Goal
– improve health of people through high quality care
TWO principles– Evidence has hierarchy - Evidence alone is not important
THREE components- Evidence - Expertise - Expectation
FOUR steps- Ask - Acquire - Appraise -Apply
Sumandeep Vidyapeeth_20154
Patient-Doctor Dyad – Not really changed through time
The point at which effecting Doctor-Patient communication and planning is informed by the best evidence
Three interacting realms of EBD
Sumandeep Vidyapeeth_20155
“Best Research Evidence” BEST means high level evidence with valid
study design and clinically effective results which can be applied locally
Sumandeep Vidyapeeth_20156
“Clinical expertise”Expertise in :
Noting signs and symptomsTaking a good historyInterpreting results of testsThinking analytically
Sumandeep Vidyapeeth_20157
“Patient Values”
Time consumption Living arrangements Working arrangements Medical care vs. other goods and services Cost of therapy
Sumandeep Vidyapeeth_20158
Evidence based decision making in health care Ultimately lead us to shared decision
Sumandeep Vidyapeeth_20159
Process Of Evidence Based Decision Making:
1. Asking specific relevant answerable questions2. Searching for the best evidence3. Reviewing and critically appraising the evidence4. Applying this information in a way to help the clinical
practice.
Sumandeep Vidyapeeth_201510
The evidence based practice can be divided into the following components:
Identifying area of uncertaintyAsking a relevant, focused, clinically important question that is answerable Selecting the most likely database for search Searching and appraising the evidence found Assessing the clinical importance and applicabilityActing on and appropriately applying the evidenceAssessing the outcomes of your actions and storing
the data
Sumandeep Vidyapeeth_201511
Formulating answerable question
Sumandeep Vidyapeeth_201512
Most fundamental/structured question A good question
Information needs and problems
(P) Problem
OR information required --who or whom
(I) Intervention --what
( C) comparison –other option well
established* better
or not
(O) outcome --what u want to
investigate
Sumandeep Vidyapeeth_201513
Most common type of questions:
Type of study:
Diagnosishow to select and interpret diagnostic tests
prospective, blind comparison to a gold standard or cross-sectional
Therapyhow to select treatments that do more good than harm and that are worth the efforts and costs of using them
randomized controlled trial > cohort study
Prognosishow to estimate the patient’s likely clinical course over time and anticipate likely complications of disease
cohort study > case control > case series
Harm/Etiologyhow to identify causes for disease
cohort > case control > case series
Sumandeep Vidyapeeth_201514
HOW TO FIND CURRENT BEST EVIDENCE?
If you don’t find evidence does not mean evidence is not there…..??
Sumandeep Vidyapeeth_201515
Searching is a skill
Sumandeep Vidyapeeth_201516
Critical appraisal…?
Learn how to find out what not to believe that is
published
Critical appraisal will help us to decide whether reported piece of research Is good enough to be used in decision making
Sumandeep Vidyapeeth_201517
Sumandeep Vidyapeeth_201518
What is critical appraisal Critical appraisal is the process of carefully and
systematically examining research to judge its
trustworthiness, its value and relevance in a particular
context. (Burls 2009)
Sumandeep Vidyapeeth_201519
Various check list for critical appraisal
CASP www.sph.nhs.uk/what-we-do/public-health-
workforce/resources
SIGN guideline developer’s handbook
http://www.sign.ac.uk/guidelines/fulltext/50/annexc.html
CEBMH
http://cebmh.warne.ox.ac.uk/cebmh/education_critical_app
raisal.htm
Sumandeep Vidyapeeth_201520
Critical appraisal
Relevance assessment
Validity assessment
Results assessment
Application assessment and application
Sumandeep Vidyapeeth_201521
Relevance assessment Determine whether the study is relevant to your clinical
question. Need to compare your PICOT with research PICOT
Clinical question Research question
P 25 years healthy female Healthy adultsI Powered brush Powered brushC Manual brush Manual brushO Plaque control and tooth
whiteningPlaque control, BOP, stains
T 6 months
Sumandeep Vidyapeeth_201522
Validity assessment
Sumandeep Vidyapeeth_201523
Different study designs need different approaches Surveys
*sampling technique*response rate
Cohort studies*appropriate cohort identified*adequate follow up
Randomized controlled trials*random and concealed allocation*blinding*loss to follow up
Sumandeep Vidyapeeth_201524
Validity assessment (For RCT)Randomized assignmentRandomization concealedBlinding Both group treated equallySufficiently long follow upGroup similar at start of the study
Sumandeep Vidyapeeth_201525
Validity assessment (For Systematic review and meta analysis)1. Did the systematic review address a focused
clinical question?
2. How detailed and exhaustive was the search for studies?
3. How high was the quality of the selected studies?
4. Data handling, publication bias and heterogeneity
Sumandeep Vidyapeeth_201526
Results – size does matter
Sumandeep Vidyapeeth_201527
Result assessment Magnitude of the result Precision of the result Clinical Vs statistical significance
Did the new treatment/intervention make any difference, if yes, is it real, if real, what is the effect???
Sumandeep Vidyapeeth_201528
What does it tell us? P value Confidence interval Odds ratio Relative risk NNT
Sumandeep Vidyapeeth_201533
Lets visit forest plot
Sumandeep Vidyapeeth_201535
Sumandeep Vidyapeeth_201536
Sumandeep Vidyapeeth_201537
HeterogeneityHeterogeneity can be assessed using the “eyeball” test or more formally with statistical tests. With the “eyeball” test one looks for overlap of the confidence intervals of the trials with the summary estimate.
Are the results similar across studies? 3 tests
Eyeball” test – do they look same?Test of “Null hypothesis” for no
significant variation (p-value)Proportion of variation not due to
chance (I2)
Sumandeep Vidyapeeth_201538
Clinical Significance Clinical significance is always debated. The
statistically significant results may or may not be of
any clinical importance or value.
Sumandeep Vidyapeeth_201539
Applying Evidence to Individual Patient
Sumandeep Vidyapeeth_201540
Application Similar Patients
Are your patients similar to those in the study? Are they so different that the results can’t help yo How much of the study effect can you expect for
your patients?
Heneghan, Carl and Badenoch, Douglas. Evidence-Based Medicine Toolkit, 2nd edition. Oxford: Blackwell Publishing: BMJ Books. 2006, p. 71.
Sumandeep Vidyapeeth_201541
Application Realistic Interventions
Is the intervention realistic in your setting? Does the comparison intervention reflect your
current practice What alternatives are available?
Heneghan, Carl and Badenoch, Douglas. Evidence-Based Medicine Toolkit, 2nd edition. Oxford: Blackwell Publishing: BMJ Books. 2006, p. 71.
Sumandeep Vidyapeeth_201542
Application Right Outcomes
Have all the right outcomes been considered? Are the outcomes appropriate to your patient? Does the intervention meet their values and
preferences?
Heneghan, Carl and Badenoch, Douglas. Evidence-Based Medicine Toolkit, 2nd edition. Oxford: Blackwell Publishing: BMJ Books. 2006, p. 71.
Sumandeep Vidyapeeth_201543
What is shared decision-making? Patient and clinician share
information with each other (clinician shares medical information, patient shares personal knowledge of illness and values)
Participate in a decision-making process
Agree on a course of action
Sheridan et al Am Jrnl Prev Med 2004
Sumandeep Vidyapeeth_201545
We do not need study evidence on everything !
We have to catch him up!
But this ain‘t evidence-based.
Sumandeep Vidyapeeth_201546
Recommended