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Evidence Based Medicine Critical Appraisal
Evidence Based Medicine Critical Appraisal
Evidence Based Medicine Critical Appraisal
Patients Name
Target Disorder:
Learner:
3-part Clinical
Question
Outcome:
individual experience
Determines the best evidence relevant to a
CRITICAL APPRAISAL
TYPE OF CLAIM
Claims of Effectiveness
Claims of Accuracy
Claims on Causation
Claims on Prognosis
o
o
o
o
TESTS FOR:
Drug treatment
Diagnostic tests
Cause-and-effect
Results
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STUDY DESIGN
o Cohort
o Case-control
Therapy
o RCT
Prognosis
o Cohort
o Cohort
Harm
o Case-control
o Cross-sectional
Diagnosis
o case-control
Economic
o Cost-effectiveness analysis, etc.
*These domains are usually addressed by different study designs.
REMEMBER THIS. ~Dra. Sosa
*RCTs cannot be done is rare diseases (i.e. SSPE), in cancer, or
when proven treatments already exist
Etiology
*The 2nd question here is better than the 1st question because of
its compliance with the PICO + Study design architecture.
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 2 of 14
***
These are an
example of a
Critically
Appraised Topic
(CAT) for
Diagnosis and an
Appraisal Form for
Diagnosis used in
EBM are forms
needed to be filled
up.
By using these
forms, a researcher
will already know if
the article is worth
reading and
utilizing for his or
her study, even by
just looking at the
validity criteria
alone.
***
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 3 of 14
***
These are an example of a
Critically Appraised Topic (CAT)
for Treatment/Therapy and an
Appraisal Form for
Treatment/Therapy, also forms
needed to be filled up.
***
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 4 of 14
ASKING
Collaborative answer of Aubrey Medina & Aibhen
Naguna: Tell your uncle that GeneXpert is a relatively new
test is not standard for MDR-TB diagnosis, so we will have to
search first for the evidence for its usefulness.
Focused question: Among 40- to 50-year old patients with
tuberculosis (P), is GeneXpert (molecular test) a more
sensitive and specific test (I) for the diagnosis of MDR-TB
(O) as compared to the gold standard, sputum
examination (C)?
Study design: Cross-sectional study
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 5 of 14
I. EVALUATING DIRECTNESS
Does the study provide a direct enough answer
to your clinical question in terms of:
P = patient population with a certain
disease;
I = the intervention( or treatment) to be
administered;
C = the comparison;
O = the outcome( or condition ) that the
treatment are intended to prevent or
promote; and
M = Methodology?
COMPARE THE CLINICAL QUESTION WITH
Clinical Question
(Researcher)
Research Question
(Article appraised)
P
I
C
O
M
*I purposely left this table for you to fill out
*This shows what the reference stand is and how the samples were obtained.
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 6 of 14
TEST
RESULT
Disease
present
Disease
absent
TOTAL
REFERENCE STANDARD
Disease
Disease
Present
Absent
True
False
Positive
Positive
(A)
(B)
False
True
Negative
Negative
(C)
(D)
A+C
B+D
TOTAL
A+B
C+D
A+B+C+D
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 7 of 14
UTILITY
FORMULA
Sensitivity (Se)
Specificity (Sp)
Positive Predictive
Value (PPV)
Negative
Predictive Value
(NPV)
DEFINITION
There is a 64.28%
probability of the
presence of
pulmonary
tuberculosis in
positive sputum
tests
Probability of disease in a
patient with a positive test
result
There is a 93.75%
probability of the
absence of
pulmonary
tuberculosis in
negative sputum
tests
( + )
( + )
-or-
( + )
( + )
-or-
Likelihood ratio
for negative result
(LR-)
75% of people
without pulmonary
tuberculosis will
have a negative
sputum test
Proportion of people
without the disease who
have a negative test for the
disease
+ =
Likelihood ratio
for positive test
result (LR+)
*Adapted and edited from the previous transcription Dra. Carnates Data Collection lecture
+ =
REFERENCE STANDARD
TEST
RESULT
Disease
present
Disease
absent
TOTAL
Disease Present
Disease Absent
TOTAL
Sensitivity
100-Specificity
A+B
100-Sensitivity
Specificity
C+D
A+C
B+D
A+B+C+D
*NOTE: These are not formulas; these simply show the principle that sensitivity and specificity decrease when the results become inaccurate.
*Although specificities, sensitivities, PPVs, and NPVs are already given, these are not enough. An optimal appraisal would involve
calculations of likelihood ratios (LRs), since the element of comparison is present.
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 8 of 14
Pretest Odds
V. INDIVIDUALIZING RESULTS
How will the results affect the probability of
disease in your patients?
WILL THE RESULTS HELP ME IN CARING FOR MY
PATIENT?
Will the reproducibility of the test result and its
interpretation be satisfactory in my setting?
Are the results applicable to my patient?
Will the results change my management?
Will patients be better off as a result of the test?
INDIVIDUALIZING RESULTS
Step 1: Estimate the pre-test probability (depends
upon the researcher)
Step 2: Convert pretest probability to odds
Step 3: Multiply pretest odds by the LR of test
result to get the post-test odds
Step 4: Convert post-test odds to post-test
probability in percent
PRETEST PROBABILITY AND ODDS
Pretest Probability
Piece of the pie divided by the whole pie
Expressed in percentage
For example, for a value of 60 out of 100 =
60% ( 60/100)
*Probability of disease
*Since the post-test probability has increased to 99% from the
pre-test probability of 60%, action to treat can now be taken with
more conviction and commitment.
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 9 of 14
NORMOGRAM
For easier post-test probability determination
without calculations, a researcher may just opt to
use a normogram
This requires the presence of the likelihood ratio
A ruler is placed on the given pre-test probability
and continued onto the likelihood ratio, and the
value to which the ruler lands on at the end will be
the post-test probability value
APPRAISING VALIDITY
Were patients randomly assigned to treatment
groups? (Randomization)
Was allocation concealed? (Allocation
concealment)
Were baseline characteristics similar at the start
of the trial? (Matching)
Were patients, caregivers, and/or study personnel
blinded to the treatment assignment? (Blinding)
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 10 of 14
METHODS
and here as well. If none is indicated, then it considered that no methodology exists.
Continuous variable
e.g. change in weight, change in
quality of life scale, change in BP
Values that are numerical
INTERPRETING RESULTS
How large was the effect of the treatment?
How precise was the estimate of the treatment
effect?
HOW LARGE IS THE EFFECT OF TREATMENT?
Compare the outcomes in the treatment and
control groups
Outcomes:
Dichotomous variable
e.g. dead or alive, hospitalized or not
Values that are nominal
MEASUREMENT OF ESTIMATES
Dichotomous variable
Relative Risk (RR)
Relative Risk Reduction (RRR)
Absolute Risk Reduction (ARR)
Continuous variable
Mean difference
Example: Express your change in weight, if it went down from 80kg (WC) to 60kg (WT)
VARIABLE
FORMULA
VARIABLE
DESCRIPTION
Absolute Risk
Reduction
= Risk change
Usually in percent (%)
Relative risk
Relative Risk
Reduction
FORMULA
OUTCOME
I lost 20kg (2% of my
risk)
My risk is now 0.75 (I now
weigh 75% of what I used to
weigh)
I lost 25% of my risk( I lost
25% of my weight)
INTERPRETATION
> 0% = Treatment is beneficial
= 0% = Treatment has no effect
< 0% = Treatment is harmful
< 1.0 = Treatment is beneficial
= 1.0 = Treatment has no effect
> 1.0 = Treatment is harmful
> 0% = Treatment is beneficial
= 0% = Treatment has no effect
< 0% = Treatment is harmful
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 11 of 14
EXAMPLE
Treated = 53%
Failure = 47% = (Rc)
New drug: Lamotrigine
Treated = 29%
Failure = 71% = (Rt)
VARIABLE
SOLUTION
INTERPRETATION
ARR
RR
RR = 0.71/.47= 1.5
RRR
Treated = 53%
Failure = 47% (Rc)
New Drug: Valproic Acid
Treated = 58%
Failure = 42% (Rt)
VARIABLE
ARR
RR
SOLUTION
=
ARR = 0.47 0.42 = 0.05
INTERPRETATION
OUTCOME
RR = 0.42/.47= 0.89
RRR
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 12 of 14
A
B
C
D
C
B
*A. RR = 2.3 (95%CI: 1.5, 3.1); B. RR = 0.63 (95% CI: 0.53, 0.73);
C. RR = 0.98 (95%CI: 0.50, 1.50); D. RR = 0.98 (95% CI: 0.95, 1.02)
----------------------------------------------------------------------------------------------------------------------------- -------------------------A. Definitely Harmful, but with a wide CI; B. Definitely beneficial, and with a short CI
C. Equal; D. May be beneficial, but still inconclusive
----------------------------------------------------------------------------------------------------------------------------- -------------------------Since we aim for a shorter confidence interval, B has the best confidence interval. Risk reduction as reflected by failure rates is
much more important than success rates
Transcriber/s: Marie Mae Pantolla, Craig Angelo Reyes
Formatting: Craig Angelo Reyes
Editor/s: John Henry Amper
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 13 of 14
NNT = 100/ARR
ARR = 0.05
NNT = 100/0.05 = 2000
Interpretation: You need to treat 2000
patients with seizures to treat 1
absence epilepsy
NNT x cost of treatment
ASSESSING APPLICABILITY
Are there biologic issues that may affect
applicability of treatment?
Are there socio-economic issues affecting
applicability of treatment?
INDIVIDUALIZING THE RESULTS
Are the likely treatment benefits worth the
potential harm and costs?
Compute for NNT (Number Needed to Treat)
SUMMARY: EBM
Clinical
problem
Experience
and expertise
Authoritative
practice
Decision
making
Clinical
problem
Ask answerable
questions
Ward rounds,
Clinics
Apply evidence
in decision
making
Acquire
(and appraise)
evidence
Journal club
Managing
bringing change
in practice
Appraise
evidence
LIFE-LONG LEARNING
Morbidity/mortality
meeting
Audit
Integrate
evidence
into practice
REFERENCES
-END-
TRANSCRIPTION DETAILS
BASIS
REMARKS
Aubrey-cordings; PD Group 25
Latest PPT;
RECORDINGS + NOTES DEVIATIONS
10-15%
CREDITS
Past topics
(Chrismark, Ken, and Seane)
Of all 18 COMMED topics, this will go on as big boss of them all. Toxic. Dangerous. Nasty. Anyhow, its done, its made, and its ready
for use in kicking Evaluation 6s ass. This is the last transcription for FCM 2, and thanks for the support and patronage. Thanks also for
giving me and Brother Nimrod the opportunity to be your COMMED liaison officers. Godspeed, and see you on the other side.
D L S H S I M e d i c i n e B a t c h 2 0 1 6 | 14 of 14