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Making Evidence More Accessible Using Pictures Rod Jackson 2009
Making Evidence More Accessible Using Pictures Rod Jackson 2009
Making Evidence More Accessible Using Pictures Rod Jackson 2009
P
Comparison Group
Exposure Group
Time
O T
Outcomes
EBP Step 2: ACCESS - search for the best evidence to answer your questions
EBP Step 4: AGGREGATE the relevant information & make an evidence-based decision: the X-factor
Step 5
APPLY
Implementation!
GATE
Graphic Approach To Epidemiology
Graphic Appraisal Tool for Epidemiology Graphic Architectural Tool for Epidemiology
www.epiq.co.nz
O T
EG CG
a c
b d
Maintenance
P
Comparison Group
Exposure Group
Time
O T
Outcomes
Participants
Study Setting
Eligible Participants
Participants
EG
CG
Outcomes (O)
yes
Dis-ease
no
O
c d
Outcomes (O)
Time (T)
incidence
prevalence
All epidemiological studies involve measuring the OCCURRENCE of disease Occurrence = Numerator Denominator
D
N
Denominator (Participants)
O = ND
Numerator (Outcomes)
EG CG
a c
b d
Occurrence = N D
P
Denominator 1: Exposure Group EG Numerator 1: a
Exposure Group Occurrence: EGO = a EG
EG CG
a c
b d
Analyses
EG CG
person-time exposure
a c Exposure Group Occurrence: EGO = a (EG x T)
b d
Numerator 2 = b
P
Allocation
Recruitment
Maintenance
Study appraisal
How well was the study done? Was it ok ( or +) or not ok (#)? or unclear (?) or not applicable (n/a) no study is perfect!
RAMBO
P appropriate Recruitment? participants representative of target population C
Study setting & eligibility criteria well described? Recruit random sample OR Recruit consecutive eligibles
O
appropriateness depends on study question
RAMBO
appropriate Allocation process? were EG & CG comparable
Allocation process well described? If allocated by investigators: Allocated randomly (e.g drugs) AND Concealed allocation OR If allocated by measurement (e.g. smoking): Adjusted for differences between EG & CG (e.g. statistical or matching)
Allocate
EG CG
RCT: Allocate randomly by Cohort: Allocate by investigators (e.g drugs) measurement (e.g. smoking)
EG CG
EG CG
RAMBO
good Maintenance? did participants remain in allocated groups (EG & CG)
EG CG
Participants &/or investigators blind to exposure (and comparison exposure)? Compliance high & similar in EG & CG Contamination low & similar in EG & CG Co-interventions low & similar in EG & CG Completeness of follow-up high & similar in EG & CG
P A EG CG
RAMBO
Blind or Objective? measurements & processes
Allocation concealed (blind) if randomised EG & CG measurements well described Outcome measurements well described Allocation/Measurement process similar for all participants
O
T
If measurement not objective (eg. automated or definitive) were assessors blind to exposure (and comparison exposure)
The GATE approach: every epidemiological study hangs on the GATE frame
There is only one basic study design: Cohort (& case-control) studies aetiology / prognosis / intervention RCT (a randomised cohort study)interventions Cross-sectional studies - diagnosis
Comparison Group
Time
Outcomes
Randomised controlled trial - cohort study where exposure allocated by randomisation process P Participants
Allocated by randomisation Exposure Group
Comparison Group
Time
Outcomes
Time
Outcomes
Before-after study
Participants
C
Exposure Group
Comparison Group
E O
Outcomes
Time
Cross-over trial
Participants
E1 C2 Comparison Group 2 E2 C1 O
Comparison Group 1 Outcomes
Exposure Group 2
Time
real-life time
Cross-sectional study
P
Participants
Comparison Group
Time
Outcomes
Disease +ve
EG CG
Disease -ve
Test
+ -
a b O
c d Likelihood +ve test if D -ve: CGO = a CG
Disease +ve
EG CG
Disease -ve
Test
+ -
O c d
Likelihood -ve test if D -ve: CGO = d CG
Test +ve
EG CG
Test -ve
Disease
+ -
a c
b d
Disease +
EG CG
CG EG
a c
b d
+ -
Test -
Disease +
EG CG
CG EG
a c
b d
+ -
Test -
a c
b d
Participants
a
eg
b
cg
Exp Group
EG
CG
Comparison Group
controls
a
Time
cases
Outcomes
E1 E2 E3 C
Comparison
Continuous measure of Exposure: e.g. body mass index Continuous measure of Outcomes e.g. lipids
E
high..med..low
medium high
CATS
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