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Resident Presentations - Evidence-Based Medicine for Haematology


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Workshop facilitated for haematology residents on September 5, 2012 at the Jewish General Hospital, Montreal.

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Resident Presentations - Evidence-Based Medicine for Haematology

  1. 1. Jewish General Hospital LIFE SCIENCES LIBRARY Library Workshop 4: Resident Presentations Chantal Cassis, MD Robin Featherstone, MLIS Francesca Frati, MLISSummer/Fall 2012 Roland Grad, MDCM, MSc, FCFP
  2. 2. Workshop 4 - ObjectivesBy the end of the workshop, you will be able to:1. Present clinical EBM summaries to your peers2. Critically reflect on the practical application of a clinical study
  3. 3. Workshops July 25 - Introduction to EBM for Haematology Aug 8 - Hands-on Searching Workshops Aug 22 - Critical Appraisal Sept 5 - Resident Presentations Sept 19 - Review
  4. 4. EBM Process FormulatingWorkshop Evaluating the clinical the Process Workshop 5 question 1 Your patient for whom you are uncertain about therapy, diagnosis, or Searching Incorporating prognosis the Evidence evidence into Workshop decision-making 2 WorkshopWorkshop 3 4 Appraising the Evidence
  5. 5. Worksheets & Resources Critical Appraisal Worksheets from JAMA Evidence: Critical Appraisal Worksheets from Dartmouth (include calculations for odds ratio, relative risk, absolute risk, etc.): /research/ebm-teach.html
  6. 6. Therapy (RCTs)1 1. Are the results valid? A. Did intervention and control groups start with the same prognosis?  Were patients randomized?  Was group allocation concealed?  Were patients in the study groups similar with respect to known prognostic variables? B. Was prognostic balance maintained as the study progressed?  To what extent was the study blinded? C. Were the groups prognostically balanced as the study progressed?  Was follow-up complete?  Were patients analyzed in the groups to which they were first allocated?  Was the trial stopped early?1.
  7. 7. Therapy (RCTs), cont.2. What are the results?A. How large was the treatment effect?  What was the relative risk reduction?  What was the absolute risk reduction?B. How precise was the estimate of the treatment effect?  What were the confidence intervals?
  8. 8. Therapy (RCTs), cont.3. How can I apply the results to patient care?A. Were the study patients similar to my population of interest?  Does your population match the study inclusion criteria ?  If not, are there compelling reasons why the results should not apply to your population?B. Were all clinically important outcomes considered?  What were the primary and secondary endpoints studied?  Were surrogate endpoints used?C. Are the likely treatment benefits worth the potential harm and costs?  What is the number needed to treat (NNT) to prevent 1 adverse outcome or produce 1 positive outcome?  Is the retention of clinical endpoints worth the increase of cost and risk of harm? 
  9. 9. Harm (Cohort Studies, Case-Control Studies)2 1. Are the results valid? Cohort Studies: Aside from the exposure of interest, did the exposed and control groups start and finish with the same risk for the outcome?  Were patients similar for prognostic factors known to be associated with the outcome (or was statistical adjustment done)?  Were the circumstances and methods for detecting the outcome similar?  Was the follow-up sufficiently complete? Case-Control Studies: Did the cases and control group have the same rise (chance) for being exposed in the past?  Were cases and controls similar with respect to the indication or circumstances that would lead to exposure?  Were the circumstances and methods for determining exposure similar for cases and controls?2.
  10. 10. Harm (Cohort Studies, Case-Control Studies), cont.2. What are the results?A. How strong is the association between exposure and outcome?  What is the risk or odds ratio?  Is there a dose-response relationship between exposure and outcome?B. How precise was the estimate of the risk?  What is the confidence interval for the relative risk or odds ratio?
  11. 11. Harm (Cohort Studies, Case-Control Studies), cont.3. How can I apply the results to patient care?A. Were the study subjects similar to your patients or population?  Is your patient so different from those included in the study that the results may not apply?B. Was the follow-up sufficiently long?  Were study participants followed-up long enough for important harmful effects to be detected?C. Is the exposure similar to what might occur in your patient?  Are there important differences in exposures (dose, duration, etc.) for your patients?D. What is the magnitude of the risk?  What level of baseline risk for the harm is amplified by the exposure studied?E. Are there any benefits known to be associated with the exposure?  What is the balance between benefits and harms for patients like yours?
  12. 12. Summarizing the Evidence (Systematic Reviews)3 1. Are the results valid? A. Did the review explicitly address a sensible clinical question?  Is the underlying biology or sociology such that, across the range of interventions and outcomes included, the effect should be similar?  Did the review include explicit and appropriate eligibility criteria? B. Was the search for relevant studies detailed and exhaustive?  Were sources of evidence and search strategies specified in sufficient detail for replication  Was the likelihood and direction of publication bias considered? C. Were the primary studies of high methodologic quality?  Were clear methodological selection criteria specified?  Were all included studies accessed by these criteria? D. Were selection and assessments of studies reproducible?  Was an explicit approach used to select and extract data from all included studies?  Was study selection and assessment validated by a blinded second observer?3.
  13. 13. Summarizing the Evidence (Systematic Reviews), cont.2. What are the results?A. Were the results similar from study to study?  How similar were the point estimates?  Do confidence intervals overlap between studies?B. What are the overall results of the review?  Were results weighted both quantitatively and qualitatively in summary estimates?C. How precise were the results?  What is the confidence interval for the summary or cumulative effect size?
  14. 14. Summarizing the Evidence (Systematic Reviews), cont.3. How can I apply the results to patient care?A. Were all patient-important outcomes considered?  Did the review omit outcomes that could change decisions?B. Are any postulated subgroup effects credible?  Were subgroup differences postulated before data analysis?  Were subgroup differences consistent across studies?C. What is the overall quality of the evidence?  Were prevailing study design, size, and conduct reflected in a summary of the quality of evidence?D. Are the benefits worth the costs and potential risks  Does the cumulative effect size cross a test or therapeutic threshold?
  15. 15. Next Workshop 10:30 am to 12:30 pm Rm 519 (Dean’s conference room), McIntyre Medical Building, McGill Slides available: