Innovative EBP: Teaching NNT Through the Use of Practice, Role Play, and Story -Darcy Vavrek ND MS University of Western States Portland, OR

Today’s main points: Lecture introduces story (7 slides) –Clinical application motivates learning –Color card voting lets students see that EBP fosters intelligent discussion but not agreement Practice problems (1 slide, 1 handout) –With time management strategy Role play (4 slides, uses practice problems) –Open ended exercise breaks up lecture –Group discussion at the end motivates learning

Randomized Controlled Trials Experimental & Control Event Rates Risk Difference (RD) Numbers needed to Treat (NNT)

Surgery vs Prolonged Conservative Treatment for Sciatica Randomized Clinical Trial Severe sciatica of 6 to 12 weeks duration U.S. – multi-center 283 participants –Early surgery – 125/141 had microdiskectomy –Conservative treatment – 55/142 underwent surgery Outcomes: –Roland disability questionnaire, VAS for leg pain, patient report of perceived recovery

Control & Experimental Event Rates Event YesNo Treatmentab Controlcd Experimental event rate a/(a+b) = rate of event in treatment group Control event rate c/(c+d) = rate of event in control group

Unadjusted Conservative Care & Early Surgery Event Rates at 2 weeks Patient Reported Recovery YesNo Early Surgery8754 Conservative Care4597 Early surgery event rate 87/(87+54) = 87/141 = 61.70% Conservative care event rate 45/(45+97) = 45/142 = 31.69%

Early Surgery (n=141) Early surgery, microdiskectomy, scheduled within 2 weeks after assignment and cancelled only if spontaneous recovery occurred before surgery. Rehabilitation of patients at home was supervised by physiotherapists using a standardized exercise protocol. 16 recovered before surgery could be performed. Median time to surgery for the 125 remaining was 1.9 weeks.

Conservative Care (n=142) General practitioners informed patients about favorable prognosis, natural course of illness, and expectation of successful recovery. Treatment aimed at restoring ADLs. Prescription pain meds as needed. Patients fearful of moving were referred to physiotherapist. Surgery was recommended if: –Sciatica present 6 months after randomization –Increasing leg pain not responsive to medication –Progressive neurological deficits Median time to surgery, for 55 who had surgery, was 14.6 weeks.

Early Surgery vs Conservative Care Those with recommended early surgery had a higher rate of recovery, at 2 weeks, compared to those receiving conservative treatment. –Early surgery – 87/141 achieved “complete” or “nearly complete” disappearance of symptoms, at 2 weeks, as measured on a 7- point Likert scale. Early surgery event rate: 87/141 recovered (61.7% unadj.) –Conservative treatment – 45/142 achieved recovery at 2 weeks Conservative care event rate: 45/142 recovered (31.7% unadj.) Peul WC, Houwelingen HC, van den Hout WB, Brand R, Eekhof JAH, Tans JTJ, Thomeer RTWM, Koes BW. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:

Risk Difference (RD) Used in RCTs Is the difference in the probability of an event between the treatment and control groups Thus, the formula for calculating RD is similar to calculating harm in previous lecture: For early surgery vs conservative care this is: –62%-32%=30% improvement –In the outcome, patient perceived recovery a - c a+bc+d

Number needed to treat (NNT) NNT: The number of patients who would need to be treated in order to achieve one additional good outcome Unadjusted calculation from lecture: –1/0.30 = 3.3 NNT Adjusted calculation reported in paper: –1/.36 = 2.8 NNT 2.8 patients need to be treated, on average –for one more patient to get appreciable benefit from recommendation of early surgery compared to conservative care –when assessed by “complete” or “nearly complete” resolution of symptoms 1 = 1 (a/(a+b))-(c/(c+d))Risk Difference

NNT handout practice problems Columns –2, 8, 26, and 52 weeks Third row –Adjusted risk difference Fourth row –95% CI for the adjusted RD Calculate –The adjusted NNT –95% CIs In-class exercise –Participants will use these numbers in role play

Breakout groups – 4 per group Role play –Physician –Intern –Patient –Family member

Patient History: LBP c Sciatica 55yo male presents for follow-up of LBP with radiculopathy (sciatica). Pain began 5 months ago after a work injury. Unresponsive to treatment after 3 months. No pain with sitting. Imaging confirms a midline herniated disc. Patient is anxious and depressed. Surgery consult recommends surgery.

Operating Bias of Role Players Physician – does not want to talk patient into surgery Intern – wants to talk patient into surgery Patient – does not want surgery Family member – wants patient to get surgery Reference article: Peul WC, Houwelingen HC, van den Hout WB, Brand R, Eekhof JAH, Tans JTJ, Thomeer RTWM, Koes BW. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:

Pros/Cons Cons discussed: Pros discussed: Decisions made:

Pros/Cons Cons discussed: –Cost of surgery – expensive How much does 12 months of treatment Insurance factors – what covered Self employed/ employer Workers comp could take time to get approved –Cusp of marked improvement –Patient does not want surgery –Surgery might not work –Surgery is scary/risky –Recurrence risk –Pain pathways may recur –Family member wants to kick out family member –Lack of mobility forever Pros discussed: –Cusp of market improvement –If insurance benefit –Return to work faster –Less whining – may lead to less anxiety depression –May have stronger placebo effect –Chores around house –Replacement discs Decisions made: –Conservative care for 4 more weeks, wait 1 to 3 more months –Having surgery (golf), another, surgery –No surgery –Palmer – one of the groups had the pt die –Updated MRI after some more waiting