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Published byEthelbert Gallagher Modified over 8 years ago
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Renee Crichlow MD, FAAFP Tanner Nissly, DO Jason Ricco, MD, MPH
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Why?
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The Accreditation Council for Graduate Medical Education (ACGME) Requirements for accreditation…residents must participate actively in such scholarly activities…
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“Develops and demonstrates skills in locating sources of scientific data pertinent to the care of patients…”
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“…Analyzing the appropriateness of research design and statistical methods…”
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“… Obtaining information about diagnostic and therapeutic effectiveness,”
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“…Applying evidence from pertinent clinical studies to patient care.”
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The Primary Goals uniform acquisition of skills and knowledge, "Abstract Attack", a method to provide uniform acquisition of skills and knowledge, Evidence Based critique of the medical literature at the point of care. Sufficient for a practicing clinician to confidently, participate in efficient and effective Evidence Based critique of the medical literature at the point of care.
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“Eschew Obfuscation”
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Eschew Obfuscation
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Santiago, BMC Medical Informatics and Decision Making 2008 8:61
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The Four Areas of Promotional Claims Effectiveness Safety Convenience Costs
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The Five Deceptions False Statement Exaggeration Unjustified Generalization Absence of Relation Transfer to Humans
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What?
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AA-Rapid Critical Appraisal Pathway Title Conclusion Background Methods Results Figure 1 Tables
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The Three Questions Pertinent to your patients’ care? Consistent or Inconsistent? Consistent or Inconsistent? Valid or Invalid?
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Studies have shown “…Journal clubs may improve knowledge of clinical epidemiology and biostatistics, reading habits, and the use of medical literature in practice…”
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Chapters of Curriculum 1. Rationale Statement, Curricular Goals, and Context of the Curriculum 2. Teaching the Strategy of Abstract Attack 3. Developing a Clinical Query--PICO 4. Search for the Evidence 5. P-value and Confidence Intervals 6. Patient Oriented Outcomes vs. Disease Oriented Outcomes 7. The RCT, Randomized Controlled Trial 8. Absolute Risk Reduction vs. Relative Risk Reduction 9. NNT, Number Needed to Treat 10. Odds Ratio and CI revisited 11. Sppin and Snnout 12. Meta-Analysis vs. Systematic Review 13. Determining the Level of Evidence and Strength of Recommendations 14. Appendix –Formative review, post-test templates levels 1-3 –Summative evaluation year-end review templates
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e.g. P-Value, Wakefield 1998 For every unit of the AA curriculum we use the AA method to critically appraise articles that illuminate the teaching point of that unit
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Ileal-lymphoid-nodular hyperplasia, non- specific colitis, and pervasive developmental disorder in children. Wakefield AJ 1998 13 patients “Abnormal laboratory results were significantly raised urinary methylmalonic acid compared with age-matched controls (p=0.003), low haemoglobin in four children, and a low serum IgA in four children.” INTERPRETATION: We identified associated gastrointestinal disease and developmental regression in a group of previously normal children, which was generally associated in time with possible environmental triggers.
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“Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children.” Wakefield AJ 1998 “INTERPRETATION: We identified associated gastrointestinal disease and developmental regression in a group of previously normal children, which was generally associated in time with possible environmental triggers.” N=13 patients “Abnormal laboratory results were significantly raised urinary methylmalonic acid compared with age-matched controls low haemoglobin in four children, and a low serum IgA in four children.”“Abnormal laboratory results were significantly raised urinary methylmalonic acid compared with age-matched controls (p=0.003), low haemoglobin in four children, and a low serum IgA in four children.”
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P-value in Danish Vaccine Study >500,000 patients Compared vaccinated and unvaccinated children Found NO significant difference in rates of autism “Conclusions This study provides strong evidence against that hypothesis that MMR vaccination causes autism.”
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P-value in Danish Vaccine Study “Conclusions This study provides strong evidencethat MMR vaccination causes autism.”“Conclusions This study provides strong evidence against that hypothesis that MMR vaccination causes autism.” >500,000 patients Compared vaccinated and unvaccinated childrenCompared vaccinated and unvaccinated children FoundFound NO significant difference in rates of autism
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Teaches the Unit…
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or “POO” is better than “DOO”.
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What does it mean to be a Patient oriented outcome? What does it mean to be a Disease oriented outcome?
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POO produces POE “Patient-oriented evidence (POE) refers to outcomes of studies that measure things a patient would care about, such as improvement in symptoms, morbidity, quality of life, cost, length of stay, or mortality. Essentially, POE indicates whether use of the treatment or test in question helped a patient live a longer or better life...” (Terms Used in Evidence-Based Medicine-- AAFP)
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DOO produces DOE “Disease-oriented evidence (DOE) refers to the outcomes of studies that measure physiologic or surrogate markers of health, e.g. such as blood pressure, serum creatinine, HgBA1c,… or peak flow. Improvements in these outcomes do not always lead to improvements in patient- oriented outcomes such as symptoms, morbidity, quality of life, or mortality.” (Terms Used in Evidence-Based Medicine--AAFP)
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Patient Oriented Outcome Disease Oriented Outcome CardiacDecreased Death from MI or CVA 5 mmHg decrease in SBP PulmonaryImproved Exercise capacity FEV1 decline is slower PediatricNo Change in Growth or development while using drug Concentration of drug in growth plates RenalLonger duration prior to Dialysis Creatinine level stability
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KEY POINTS Patient Oriented Outcomes and Disease Oriented Outcomes: POO indicates “whether use of the treatment or test in question helped a patient live a longer or better life...” DOO may lead to POO in another study OR may be the only data currently available Pharmaceutical Industry may make claims framed as POO based on a study of DOO DOO may be significant but have no bearing on POO
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Leads the Attack…
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AA-Rapid Critical Appraisal Pathway Title Conclusion Background Methods Results Figure 1 Tables Pertinent to your patients’ care? Consistent or Inconsistent? Valid or Invalid?
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Questions for discussion STRUCURE What kind of study is this? What’s the PICO? Were all patients accounted for in Fig 1 CONTENT Why did they do THIS study? Is this POO or DOO? PRACTICE IMPACT What more information do you need? Do you think this study might influence your practice, why or why not?
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For information on “AbstractAttack” curriculum rcrichlo@umn.edu
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