1. HelpDesk Answers Online Writing Demonstration
Corey Lyon, D.O.
University of colorado

2. Objectives
Gain an understanding of how to use statistics in your manuscript
Exposure to using an Evidence Table to organize your writing.
See examples of writing in the HDA format
Applying the evidence to provide an evidence based answer with a Strength of Recommendation (SOR)

3. Critical Components of an HDA
Clinical Question
Evidence Based Answer (35-75 words, with SORT grade)
Evidence Summary ( words)
References ( words, with STEPs)
Handout #1 – example manuscript
The ideal word count is 500, including references. HDAs
should run no more than 600 words – a small table counts
for approximately 100 words.

4. Clinical Question
What is the minimum number of days that antibiotics should be given to patients with community acquired pneumonia?

5. Evidence Synthesis and Preparing to Write
After reviewing all the articles to draft your manuscript
Organize your information
Recommend using an Evidence Table

6. Review of HDA writing structure
HDAs are VERY structured, concise articles that deliver the bottom line and supporting evidence only
no editorializing or personal biases. ‘Just the facts!’
Plan your evidence summary with an outline or by organizing a brief paragraph on each piece of evidence you have selected to support your answer.
Evidence should be offered beginning with the strongest and moving to the weaker.
List the references (strongest first) and make sure you have aligned the footnotes with reference list

7. HDA writing structure - continued
First draft your Evidence Summary ( words)
Then draft your Evidence Based Answer (35-75 words)
Your Evidence Based Answer will need a SOR assigned that matches the quality of evidence you presented
Each SOR needs an explanatory phrase
Each reference needs a STEP grade

8. Writing with Transparency
“The voice” of HDAs are unique
The writing is very concise and descriptive
Write with enough detail that your readers could practically reproduce the study
Do not describe a study by lead author

9. Descriptive writing Descriptive writing includes
Study design (RCT, cohort study, etc)
Including the question the study was trying to answer
Number of patients
Number of studies included if discussing a systematic review
Names, dose, frequency of any drugs
Description of experimental and control groups
Tell your readers what is being compared to what
Define the outcomes
Be specific; define what is “better” (ie how many days,
how many point on a pain scale, what is the definition
of cure…)

10. Presenting the Evidence
It is not enough to tell your readers the results
You need to “show them the evidence”
Show statistical significance
But don’t over rely on “P values” – that doesn’t show the “magnitude of effect”, ie How much better.
Use Confidence Intervals
When possible, convert data into user friendly statistics
NNT, likelihood ratios, confidence intervals, etc

11. Organize Your Articles
Study 1
Study 2
Study 3
Citation
Population
Study Design
Intervention
(N in the Group)
Comparison
Follow-Up Period
Outcomes Measure
Effect Estimate
(CI or p)
Study Quality
Reviewer Comments
EVIDENCE TABLE
What:
Tabular description of the studies.
Compare studies by characteristics.
Why:
Prevent errors of interpretation.
Increase clarity of analysis.
Plan a statistical analysis.

12. Reference 1

13. Short vs. long course antibiotics – meta-analysis
Citation
Population
Study Design
Intervention
(N in the Group)
Comparison
Follow-Up Period
Outcomes Measure
Effect Estimate
(CI or p)
Study Quality
Reviewer Comments
Short- versus Long-Course Antibacterial Therapy for Community-Acquired Pneumonia; A Meta-Analysis
Dimopoulos G, Matthaiou D, Karageorgopoulos D, Grammatikos A, Athanassa1 Z ,Falagas1
Adult (n= 1,097) and children (n=4,012) diagnoses with community acquired pneumonia
2008 meta-analysis of 7 double blind RCT (5 involving adults, 2 involving children)
Short course antibiotics (3-7 days for adults; 3 days for children)
Antibiotics varied from study to study, but compared same drug at standard dosing for different durations of treatment
Long course antibiotic (at least 2 days longer than short course treatment; 7-10 days for adults; 5 days for children)
End of therapy and later follow up defined as days after treatment
Clinical success (complete resolution or improvement symptoms and signs of CAP) at end of therapy; Clinical success at the late follow up period
Clinical success at end of end of therapy (n=5,107; OR 0.89; 95% CI, ) = no difference
Clinical success at later follow up (n=2,762; OR 0.98; 95% CI, )= no difference
Adult patients only (n=1095; OR 0.92; 95% CI, ) = no difference.
All studies were of good quality

14. Draft from Reference 1 From the table, make a summary paragraph
In 2008, a meta-analysis of seven double blind randomized controlled trials (5 involving adults and 2 involving children) compared short verses long antibiotic course of therapy for CAP. The medications varied from study to study, but compared the same drug at standard dosing for different durations of treatment within each study. No differences were found between short (adults 3-7 days; children 3 days) and long (adults 7-10 days, children 5 days) course regimens for clinical success at end of therapy (5107 patients; OR 0.89; 95% CI, ) or at later follow up, defined as days (2,762 patients; OR 0.98; 95% CI, ). In the subset analysis of adult patients only, no difference was seen between short and long course of therapy at the end of treatment(1,095 patients; OR 0.92; 95% CI, ).

15. Another Evidence Table Example
Reference 2

16. Short vs. long course antibiotics – RCT
Citation
Population
Study Design
Intervention
(N in the Group)
Comparison
Follow-Up Period
Outcomes Measure
Effect Estimate
(CI or p)
Study Quality
Reviewer Comments
High-Dose, Short-course Levofloxacin for Community Acquired Pneumonia: A New Treatment Paradigm
Dunbar L, Wunderink R, Habib M, et al.
Adult (n= 390) diagnoses with mild-severe community acquired pneumonia; 41% hospitalized
2003 multicenter double blind RCT
Short course high dose Levofloxacin(750 mg/day X5 days) – 198 patients
Long course lower dose Levofloxacin (500mg/day X 10 days) – 192 patients
End of therapy visit which was 7-14 days after treatment was finished
Nonin
Clinical response after therapy – cure, improvement, or failure
Clinical efficacy – clinical success rate in 750 mg group 92.4% (183 of 198 patients)
Clinical success rate in 500mg group – 91.1% (175 of 192 patients)
95% CI around the difference 10-day regimen minus 5-day regimen, -7.0 to (noninferiority is established if the upper limits of 2-sided 95% CI is <10%)
Moderate quality – 70% follow up

17. Draft Reference 2
A multicenter, randomized, double blind study of 390 patients with mild-severe community acquired pneumonia (41% hospitalized) examined the efficacy of a short course, high dose treatment (750mg/day X 5 days; N=198) to a longer course, lower dose treatment (500mg/day X 10 days; N=192) with levofloxacin IV/PO. The clinical success rate was 92.4% (183 of 198 persons) for the 750 mg group and 91.1% (175 of 192 persons) for the 500 mg group (95% CI around the difference 10-day regimen minus 5-day regimen, -7.0 to 4.4; noninferiority is established if the upper limits of 2-sided 95% CI is <10%).

18. Another Evidence Table Example
Reference 3

19. Short vs. long course antibiotics – Cohort
Citation
Population
Study Design
Intervention
(N in the Group)
Comparison
Follow-Up Period
Outcomes Measure
Effect Estimate
(CI or p)
Study Quality
Reviewer Comments
Seven-day antibiotic courses have similar efficacy to prolonged courses in severe community-acquired pneumonia – a propensity adjusted analysis
Choudhury G, Mandal P, Singanayagam A, et al
Adult (n= 328) diagnoses with severe community acquired pneumonia admitted to the hospital
Observational study; duration of antibiotic was at the discretion of the attending physician.
7 days of antibiotic treatment (that were clinically stable within 7 days)– 164 adult patients
> 7 days (mean 12 days) – 164 well matched adult patients
30 days
Nonin
30-day mortality, Need for mechanical ventilation (MV), development of complicated pneumonia
30 day mortality; 7 vs >7 days = 3% vs 4.4%; OR 0.67; 95% CI,
Requiring MV; 7 vs >7 days=3.2% vs 3.8%; OR 0.92; 95% CI,
Complicated pneumonia; 7 vs >7 days=3.1% vs 1.9%; OR 0.63; 95% CI,
Cohort study, unsure of any unmeasured confounders

20. Draft Reference 3
A recent observational study was conducted to examine whether a 7 day course of antibiotic treatment (164 adult patients) is equivalent to a longer course (164 well matched adult patients) in patients hospitalized with severe CAP. The duration and choice of antibiotics were at the discretion of the attending physician. There was no difference in patients treated with a 7 day course of antibiotics (that were clinically stable before 7 days) compared to those patients treated for >7 days (mean 12 days) in 30 day mortality (3% vs 4.4%; OR 0.67; 95% CI, ), requiring mechanical ventilation (3.2% vs 3.8%; OR 0.92; 95% CI, ), or development of a complicated pneumonia (3.1% vs 1.9%; OR 0.63; 95% CI, ). Even though the patients in the 2 groups were well matched for confounders, there could still be unmeasured confounders contributing to the outcomes.

21. Guideline
If possible, include a guideline in your evidence based summary

22. Review Manuscript
Lets review the draft of the completed Evidence-Based Summary

24. Evidence Based Answer
From your summary, draft an Evidence Based Answer with SOR using the SOR algorithm
Patients with community-acquired pneumonia (CAP) should be treated for a minimum of 5-7 days (SOR A, based on a meta-analysis of RCTs and evidence-based guideline). Patients should be afebrile for hours and have symptom improvement before discontinuing treatment (SOR B, based on an evidence based guideline with moderate level of evidence.)

25. Summary Use the evidence based table to help organize your writing
The HDA style of writing is very concise, descriptive writing
Write your Evidence Based Summary first, then write your Evidence Based Answer
Give every reference a STEP using the 2011 CEBM Levels of Evidence table
Give your Evidence Based Answer an SOR, using the SOR algorithm

26. HDA Project Coordinator hda@fpin.org FPIN Office 573-256-2066
FPIN Contact Information
HDA Project Coordinator FPIN Office