1. Step 3: Critically Appraising the Evidence: Statistics for Harm and Etiology

2. Table of Contents Clinical Statistics Calculator (Excel) Statistics for: –Harm/Etiology & Prognosis Control Event Rate (CER) & Experimental Event Rate (EER) Number Needed to Harm (NNH) –Absolute Risk Increase (ARI)Absolute Risk Increase (ARI) Relative Risk (RR) Odds Odds Ratio (OR) Practice Exercises

3. Making It Easier If available, find the best evidence in secondary sources where analysis has already occurred. If not pre-assessed, use critical appraisal worksheets to help you through the process.

4. Importance of Critically Appraising the Evidence Understanding the Limitations of the Author’s Analyses and Interpretations of the Data Assessing Internal Validity Assessing External Validity Identifying Potential Confounding Variables –Simpson’s ParadoxSimpson’s Paradox

5. Critical Appraisal Basics View movie as: –QuickTime (.mov)QuickTime (.mov) –Flash (.swf)Flash (.swf) Double-click on video for full-screen mode.

6. Generalized 2x2 Clinical Table Target Outcome +- Intervention/ Comparison +a (True Positives) b (False Positives) -c (False Negatives) d (True Negatives)

7. Control Event Rate (CER) and Experimental Event Rate (EER) Experimental Event Rate (EER) –The proportion of patients (in the intervention) who experienced the target outcome Control Event Rate (CER) –The proportion of patients (in the comparison group) who experienced the target outcome

8. Calculating CER and EER Experimental Event Rate (EER) –a/(a+b) Control Event Rate (CER) –c/(c+d)

9. Number Needed to Harm (NNH) The estimated number of people treated for each patient the treatment harms beyond baseline/control risk. So smaller numbers indicate greater probability of harm as a result of the treatment

10. Calculating NNH The calculation of NNH is the same as that of NNT, but the interpretation is differentiated by the adverse outcomes present in harm studies. Here the term NNH effectively replaces NNT. Similarly Absolute Risk Increase (ARI) is calculated in the same way that ARR is calculated but the intervention increases the amount of harm instead of therapeutic gain. NNH = 1/ARI = 1/|CER – EER|

11. NNH Video View movie as: –QuickTime (.mov)QuickTime (.mov) –Flash (.swf)Flash (.swf) Double-click on video for full-screen mode.

12. Relative Risk (RR) The number of treated/exposed patients with the target outcome for every patients in the control with the target outcome –(Also used in therapy articles) RR = EER / CER = (a/(a+b)) / (c/(c+d))

13. Relative Risk Video View movie as: –QuickTime (.mov)QuickTime (.mov) –Flash (.swf)Flash (.swf) Double-click on video for full-screen mode.

14. Odds The number of times the target outcome occurred in patients exposed to the risk for each time the target outcome occurred in patients not exposed to the risk.

15. Odds Ratio (OR) OR = (a/b) / (c/d) = a*d / b*c A measure of association When large, there is greater association

16. Try it on your own. Critical Appraisal Practice Exercises –From CEBM

17. Links to Other Websites and Hands-On Activities EBM Glossary –From CEBM Critical Appraisal Practice Exercises –From CEBM

18. Congratulations! You have successfully completed Step 3. The End