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ELBA
BA
Topics
Making a Study
Medical Statistics
Critical appraisal
Clinical governance
Modern way to deliver best medical care to the
patients.
Shared responsibility of all health professionals
to provide optimal care to the patients in a way
that they would like to be treated themselves.
It consist of 9 components:
3 Health professionals
3 Patients
3 Medical care system
Health professionals
1. CME
2. Team work
3. Risk management
Patients
1. Advice cards
2. Good communication
3. Access to complains
Medical care system
1. EBM
2. Audit
3. Updated guidelines
Medical
care
system
Guidelines
Guidelines
1. Juniors
2. EBM
3. NICE
4. Updated
5. Changeable
AUDIT
Audit chain
Audit
Is a process by which health professional
assess, evaluate and improve the care of
patients in a systematic way.
It is best summarized by a circle or chain
process.
Standard
Problem Data
Change Method
Results
EBM
EBM
1. Formulation of question
2. Search for evidence
3. Critical appraisal
4. Applying of evidence
5. Evaluation of effect
Formulation of question
1. Population
2. Intervention
3. Comparison !!
PICO
4. Outcome
Recommendation grades
and levels of evidence
From A to E
A
At least one high quality meta-
analysis, systematic review of
RCTs, or RCT with a very low risk
of bias, and directly applicable to
the target population.
B
A body of evidence including well conducted
casecontrol or cohort studies with a low
risk of confounding, bias, or chance and a
moderate probability that the relationship
is causal, directly applicable to the target
population, and demonstrating overall
consistency of results.
C
A body of evidence including well conducted
casecontrol or cohort studies with a low
risk of confounding, bias, or chance and a
moderate probability that the relationship
is causal, directly applicable to the target
population and demonstrating overall
consistency of results.
D
Non-analytic studiesfor example,
case reports, case series, or
expert opinion.
E
No evidence exists; recommended
best practice based on the clinical
experience of the guideline
development group.
Study
Research Study
1. Idea
2. Question
3. Search
4. Design
Milestones of a Research study
Bias
1. Selection
2. Measurement e.g. Recall Bias
3. Confounding
Confounding Factors
Major:
Controlled by well study design
Minor:
Controlled by Logistic regression analysis
Unknown:
Remains unknown until detected by other study
Case Control study
Retrospective study
Two groups
Control group
Determine the causation (Past exposure)
Suitable for rare disease
t-test for parametric Example:
Odds ratio CRF in Bartter Syndrome
Note: Case report or case series is completely different
Cohort study
Mainly Prospective study
Use recall if retrospective
Two groups
Control group
t-test for parametric
Evaluate the risk (Future exposure) or incidence
Suitable for common disease
Relative Risk (RR)
Example:
Hypertension in Obesity
Cross sectional study
Present time
Evaluate the disease frequency or
risk factor
Diagnosis & prevalence
Example:
Incidence of Familial short stature
Cross over study
Each individual exposed to each arm
To see which intervention is better
Needs wash out period in-between
Evaluate the short term effect of intervention
Suitable for relatively stable chronic disease
Example:
ACEI Vs Ca channel blocker in renal hypertension
Pilot study
One of Prospective study
Small sample size
No control group
Example:
Deafness after bacterial meningitis
Randomized Control Trial
Intervention
Two or more groups
Needs control group
Placebo
Example:
Randomization
Pantoprazole in GORD in infancy
Blindness
Efficacy (Statistically)
Effectiveness (Clinically)
Meta-analysis
Different studies with
similar subject (Usually
RCT)
Pooled result on a graph
Log scale or Frost plot
Expressed as Odds ratio
or Relative Risk
Meta-analysis is the
statistical method used
in Systematic review
Example:
Steroid in Bronchiolitis Systematic review is NOT a review article
Conclusion of study type
Case control: Effect of multiple risk factors on rare
outcome
Cohort : Rare risk factor on multiple outcome
Cross sectional: for incidence and prevalence
RCT: Assessment of intervention effectiveness
Statistics
Medical statistics
Statistics
Definition: Measurement of chance.
Studying population sample to give idea about
all population (Distribution)
Quantify the degree of difference between 2 or
more groups of variables (tests of significance)
Ensure that research results are comparable and
can be generalized (Appraisal)
Statistics
1. Measures of Distribution
2. Measures of Central tendency
3. Measures of Dispersion
4. Measures of Probability
5. Measures of Effect
1. Distribution
1.Normal Gaussian :Most of variable
2.Skewed: Trend to either extreme
3.Binomial: Two possible outcome only
4.Poisson: Rare event in large population
1. Distribution
(Screening tests)
Simple Confirmatory test
Cheap Total
Screening + ve - ve
Reliable
A B AB
Applicable + ve
Serious illness C D CD
- ve
Intervention available
Total AC BD ABCD
Example Screening + ve
80
- ve
20
Total
100
+ ve
- ve 40 160 200
2. Prevalence =
3. Sensitivity =
4. Specificity =
5. Positive predictive value =
6. Negative predictive value =
7. Likelihood ratio for positive result =
8. Likelihood ratio for negative result =
9. Yield of the test =
pre-test Odds =
post-test Odds =
Confirmatory test
Example Screening + ve
80
- ve
20
Total
100
+ ve
- ve 40 160 200
2 X 2 table
Pearsons Correlation
Parametric
Linear correlation
r value -1 to +1
Closer to zero = less correlation
Closer to 1 = stronger correlation
Regression
1. Multiple linear regression
2. Logistic regression
Regression
Multiple linear regression
Formula Y= a + b X
(Regression coefficient)
A is Y value when X is zero
B is the degree of sloping of the line to the baseline
Logistic Regression
Used when the dependent variable response is binary Two possible
outcome .
Comparing these outcome with one or many independent variables
By fitting the data to Logistic S-shaped curve
A B AB
Exposed
C D CD
Non
Total AC BD ABCD
Diseased Non Total
60 40 100
Exposed
Example
20 80 100
Non
Total 80 120 200
Absolute risk = ??
Relative risk = ??
AR Reduction= ??
RRR= ??
Number needed to treat = ??
Odds ratio= ??
Diseased Non Total
60 40 100
Exposed
Example
20 80 100
Non
Total 80 120 200