so much evidence 1

29
So Much Evidence What is Next

Upload: hesham-gaber

Post on 07-May-2015

2.010 views

Category:

Health & Medicine


4 download

TRANSCRIPT

Page 1: So much evidence 1

So Much Evidence

What is Next

Page 2: So much evidence 1

Process of Randomisation ParticipantsParticipants

R a

n d

o m

l

y A

s s

i g

n e d

R a

n d

o m

l

y A

s s

i g

n e d

Intervention GroupIntervention Group

Control GroupControl Group

Follow-upFollow-up

Follow-upFollow-up

Intervention Intervention GroupGroup

Control Control GroupGroup

O u

t c

o m

e C

o m

p a

r e

O u

t c

o m

e C

o m

p a

r e

dd

Page 3: So much evidence 1

Assessed for eligibility (n= 245)

Excluded (n= 15)

Not meeting inclusion criteria (n=7)

Refused to participate (n=5)

Social reasons (n=3)

Received IUI (110)

Analyzed (n=110)

Cycles cancelled (n=5)

Inadequate response (n=4)

Hyper-response (n=1)

Group I (n=115) received Merional + CC

Cycles cancelled (n=8)

Inadequate response (n=6)

Hyper-response (n=2)

Group II (n=115) received Merional alone

Received IUI (107)

Analyzed (n=107)

Allocation

Analysis

Follow-Up

Enrollment

Randomized (n=230)

Page 4: So much evidence 1

The best evidence for different types of question

Level Treatment Prognosis Diagnosis

I Systematic Review of …

Systematic Review of …

Systematic Review of …

II Randomised trial

Cohort Cross sectional

III

Page 5: So much evidence 1

systematic reviews

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2200

2400

2600

2800

3000

3200

3400

3600

3800

4000

19

95

/1

19

95

/2

19

96

/1

19

96

/2

19

96

/3

19

97

/1

19

97

/2

19

97

/3

19

97

/4

19

98

/1

19

98

/2

19

98

/3

19

98

/4

19

99

/1

19

99

/2

19

99

/3

19

99

/4

20

00

/1

20

00

/2

20

00

/3

20

00

/4

20

01

/1

20

01

/2

20

01

/3

20

01

/4

20

02

/1

20

02

/2

20

02

/3

20

02

/4

20

03

/1

20

03

/2

20

03

/3

20

03

/4

20

04

/1

20

04

/2

20

04

/3

20

04

/4

20

05

/1

New protocols

Existing protocols

New reviews

Updated reviews

Existing reviews, not incl updates

Reviews and protocols for reviews on The Cochrane Database of Systematic Reviews

Issue 1/2005Alderson, 2005

Page 6: So much evidence 1

Too much information

0

500000

1000000

1500000

2000000

2500000

Biomedical MEDLINE Trials Diagnostic?

Med

ical

Art

icle

s p

er Y

ear

5,000?per day

1,500 per day

55 per day

Page 7: So much evidence 1

OBGYN in Pubmed

• 563 meta-analysis • 7184 RCT

Page 8: So much evidence 1

Ready Made EBOG

• RCOG• SOGC• Cochrane Library• UpTodate

Page 9: So much evidence 1

“I don’t know…”

“I don’t really care about all of this research stuff…”

“I just want to take care of patients…”

Unnamed Ob-Gyn Resident

Still There is a Problem

Page 10: So much evidence 1

Many “Leaks” from research to practice

Aware Accept Target Able Recall Agree Done

ValidResearch

If 80% achieved at each stage then0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21

Page 11: So much evidence 1

(a*+) (b+)

(c*) (d)

Minimum clinicalImportant difference

No difference

Another Problem : Which are (i) statistically significant * and (ii) Clinically significant +?

Page 12: So much evidence 1
Page 13: So much evidence 1

So

• Too many information• Little applied

Page 14: So much evidence 1

Individual

Page 15: So much evidence 1

EBP

The EBM Model

BestEvidence

Client Values and Expectations

Practitioner’s IndividualExpertise

Sackett et al., 1997

Page 16: So much evidence 1

EBP Model

Institution state and

circumstances

Clinical Expertise

Client Preferences and actions

ResearchEvidence

Page 17: So much evidence 1

But still

Knowledge needs to be managed

much more effectively than it

has been in the past

Page 18: So much evidence 1

“Evidence Base” Community

• “The purchase of treatments and services that have been scientifically confirmed to improve outcomes.” (Lehman et al, 2004)

Page 19: So much evidence 1

“Evidence Base” Community

• Evidence mapping• Mining the Research• Missing Pieces: Identifying the Gaps in

Evidence

Page 20: So much evidence 1

Unexplained InfertilityIUI alone IUI + O.I

Timed intercourse O.I alone

Spontaneous intercourse??

Page 21: So much evidence 1

Ines TrialIUI + O.I

IVF + sET

NC IVF

Page 22: So much evidence 1

Timing of IUI

24hs32hs40hs

No Difference on Pregnancy rate

(Aboulgeit et al,2010)

Page 23: So much evidence 1

“Evidence Base” Community

• engaging patients in research• working with guideline developers• Reporting and discussing practice guidelines• Podcasting as a Dissemination Strategy• funding for Knowledge Translation and

Dissemination

Page 24: So much evidence 1

Moving Methodology Forward

• prognostic evidence in systematic reviews of interventions

• Revise current statistical analysis• There’s Nothing Constant but Change

Page 25: So much evidence 1

Steps For Evidence Base Community Implementation

Information sharing with decision Makers

Organization & Fund raising

Clinical Care ImprovementTraining on EBP’s, supervision, consultation and support

Engagement Strategic planFocus on outcomes that clients value.

Improved Women Health

Clinicians, consumers, Stakeholers

Feedback :Efficiency & Effectiveness

Page 26: So much evidence 1

Elements Important (Fixsen et al, 2005)

• Commitment of leadership to the implementation process.

• “unfreezing” current organizational practices.• Resources for extra costs, effort, materials, recruiting,

access to expertise, retraining.

Page 27: So much evidence 1

So

• There is a need for an authorised body to handle these tasks

• To communicate with decision makers• To cooperate with existing societies • To gather interested people: doctors and

consumers

Page 28: So much evidence 1

Hence

Page 29: So much evidence 1

• International society• Open to every one• Starting activity from September 2010• Cooperate with different societies involved in

women health