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Step 3:

Critically Appraising
the Evidence:
Statistics for Therapy
Table of Contents
• Clinical Statistics Calculator (Excel)
• Statistics for:
– Therapy
• Control Event Rate (CER) & Experimental Event Rate (EER)
• Number Needed to Treat (NNT)
– Absolute Risk Reduction (ARR)
• Relative Risk (RR)
• Odds
• Odds Ratio (OR)
• Practice Exercises
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.
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 Paradox
Critical Appraisal Basics
• View movie as:
– QuickTime
(.mov)
– Flash (.swf)

• Double-click on video for full-screen mode.


Generalized 2x2 Clinical Table
Target Outcome
+ -
+ a (True b (False
Intervention/ Positives) Positives)
Comparison - c (False d (True
Negatives) Negatives)
Control Event Rate (CER) and
Experimental Event Rate (EER)
• Experimental Event Rate (EER)
– The proportion of patients (in the intervention)
who experienced the target disorder with the
treatment
• Control Event Rate (CER)
– The proportion of patients (in the comparison
group) who experienced the target disorder
without the treatment
Calculating CER and EER
• Experimental Event Rate (EER)
– a/(a+b)

• Control Event Rate (CER)


– c/(c+d)
Number Needed to Treat (NNT)
• The estimated number of patients needed
to be treated for every patient benefiting
from the treatment beyond baseline/control
expectation
• So small numbers indicate greater
effectiveness
Calculating NNT: Starting Off
• Essentially we want to know how many
patients we must treat before we can expect
one successful treatment beyond what we
would normally expect without treatment.
• First consider, what we already know:
– We know both the proportions of how many
patients still had the target disorder that were
treated (EER) and that were not treated (CER).
Calculating NNT: Establish Baseline
• With these two proportions we can find the
proportion of successful treatment beyond
the baseline expectation (control).
• From there, we can determine how many
we would need to treat to expect one
success.
• Now let’s start from the baseline: Find the
proportion of untreated patients with the
target disorder (CER).
Calculating NNT: Calculating
Absolute Risk Reduction (ARR)
• Now we want to know how much better the
treatment did than no treatment at all. So
we find the proportion of the treated
patients that had the target disorder (EER)
• Now we find their difference (CER-EER),
which we call the Absolute Risk Reduction
(ARR).
Calculating NNT: ARR Example
• That is if 10% of the untreated patients had the
disease and 3% of the treated patients had the
disease, then the treatment helped 7% (=10%-3%)
of the treated patients (which if left without
treatment would still likely have the disease). So
0.07 would be the ARR.
• Hence ARR is the probability that treatment will
reduce the risk of a given patient beyond baseline
expectation.
Calculating NNT: Using the ARR
• Now we know that the treatment reduced the risk
of a proportion of patients, which we call Absolute
Risk Reduction and that ARR = CER – EER.
• In other words, ARR is the number of successful
treatments beyond baseline expectation divided by
the number of treated patients.
• Now we’re close. NNT is the number of treated
patients per successful treatments beyond baseline
expectation. Can you see the relationship yet?
Calculating NNT:
Another way of looking at it
• In this situation, we should look for a way to invert
our number.
• We know that we can divide any number by 1
without altering it. So ARR = ARR/1. So think of
ARR as a fraction.
• Now think of the number of successful treatments
beyond baseline expectation as the unit on top of
the fraction (i.e. ARR) and the number of treated
patients as the unit on the bottom.
Calculating NNT: Final Touches
• Now if we take the inverse (i.e. flip our
fraction over) and calculate 1/ARR, we get a
number where the units are flipped.
Thereby, this number has the number of
treated patients as the unit on top of the
fraction (i.e. ARR) and the number of
successful treatments beyond baseline
expectation as the unit on the bottom. This
is exactly how we defined NNT.
Calculating NNT: The Formula

• NNT = 1/ARR = 1/|CER – EER|


– Often rounded up to nearest whole number
NNT Question
• View movie as:
– QuickTime
(.mov)
– Flash (.swf)

• Double-click on video for full-screen mode.


Answer to NNT Question
• View movie as:
– QuickTime
(.mov)
– Flash (.swf)

• Double-click on video for full-screen mode.


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))
Relative Risk Video
• View movie as:
– QuickTime
(.mov)
– Flash (.swf)

• Double-click on video for full-screen mode.


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.
Odds Ratio (OR)
• OR = (a/b) / (c/d)
• = a*d / b*c

• A measure of association
• When large, there is greater association
Try it on your own.

• Critical Appraisal Practice Exercises


– From CEBM
Links to Other Websites
and Hands-On Activities
• EBM Glossary
– From CEBM
• Critical Appraisal Practice Exercises
– From CEBM
Congratulations!
You have successfully
completed Step 3.
The End