Written by Hsern Ern Tan

UCS Exam Revision Notes

Lecture 1 Introduction to Research
What is research? o A systematic attempt to provide answers to question o The systematic and objective analysis and recording of controlled observations that may lead to the development of generalisations, principles or theories o A systematic way of asking questions, a systematic method of enquiry Types of research o Lab/Clinical/Epidemiological/Sociological o Experimental/Observational o Qualitative/Quantitative Research Process o General research topic o Aims / Research question o Research design o Data collection o Data analysis o Report Evidence Based Medicine o The integration of research evidence, clinical expertise and patient values Scientific Research Method o A systematic procedure for carrying out an activity specifying how knowledge should be acquired, stated, and evaluated for its truth/falsity o A set of rules for undertaking scientific research with three basic elements: Scepticism (any statement is open to doubt), determinism (events occur according to laws), empiricism (enquiry conducted through observation, verified through experience) o Method Initial observation, description (senses) Problem (experimental question) Hypothesis (rationalisation for observations / likely explanation) Experimentation and observation (test hypothesis and observe) Results (collect data and perform calculations) Draw Conclusions (summarize, check hypothesis, draw conclusions to explain problem, give solution, predict) Hypotheses o An explanation that is based on prior scientific research/observations that can be tested o Hypothesis = prediction of the outcome of an experiment o Theory = well-substantiated (observation and experimental support) explanation that explains some aspects / organised system of accepted knowledge to explain phenomena o Law = well tested and supported theory that is true for a variety of circumstances / a generalisation that describes recurring facts or events in nature Characteristics of Research o Logical o Understandable o Confirmable o Useful o Substandard = misuse patients/participants, misuse resources, misleading published research o High quality = based on work of others, can be replicated, generalizable, logical, incremental Stages o Review o Question/hypothesis o Research design o Data collection o Interpret results o Disseminate Rosenthal effect o Researchers opinion/preconceptions influence results Hawthorne effect o Presence of researches influences results

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Lecture 2 Research Designs

Study Quality o Validity = truthfulness o Reliability = repeatability Qualitative / Quantitative o Qualitative strength = validity, Quantitative strength = reliability o Qualitative compliments quantitative by: providing preliminary understanding allowing validation through triangulation exploring complex information o Qualitative through documents, passive obs, participant obs, in depth interview, focus groups o Qualitative approaches Phenomenological Examining human experiences through descriptions provided by people involved Describing the meaning that experiences hold for each subject Eg. What is it like for a mother to live with a dying child Bracketing = process whereby researcher identifies expectations and deliberately ignores Grounded theory Developed by Glaser + Strauss A theory grounded in data, developed from the analysis of collected data Generation over testing of hypotheses Ethnography Collection and analysis of data about cultural groups Where you go and live in the community Learning from people Epidemiology o The study of the distribution and determinants of health related states or events in specified populations and the application of this study to the control of health problems

o o o o

Retrospective = looking back to determine factors leading to current disease Cross sectional = a one short survey measuring variables at one point in time Prospective = begin in the present and follow subjects in time Studies Cross sectional study First stage Looks for potential relationships Eg. Visited dental professionals by disadvantage Case control study (Outcome Exposure) Eg. People who have MS and exposure to amalgam Retrospective Advantages Disadvantages Cheap, easy, quick Case & Control selection difficult Multiple exposures can be studied Subject to bias Rare disease / Long latency disease can be Direct incidence estimation impossible studied Suitable when randomisation is unethical Temporal relationship not clear Multiple outcome cannot be studied Hard to estimate attributable fraction (reduction in disease when risk factor is removed) Temporal relationship not clear Cohort study (Exposure Outcome) Eg. Does exposed to day care result in asthma?

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Prospective Advantages Can establish population based incidence Accurate relative risk (risk of an event after exposure) Can examine rare exposures Time to event analysis possible Where randomization not possible Magnitude of risk factors quantifiable Less bias Multiple outcomes can be studied Disadvantages Lengthy & expensive May need large samples Not suitable for rare disease Not suitable for long latency diseases Unexpected environmental changes influence association

RCT Prevalence of disease o

o o Prevalence of disease = Total no. of cases of disease Total population @ a given point/period of time

High blood pressure (eligible patients) given random treatment, checked for outcome

Expressed in = percent, number of cases per 10 000, number of cases per 100 000 Use = Overall impact of disease in a community, need for health care resources Incidence of disease
o Cumulative incidence = No. of new cases over a period of time Population at risk at start of the period

Expressed in = percent, number of cases per 10 000 population at risk per year, number of cases per 100 person years of observation o Used = Identify factors associated with disease, measuring strength of association between a factor and a disease Uncertainty principle o Physicians who know which treatment is best for patient cannot enter patient into a RCT Variables o Independent o Dependent o Control o

Lecture 3 Critical Analysis of Papers I

Literature & research o Generates ideas o Helps form significant questions o Instrumental in the process of research design Critical Thinking o Discernment o Analysing o Evaluating Reviewing the Literature vs. Literature review Reviewing literature Literature Review Informing yourself of whats happening in the field Informing audience of what is happening in the field Gaining topical and methodological knowledge Establishing your credibility as a knowledgeable researcher Finding potential gaps in literature leading to Research Arguing significance of research questions Questions Critically evaluating methods Providing context for own method Critical analysis 1. Objectives of the study 2. Authors research centre, principal author, 3. Type of journal peer reviewed, ISI Indexed, Impact Factor, National/International, Target audience 4. Abstract clear outline of study, matches article 5. Introduction why study needed, purpose of study, background, how to this contributes to knowledge, aims, strategy and variables 6. Methods appropriate design, identify study type, inclusion/exclusion of subjects, control groups, sufficient detail 7. Results do the results reflect the aims, presented appropriately, values rather than results, tabulated and labelled, correct statistics 8. Discussion aims adequately addressed, justified, limitations

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Lecture 4a Evidence Based Medicine

What is evidence based medicine? o EBM is the integration of best research evidence with clinical expertise and patient values Dave Sackett o The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research o An appropriate to health care that promotes the collection, interpretation and integration of valid, important and applicable patient-reported, clinician observed and research derived Sacketts distinction o Background questions general understanding of disease Eg. Does caries increment stay relatively constant through life or are there periods of greater activity o Foreground questions How do we manage patients with the condition Problem, Intervention, Comparison, Outcome Eg. In adult interproximal caries, does amalgam offer better protection against recurrent caries than a composite restoration? Evidence based practice o Ask o Find o Appraise o Act o Evaulate Systematic review {EXAM Q} o Involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal and synthesis of all relevant studies that address a specific clinical question Deborah Cook Meta-analysis o A type of systematic review that uses statistical methods to combine and summarize results Cochrane o Global group of health care professionals (1993) o Goal is to prepare, maintain and disseminate, up-to-date reviews by specialty and RCT in all areas of medicine

Lecture 4b Dealing with Data 1

Major question in survey analysis o Appropriate level o Distribution of each variable o How do independent/dependent variables relate o How does independent relate to dependent o Explanation of relationships Initial quality check of data o Editable? Initial clerical checking Check for omissions, legibility, logical inconsistencies Valid coding range checks Frequency distributions o Coding? List question List short variable name List record which variable is located List valid codes for each question and their labels List missing data codes for each question List any special coding instructions which was used for particular questions o Fair representation / Enough detail? Statistics o Descriptive and Inferential statistics Descriptive data Describe specific characteristics of data such as how many cases fall into a particular category of measurement, typical values and the degree of interrelationship or correlation among measurements Eg. Births/deaths, marriage/divorce, morbidity Inferential data Sample from a population From the sample, infer characteristics of the population

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Types of data Quantitative data Discrete (in steps) Continuous (may take any value) o Grouping causes loss in information and use of arbitrary values Qualitative data (recorded in numbers only for convenience) Categorical (can tae a number of levels that have no intrinsic numerical meaning) Binary (two levels only) Ordinal (have a natural order to their outcomes) Measures of centrality Mean = average (best when have a symmetric distribution with thin tails) Median = middle (if skewed use median) Mode = set of values occurring most frequently (not good measurement of centrality) Measures of dispersion Range = diff between max and min values Variance = quantifies the amount of variability or spread around the mean, the average of the squared deviations Standard deviation = square root of variance Normal distribution Symmetric Two parameters, mean and mode Highest point is at the mean, median and mode 68.26% within 1sd 95.44% within 2sd 99.72% within 3sd

Lecture 5 Ethics and Research

Human research o Research conducted with or about people, or their data or tissue o It is governed by Commonwealth government > National Health and Medical Research Council > UWA HREC > Deans & Heads of School > Individual teachers/researchers o Examples of poor studies: NZ Cervical Cancer study (women withheld from normal treatment) The Pill Tuskegee Study (investigated untreated syphilis) Ethics o The subject of ethics is best thought of as the critical scrutiny of moral thought and morality as it affects our ideas of right conduct Basic Ethical Principles from the NMHRC o Integrity In the researchers who are committed to the advancement of knowledge, pursuit and protection of truth and to rigorous scientific method Communication of research results o Respect for persons Welfare, rights, beliefs, customs, protection for people, recognition of autonomy Beneficence (for the benefit of) Avoiding harm and promoting well-being Maximising benefits, minimising harms No Harm Physical, physiological, social, cultural, financial To individuals / groups o Scientific adequacy Research must be justifiable in terms of its potential for knowledge contribution Research design must account for participant selection, data collection, analysis and interpretation Researchers must have adequate expertise to conduct project + data o Justice Benefits of research should be balanced against the burdens of the research o Informed consent Provision of clear and coherent info to participants (cost, purpose, risks, complications etc.) Excercise voluntary choice to participate or not, given participant is competent to make that choice Restrict circumstances for research without consent o Privacy and confidentiality Individuals have a sphere of life private to themselves Legal/ethical obligations when info given

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Safe storage of data HREC (Human research ethics committee) o Committee made of 7+ members: A chairperson 2 lay members M/F knowledgable in research domains knowledgeable in health care religion lawyer o Role is to consider protocols, record decisions, monitor research, handle complaints, report to AHEC

Lecture 6 Critical Thinking

Critical Thinking o [Dfn] Reasonable, reflective thinking that is focussed on what to believe or do o Consists of mental processes: discernment, analysing, evaluating o Avoid and beware of: prejudice, bias, propaganda, self-deception, distortion, misinformation Factors affecting critical thinking o Knowledge and experience o Intellectual skills and strategies o Attitudes and dispositions: use them objectively, rather than subjectively o Thinking environment, e.g. hard to if in a creek with alligators Steps involved o Identifying the problem: px presenting complaint, detailed medical/dental hx o Formulating hypotheses: ways to solve the problem o Evaluating the hypotheses: need to collect data to prove case o Deriving conclusion Dispositions o Keep in mind the original/basic concern o Withhold judgement when evidence and reasons are insufficient o Seek reasons (why is it occurring?) o See similarities and differences (patterns) o Investigate by seeking evidence and counterevidence o Judge the credibility of a source, or to judge whether an observation is reliable (credentials) o Determine whether a generalisation is warranted

Lecture 7 Questionnaire Design

Data o Qualitative vs quantitative o You can use existing data from NHANES, ABS, WADLS o Or make a new questionnaire to get new data or use previous questions Questionnaires Advantages Disadvantages Accepted method of data collection Often relies on researched to ask the right question Sometimes cheaper Does not subtle exploration of answers (Q limits response) Same to all participants Varying response (misunderstand the question) Can reach large numbers of people relatively easily Need to get is right the first time (hard to chase missing data) Provide quantifiable answers Relatively easy to analyse (quick results) Planning a survey o Stage I: Define the scope of the research o Stage II: Developing a research design and plan o Stage III: Execution of the survey o Stage IV: Analysis and reporting the results Questionnaire Steps 1. Choosing a topic + defining objectives Have very clear objectives and use them as a guide through out 2. Defining / Clarifying variables + the relationships [Dfn] Any quantity that varies Conceptual, operational, variable definitions Relationships: Independent, Dependednt, Intervening and confounding Select variables based on aim, knowledge of literature, approach, funding 3. Choosing data collection method Telephone survey

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Advantages

Disadvantages

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5.

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Quick results High refusal rate Can use large samples No way of verifying ID or respondent Economical Excludes other collection ways (eg. observation) More open communication Restricted sample to those with phones Reduces bias as interview unseen Offers greater anonymity Interview Postal survey Formulate + format questions Use focus groups / in-depth interviews Consultation with stakeholders (those involved) Critical review of literature and reports Focus on objectives of study Closed questions = easier to analyse, lack additional info Open questions = harder to analyse, yield the less predicted data and additional info Choice b/n open and closed depends on purpose of survey, respondent characteristics, access to skilled coders, time to develop and code the questionnaires Check design Concise and clear Introduce what you are doing Clear instructions Natural sections Instructions on how to return form Check wording Language simple? Shorter questions possible? Question double-barrelled? Question leading? Question negative? Can respondent answer question/have necessary knowledge? Words have same interpretation for everyone? Pre-testing and piloting questions Test questionnaire (eg. Colleagues) Also pilot (guide) the subjects as similar to the actual study sample Estimate cost, duration and develop protocols Drawing the sample Be clear about sample Type (convenience, strata, cluster) Execute and monitor survey Improve response rate by: Being concise Pre-survey info sheets Incentives Reply paid envelopes Follow up call Preparing, planning, implementing data analysis Data into Excel, Stata, SAS or SPSS Coding sheet: variable name (eg. Sex), codes used (eg. 1=M,2=F) , explanation variable (eg. Sex recorded by parent) Writing + disseminating research report

Lecture 8 Dealing with Data 2

Data analysis 1. Enter into excel 2. STATA, SAS, SPSS 3. Coding sheet Variable name Codes used Explanation variable 4. Clean data Range checking (eg. Male = 1, Female = 2, then 3 is like whatthecrap) Contingency checking (eg. Described 5 visits to dentist, only went 1 once)

Written by Hsern Ern Tan

Know data Frequency distributions o Symmetrical o Skewed Positive hump to the left, (L R)mode, median, mean Negative hump to the right, (L R)mean, median, mode o Normal distribution (1sd = 68.26%, 2sd = 95.44%, 3sd = 99.72%) Inferential statistics o p-values o Confidence intervals Hypothesis testing 1. Set up null hypothesis (H0) The null hypothesis is a theory which says that there is no association between the variables It basically means that the results of the study are all due to chance, not due to an actual relationship Eg. Trialling a new drug, H0 could be that there is no difference between the new drug and old drug 2. Set up alternative 3. Choose alpha 4. Take a sample and calculate 5. Look up table for p-value P-value is the probability that the result is due to chance rather than a true relationship between the variables If the P-value is less than 0.05 we reject the null hypothesis (i.e. reject the idea that there is no relationship and say that there is a statistically significant relationship) 6. Compare p to alpha 7. Decide whether to reject H0 Example Data Analysis Effect of Alcohol on performance time Errors 1. State the null hypothesis and alternative H0 is True H0 is False a. H0: There is no decrease in time b. Alternative: There is a decrease in time Reject Type 1 error ok 2. Verify data conditions + analyse data with stats Accept ok Type 2 error a. No outliers, skewness with a boxplot o Type 1 Error ( = false +ve) = the null hypothesis is true b. Mean, SD, p-value, t-value etc. 3. Find p-value (i.e. that there is NO relationship between A and B) but a. p-value = 0.013 you rejected it saying that there IS a relationship 4. Decide whether it is statistically significant or not between A and B a. Using a=0.05, p=0.013<0.05 thus reject H0 o Type 2 Error ( = false ve) = the null hypothesis is false b. Alcohol has a statistically significant effect and decreases performance time (i.e. that there IS a statistically significant relationship between A and B) but you accepted it saying that there is a NO relationship between A and B when there really was! You wrongly concluded there to be no association between A and B. You Type II error idiot. Power o P (rejecting null when false) = 1 P() o Want to have as much power! (Usually about 80%) o Eg. H0 stated that there was no relationship between A and B, you rejected it saying there was a relationship. You were correct, there was a relationship. i.e. the right thing to do Controlling Type 1 and Type 2 errors o = constant, n o n = constant, n o n o There is an inverse relationship between the two errors Confidence intervals o CI is the expected range in which population statistic will be found at a given level of confidence o Eg. CI 95% means we are 95% certain that the true mean will be found within this range Non-parametric statistics Advantages Disadvantages Can be used for non-normal data Loose information Ordinal scale data can be used Some non-parametric tests are labour intensive for large samples Some protection against outliers Can be used if we know little of sample population

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Lecture 9 Epidemiology
Definition o The study of the distribution and determinants of health related states and events in populations and the application of study to control of health problems Assumptions o Diseases does not occur by chance o Diseases are not randomly distributed Error Types Components 1. Random Error (noise) o Frequency o Individual variation o Distribution o Sampling error o Measurement error o Determinants 2. Systematic Error (bias) Uses o Selection bias o Establish a cause o Measurement bias o Study natural history of a disease o Assess health status o Evaluate the impact of intervention Qualitative vs Quantitative Qualitative Quantitative Understanding Prediction Interview/Observation Surveys/Questionnaires Discovering frameworks Existing frameworks Textual (words) Numerical Theory generating Theory testing Quality > Sample size Sample size core to reliability Subjective Objective Embedded knowledge Public Models of analysis: Fidelity to text Model of analysis: Parametric, non-parametric Causation o Strength o Consistency o Specificity o Temporality o Biologic gradient o Plausibility o Coherence o Experimental evidence o Analogy Strength of association Relative Risk Odds Ratio Strength of Association 0.83 1.00 1.0 1.2 None 0.67 0.83 1.2 1.5 Weak 0.33 0.67 2.5 3.0 Moderate 0.10 0.33 3.0 10.0 Strong <0.01 >10.0 Approaching infinity Prevalence vs Incidence Prevalence Incidence Prob (already having disease) Prob (getting disease in given time period) Numerator = all cases of disease Requires follow up Depends on duration of disease Does not depend on duration of disease Estimates burden of disease Used when studying causes of disease Relative risk o For cohort
Disease Not Diseased b d

o -

Relative Risk =

Incidence of disease in exposed Incidence of disease in non-exposed

a/(a+b) c/(c+d)

Exposed Not Exposed

a c

Odds Ratio o For case-control

Exposed Not Exposed b d

Odds ratio =

Odds of exposed cases/disease Odds of exposed controls/healthy

a/b c/d

Case (Disease) Control (Healthy)

a c

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Lecture 10 Epidemiology 2
Case-control Advantages Appropriate for rare diseases Usually quick Does not require large samples Allows exploration of multiple exposures Disadvantages Recall bias Selection bias (controls as similar to cases as possible) Representive bias (typical cases) May not get all risk factors Time-sequence may not be determined Cannot calculate incidence Survival bias

Randomised Controlled (Clinical) Trial o Strongest design for clinical study because of randomisation minimises bias by patients in each group are as similar as possible Advantages Disadvantages Respected approach Not suitable of many research questions Quality data produced Loss of data due to lack of follow up Random allocation Time consuming and expensive Strength if double blind Often ethical problems Can study multiple outcomes Difficult to ensure compliance + avoid contamination Incidence can be measured Excellent data on baseline measures Systematic review o Comprehensive survey of a topic in which all of the primary studies of highest level evidence have been systematically identified, appraised and then summarised according to an explicit and reproducible methodology Meta-analysis o Survey in which all the studies are similar enough statistically that the results are combined and analysed as one study

Lecture 11 Critiquing Paper 2 + Revision (aka Bullcrap Useless Lecture)

Critiquing questions o Valid Appropriate methodology Eliminates bias and confounding factors o Reliable Real results of due to chance P-values, Confidence intervals, Odd-ratio diagrams o Applicable Will it help

Dude. *epic pause* Exams are over. 2 year is freaking over. Sweeeet. Have fun studying. UCS is a great unit.
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If you actually read this, you really are a loser. =P Its in small font for a reason. Sooo, what, youre like on a billion percent zoom? Oh [rant] If you had the freaking FCD 08 paper, you should have posted it. Selfish *bad word* Heard of sharing before? >:-( Not cool, not the right attitude. Take Foos example. [/rant] This box is actually a waste of time. This unit is actually a waste of time. I bet Bayan is hunching up trying to read this. Glad this is all going to end up looking like a line when you print it. Hey this actually counts to the word count.

You guys are pretty awesome. 2 year wasnt. Im kidding. It was actually pretty cool. But you guys were what made it cool. -Hsern Ern, 8:20pm 11 Nov 2009
PS. Stuff studying the other boxes. This is the box to study. :P
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