Making evidence more accessible using pictures

Rod Jackson Oxford 8/9/09

What is Evidence Based Practice?

What is Evidence Based Practice?

The 6 steps of Evidence Based Practice

1. 2. 3. 4. 5. 6. ASK a focussed question ACCESS - search for epidemiological evidence to help answer question APPRAISE the evidence for its validity, effect size, precision) AGGREGATE the evidence with patient/community, clinical/hlth & policy issues & make an evidencebased decision APPLY your decision [AUDIT your practice (i.e. check your actual practice against evidence-based practice on a regular basis)].

The GATE frame

Graphic Approach To Epidemiology

PECOT: the 5 parts of every epidemiological study Participants

P
Comparison Group

Exposure Group

Time

O T

Outcomes

All epidemiological studies can be hung on the GATE frame

EBP Step 1: ASK - turn your question into 5 parts (PECOT)

1. Participants (patient(s) you want to treat) 2. Exposure (an intervention if about therapy) 3. Comparison (there is always an alternative! - another therapy, nothing 4. Outcome (usually a disease or condition you want to prevent or manage) 5. Time frame (over which you expect a result)

EBP Step 2: ACCESS - search for the best evidence to answer your questions

Use the PECOT components to choose search terms

EBP Step 3: Appraise the evidence

using PECOT & RAMBO on the GATE frame
P E C O T T O E C P Recruitment Allocation Maintenance Blind or
Objective measurements & processes

EBP Step 4: AGGREGATE the relevant information & make an evidence-based decision: the X-factor

X-factor: making evidence-based decisions

Epidemiologic evidence Patient / community preferences Policy issues Clinical / population health considerations

expertise: putting it all together the art of practice

Step 5

APPLY
Implementation!

Step 6: AUDIT - evaluate & improve performance

1. Determine best practice (EBP Steps 1-4) 2. Assess current practice: survey 3. Compare with best practice - is there a gap? 4. Consider reasons for gap, identify processes to reduce gap & implement 5. Re-survey: is there any improvement?

= quality improvement / audit

GATE
Graphic Approach To Epidemiology
Graphic Appraisal Tool for Epidemiology Graphic Architectural Tool for Epidemiology

www.epiq.co.nz

The GATE frame

the shape of every epidemiological study

GATE study design (PECOT)

P

O T

GATE study analyses (EGO & CGO)

EG CG

a c

b d

GATE study appraisal (RAMBO)

P
Blind or Objective measurements & processes
Allocation Recruitment

Maintenance

GATE study design (PECOT)

Participants

P
Comparison Group

Exposure Group

Time

O T

Outcomes

Participants
Study Setting

Eligible Participants

Participants

Exposure & Comparison Groups

Exposure or Intervention Group (EG)

EG

CG

Comparison or Control Group (CG)

Outcomes (O)

yes

Dis-ease
no

O
c d

Outcomes (O)

Time (T)

incidence

prevalence

GATE study analyses

All epidemiological studies involve measuring the OCCURRENCE of disease Occurrence = Numerator Denominator

D
N

Denominator (Participants)

O = ND
Numerator (Outcomes)

GATE study analyses

P
Denominator 1: Exposure Group EG Numerator 1: a Overall Denominator Denominator 2: Comparison Group CG Numerator 2: b

EG CG

a c

b d

Occurrence = N D
P
Denominator 1: Exposure Group EG Numerator 1: a
Exposure Group Occurrence: EGO = a EG

EG CG

Denominator 2: Comparison Group CG Numerator 2: b

a c

b d

Comparison Group Occurrence: CGO = b CG

Estimating effects & associations involves comparing occurrences

Relative Effect or Risk = EGO CGO e.g. relative risk (RR), risk ratio, prevalence ratio, incidence ratio Absolute Effect or Risk Difference = EGO - CGO e.g. risk difference (RD), absolute risk Number Needed To Treat (NNT) = 1 RD

Analyses

its all about EGO & CGO

Occurrence = ND per unit of time

P
Denominator 1: Exposure Group EG x T Numerator 1= a Denominator 2: Comparison Group CG x T

EG CG

person-time exposure
a c Exposure Group Occurrence: EGO = a (EG x T)

b d

Numerator 2 = b

Comparison Group Occurrence: CGO = b (CG x T)

GATE study appraisal (RAMBO)

Blind or Objective measurements & processes

P
Allocation

Recruitment

Maintenance

Study appraisal
How well was the study done? Was it ok ( or +) or not ok (#)? or unclear (?) or not applicable (n/a) no study is perfect!

RAMBO
P appropriate Recruitment? participants representative of target population C
Study setting & eligibility criteria well described? Recruit random sample OR Recruit consecutive eligibles

O
appropriateness depends on study question

RAMBO
appropriate Allocation process? were EG & CG comparable
Allocation process well described? If allocated by investigators: Allocated randomly (e.g drugs) AND Concealed allocation OR If allocated by measurement (e.g. smoking): Adjusted for differences between EG & CG (e.g. statistical or matching)

Allocate

EG CG

RCT: Allocate randomly by Cohort: Allocate by investigators (e.g drugs) measurement (e.g. smoking)

EG CG

EG CG

RAMBO
good Maintenance? did participants remain in allocated groups (EG & CG)

EG CG

Participants &/or investigators blind to exposure (and comparison exposure)? Compliance high & similar in EG & CG Contamination low & similar in EG & CG Co-interventions low & similar in EG & CG Completeness of follow-up high & similar in EG & CG

P A EG CG

RAMBO
Blind or Objective? measurements & processes
Allocation concealed (blind) if randomised EG & CG measurements well described Outcome measurements well described Allocation/Measurement process similar for all participants

O
T

If measurement not objective (eg. automated or definitive) were assessors blind to exposure (and comparison exposure)

The GATE approach: every epidemiological study hangs on the GATE frame

There is only one basic study design: Cohort (& case-control) studies aetiology / prognosis / intervention RCT (a randomised cohort study)interventions Cross-sectional studies - diagnosis

Cohort (follow-up) study: archetypal epidemiological approach

Participants

Allocated by measurement (not by randomisation) Exposure Group

Comparison Group

Time

Outcomes

Best design for investigating aetiology (risk), prognosis

Randomised controlled trial - cohort study where exposure allocated by randomisation process P Participants
Allocated by randomisation Exposure Group

Comparison Group

Time

Outcomes

Best design for investigating treatments

Case series is a Cohort study with no comparison group

Participants

Allocated by measurement Exposure Group

Time

Outcomes

Before-after study
Participants

Allocated by timing of intervention

C
Exposure Group

Comparison Group

E O
Outcomes

Time

Cross-over trial
Participants

Allocated by randomisation Exposure Group 1

E1 C2 Comparison Group 2 E2 C1 O
Comparison Group 1 Outcomes

Exposure Group 2

Time

real-life time

Cross-sectional study
P

Participants

Allocated by measurement Exposure Group

Comparison Group

Time

Outcomes

best design for prevalence and diagnostic test accuracy

Diagnostic test accuracy study

P

Disease +ve

EG CG

Disease -ve

Test

+ -

a b O
c d Likelihood +ve test if D -ve: CGO = a CG

Likelihood +ve test if D+ve: EGO = a EG

Diagnostic test accuracy study

P

Disease +ve

EG CG

Disease -ve

Test

+ -

O c d
Likelihood -ve test if D -ve: CGO = d CG

Likelihood -ve test if D+ve: EGO = c EG

Diagnostic test for disease prediction

P

Test +ve

EG CG

Test -ve

Disease

+ -

a c

b d

Likelihood of D if test +ve: EGO = a EG Positive predictive value

Likelihood of no D if test -ve CGO = d CG Negative predictive value

Diagnosis: test accuracy

Disease +

EG CG

CG EG

a c

b d

+ -

Test -

Diagnosis: test accuracy

Disease +

EG CG

CG EG

a c

b d

+ -

Diagnosis: disease prediction

Test -

Case control study

Exposed Cases Controls Not Exposed

a c

b d

for investigating aetiology, interventions when outcomes rare

Case control study

nested in a virtual cohort study Exp. Cases Controls Not Exp.

Participants

a
eg

b
cg

Exp Group

EG

CG

Comparison Group

controls
a

Time

cases
Outcomes

GATE: multiple categories

Participants P

Multiple Exposure categories

E1 E2 E3 C

Comparison

Multiple Outcome categories

GATE: continuous measurements

Participants P

Continuous measure of Exposure: e.g. body mass index Continuous measure of Outcomes e.g. lipids

E
high..med..low

Correlation coefficient low

medium high

Life is a non-randomised trial

The 6 steps of EBP

1. 2. 3. 4. 5. 6. ASK a focussed question ACCESS - search for epidemiological evidence to help answer question APPRAISE the evidence for its validity, effect size, precision) AGGREGATE the evidence with patient/community, clinical/hlth & policy issues & make an evidencebased decision APPLY your decision AUDIT your practice (i.e. check your actual practice against evidence-based practice).

A CAT documents the steps for a specific question

CATS
Download from www.epiq.co.nz

GATE-lite