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Critical Appraisal: Therapy article

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George G. Lim

on 31 August 2018

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Transcript of Critical Appraisal: Therapy article

Clinical Decision-making
using an article about Treatment

Professor I, Department of Surgery
Faculty of Medicine & Surgery
University of Santo Tomas

A 72-year old female consults you for hypertension and elevated cholesterol. During your discussion on cardiac risks, she inquires about the need to take an anti-cholesterol drug.

What advise will you give?
Knowing the patient’s true state is often unnecessary
Treatment error is always a possibility when the diagnosis is uncertain
The need for diagnostic certainty depends on the penalty for being wrong
...making choices
Should I request for a laboratory examination or treat right away?
Between two diagnostic alternatives, which one should I request?
Should I start treatment or observe first?
Between two or more drugs, which one should I prescribe?
old paradigm
Common sense
Medical Evidence
new paradigm
Medical Evidence
Common sense
Hypercholesterolemia promotes coronary artery disease thus cholesterol is a risk factor
Lowering cholesterol also lowers the risk of coronary artery disease
If cholesterol is elevated by laboratory examination, it can be lowered by drugs
National Cholesterol Education Program: screen all adult patients and intervene when necessary
Formulate the problem into a question
Conduct a systematic medical literature search
Critically appraise the medical literature
Apply the results
Evaluate the application
Search & select
Among elderly patients who have elevated cholesterol, will anti-cholesterol drugs be beneficial?
Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study
Study design?
Quick and cheap
Only feasible method for very rare disorders or those with long lag between exposure and outcome
Fewer subjects needed than crosssectional studies
Reliance on recall or records to determine exposure status
Selection of control groups is difficult
Potential bias: recall, selection
Cheap and simple
Ethically safe
Establishes association at most, not causality
Recall bias susceptibility
Confounders may be unequally distributed
Neyman bias
Group sizes may be unequal
Ethically safe
Subjects can be matched
Can establish timing and directionality of events
Eligibility criteria and outcome assessments can be standardized
Administratively easier and cheaper than RCT
The controls may be difficult to identify
Exposure may be linked to a hidden confounder
Blinding is difficult
Randomization not present
For rare disease, large sample sizes or long follow-up necessary
All subjects serve as own controls and error variance is reduced thus reducing sample size needed
All subjects receive treatment (at least some of the time)
Statistical tests assuming randomization can be used
Blinding can be maintained
All subjects receive placebo or alternative treatment at some point
Washout period lengthy or unknown
Cannot be used for treatments with permanent effects
Unbiased distribution of confounders
Blinding more likely
Randomization facilitates statistical analysis
Expensive: time and money
Volunteer bias
Ethically problematic at times
Provide the BEST evidence of effectiveness
Individuals are randomly assigned (randomization) to either of the groups
Randomization tries to make the groups SIMILAR
They are observed FORWARD in time and their outcomes compared
The outcome can be the cure of a disease, relief of symptoms, or improvement in quality of life
Is the objective of the article comparing interventions similar to your clinical dilemma?
Is the objective of the article comparing interventions similar to your clinical dilemma?
The objective of the study is to compare Simvastatin, an anti-cholesterol drug with placebo
Is the article likely to be true?
Are the results valid?
How large is the size of the effect?
Will the findings work in my patient?
Population of the study (P) – should be similar to the characteristic of your patient
Intervention/comparative intervention/exposure (I) – should include the therapeutic intervention you want to test
Outcome of the study (O) – one of the outcomes measured should be the goal you and your patient wish to work for
Was the assignment of patients to treatments randomized?
The title, abstract and the methodology section stated that the study was a double-blind randomized controlled trial
Were all patients who entered the trial properly accounted for and attributed at its conclusion?
Was follow-up complete?
Were patients analyzed in the groups to which they were randomized?
Drop-out rates are greater than event rates
Gross imbalance in drop-out rates between groups
Worst assumptions lead to opposite conclusions
Were all patients who entered the trial properly accounted for and attributed at its conclusion?
4,444 patients were randomized and analyzed according to intention-to-treat principle.
In the Table for the main analysis, the sum of patients in each group totaled 4,444, the number who were randomized
Were patients, health workers, and study personnel blind to treatment?
The study was a double-blind controlled trial
Were the groups similar at the start of treatment?
Table 1 of the results section showed no major difference in the baseline characteristics between the two groups
Aside from experimental intervention, were the groups treated equally?
There were no planned co-intervention for the two groups
What are the Results?
If you weighed 80 kg after the Christmas holidays, and 60 kg after a summer diet, what would be the ways of expressing your weight loss?
I lost 20 kg (absolute weight reduction)
I am now 75% of what I used to weigh (relative weight)
I lost 25% of my weight (relative weight reduction)
Can the results be applied to my patient care?
Subjects included in this study were patients with angina or MI and elevated cholesterol
Were all clinically important outcomes considered?
The main outcomes considered were new onset of MI, coronary death, and overall cause of death
Are the likely treatment benefits worth the potential harm and cost?
33 patients to prevent 1 death (or save 1 life)
40 mg tab at @ P 25.00
At 365 days = P 18,250
For 33 patients = P 602,250
For 5 years = P 3M
Can the results help me in caring for my patient?
Are your patient’s values and preferences satisfied by the regimen and its consequences?
Do your patient and you have a clear assessment of their values and preferences?
Are they met by this regimen and its consequences?
72-year old patient
A 72-year old female consults you for hypertension and elevated cholesterol. During your discussion on cardiac risks, she inquires about the need to take an anti-cholesterol drug.

What advise will you now give?
I would rather not give an anti-cholesterol drug. The benefit is too small for the cost it will take.
I will prescribe an anti-cholesterol drug.
My patient can afford the cost even if the benefit is not large.
NAME:_________________________________ SEC: _____ DATE: ____________
______ 1. The relative risk of spontaneous bleeding with a new antiplatelet drug compared with clopidogrel in the patients with coronary stents is 0.95 (95% CI = 0.89-1.09). What would be your interpretation?
A. The new drug is clearly better than clopidogrel
B. The new drug caused less spontaneous bleeding
C. The new drug did not reduce spontaneous bleeding
D. The new drug caused more spontaneous bleeding
______ 2. The case control study design may sometimes be acceptable in answering a clinical treatment dilemma in the following situations EXCEPT:
A. Rare condition
B. The best treatment is urgently needed
C. Limited resources
D. Long follow-up period for the disease
______ 4. An article reports that chemotherapy following surgery decreases cancer deaths among patients with Stage 2 renal cancer. At a median follow-up of 6 years, the study reveals 2 out of 100 receiving chemotherapy after surgery died while 3 out of 100 died in those with surgery alone. The relative risk of cancer death with adjuvant chemotherapy is:
A. 0.33
B. 0.95
C. 0.67
D. 1.34
______ 5. 401 asthma patients were assigned to receive a new inhalant vs. placebo to determine its efficacy in preventing recurrent attacks. The drop-out rate in the treatment group is 20 out of 200 while 8 out of 200 in the placebo group dropped out. The result shows that 9/180 (5%) in the treatment group and 23/192 (12%) in the control group developed recurrent asthma attacks within 2 years. What can you conclude?
A. The study population should be increased
B. The drop-out rates are generally acceptable
C. The new inhalant is not better
D. The new inhalant should be recommended for general use
______ 3. To find out whether preoperative antibiotics prior to hysterectomy would result in less postoperative wound infections, you would perform a:
A. Cohort study
B. Case-control study
C. Cross sectional survey
D. Randomized controlled trial
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