review sheet for final term 3 FPU EBP

Question 1

Clinical Prediction Rules (CPRs)

Answer 1

Utility of CPRs in physical therapist practice

Therapist tool = make decision based on predictable things from history and exam:

Includes:

Making a diagnosis, prognosis, making patients to best interventions, predict response to treatment for an individual patient

Question 2

• Ottawa Ankle Rules (OARs) - diagnosis
  ✓Should a patient with acute ankle pain be evaluated with an X-ray?
• Rule for Shoulder Pain – prognosis
  ✓What is the risk of persistent symptoms in a patient with shoulder
  pain?
• Rule for Neck Pain - response to treatment
  ✓Which patients with neck pain will benefit from thoracic spine thrust
  manipulation?
  ✓Note: this is different from effect of intervention-
  EXAMPLES of ….

Answer 2

CLINCAL PREDICTION RULES (CPR’s)

Question 3

• Combinations of clinical findings that are
  ✓systematically derived or developed
  ✓statistically tested
• Stepwise logistic regression is often used to develop
  the most economic model
• Which combination of predictors (variables) will provide
  most accurate diagnosis?

Answer 3

clinical prediction rule

Question 4

3 steps for clinical prediction rule?

Answer 4

derive
validate
impact

Question 5

derive

Answer 5

ID factors with predictive power

Question 6

validate

Answer 6

evidence of reproducibility accuracy
Narrow or broad

Question 7

impact

Answer 7

evidence that rule changes physician behavior and improves patient outcomes and/or reduces cost

Question 8

Levels of CPRS

Answer 8

Level 1 best – impact analysis – influencing clinician behavior and improving outcomes

Level 2 Broad – varying setting – used with confidence

Level 3 narrow – similar setttings as study – used with caution

Level 4 – things that have predictive power – rules need more info to be applied

Question 9

level 3 CPR

Answer 9

Level 3 narrow – similar setttings as study – used with caution

Question 10

level 1 CPR (is the best level for CPR?)

Answer 10

Level 1 best CPR – impact analysis – influencing clinician behavior and improving outcomes

Question 11

level 4 CPR ? worst ?

Answer 11

Level 4 – things that have predictive power – rules need more info to be applied

Question 12

• Look for factors that potentially contribute to diagnosis
• Sn and Sp: good for ruling dx in or out?
  ✓ OARs: Sn = 95%; Sp = 50% (better for ruling out fx)
• Analyzed using stepwise logistic regression to use the least number
  of predictors that can most accurately predict the outcome. (Refer
  to concept of ROC curve)

WHICH step of CPR process does this look like?

Answer 12

step 1 derive the model

Question 13

• Confirm accuracy on different samples in different settings to show that the model is robust

Which step of CPR does this look like?

Answer 13

step 2 - validation portion of CPR

Question 14

• Has the CPR been widely adopted, and has it improved diagnosis,
  and has it been shown to reduce cost or risk?
  ✓ OARs have significantly reduced number of X-rays

Which step of the CPR does this look like ?

Answer 14

step 3 - the impact portion

Question 15

1.Operationally define the SAMPLE?
Sample homogeneity? Inclusion/exclusion criteria (age, UL pain)
2.Subjects representative of the population ?
Address issue of SAMPLE bias
3.Include all relevant predictive factors in development process?
Compare to gold standard, all the factors?
4.Predictive factors operationally defined?
A clear definition of these variables is necessary to correctly identify
which subjects have these characteristics and to optimize the
accuracy of the prediction rule.
5.Large enough sample size to accommodate the predictive factors?
Statistical POWER
6.Outcomes of operationally defined?
A clear definition of outcomes is necessary to avoid misidentification
7.Outcomes masked?
Masking tester/assessor reduces an opportunity for BIAS
8.Collect info from ALL subjects?

Questions to ask when looking at _______ of articles about the _____ development

Answer 15

validity
derivation / rule
Assessment of study credibility – CPR derivation

Question 16

Is it good, need to show in different samples and in different settings

Did you compare?

CPR vs gold standard, CPR vs outcomes

Were ALL subjects Measures by gold stanard, outcomes

Blinded?

Confirm findings with a new set of people ?

Validated for a population other than the one it was made for ?

These are questions for what process?

Answer 16

validating CPR

Question 17

✓Sensitivity, specificity, predictive values,
positive/negative likelihood ratios (LR+, LR-)

Answer 17

diagnostic categories

Question 18

✓Odds ratios, risk ratios, hazard ratios

Answer 18

prognostic categories

Question 19

odds ratio

Answer 19

The OR is calculated by comparing the odds of an event happening in one group to the odds of it happening in another group

Question 20

Interpreting the Odds Ratio:

Answer 20

An OR of 1 indicates that the odds are the same in both groups, meaning there’s no difference in the likelihood of the event.

An OR greater than 1 suggests that the event is more likely to occur in the first group compared to the second.

An OR less than 1 suggests that the event is less likely to occur in the first group compared to the second.

Question 21

Risk ratio

Answer 21

When risks are computed in a study, the risk ratio is the measure that compares the Risk exposed to the Risk unexposed . The risk ratio is defined as the risk in the exposed cohort (the index group) divided by the risk in the unexposed cohort (the reference group). A risk ratio may vary from zero to infinity

Question 22

hazard ratio (HR)

Answer 22

a measure in survival analysis that compares the probability of an event occurring in one group to the probability of the same event occurring in another group, over a specified period of time. It’s a ratio of the hazard rate in one group to the hazard rate in another. The hazard rate is the instantaneous probability of an event occurring at a given time, assuming that the event has not already occurred

Question 23

likelihood ratios

Answer 23

Likelihood ratios are used for assessing the value of performing a diagnostic test

Question 24

sensitivity and specificity

Answer 24

They use the sensitivity and specificity of the test to determine whether a test result usefully changes the probability that a condition exists

Question 25

Sensitivity & specificity refer to groups of people whereas likelihood ratios (LRs) can be applied to individual patients.

Answer 25

yup

Question 26

lack of impact analysis, limited applicability to diverse populations, insufficient patient understanding, inadequate outcome measurement, biases in predictor or outcome variable definition and measurement, and barriers to clinician acceptance and implementation

Answer 26

threats to CPR's

Question 27

Is the study high quality? Does the design minimize bias/ Are the results important enough to use? Is your patient/client represented in the study sample? Patient/client values and preferences regarding: ✓Desire to know the future regardless of its nature ✓Belief in the value of scientific evidence ✓Previous experiences

Answer 27

considerations relevant to deciding whether to use evidence with the patient/client

Question 28

“... statements that include recommendations intended to optimize patient care. They are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”

Answer 28

Clinical Practice Guidelines

Question 29

Rationale for “Quality of Evidence = Level of Evidence” and Strength of Recommendation used to classify the CPGs (GRADE); Levels of Evidence * Central to a CPG creation is the quantity and quality of the evidence relating to the topic of CPGs. * The studies located may have varying degree of bias associated with different research designs. * As a result, authors of CPGs typically rely on “Levels of Evidence” to characterize the strength of the recommendation in the Guideline

Answer 29

The GRADE working group Quality of evidence high, mod, low, very low High further research unnecessary, mod further research will be good for confidence, low further research would be very good to improve our confidence, very low uncertain The GRADE guidelines strong for, weak for, weak against, strong against 1st two feel the desirable consequences outweigh the undesirable consequences 2nd two feel the desirable consequences do not out weight the undesirable RCTS help rate things high but can be downgraded a level if 1.Bias of study design and implementation 2.Population, intervention, control, outcome issues 3.Unexplained heterogeneity or inconsistent findings 4.Very wide confidence intervals, imprecision 5.Publication bias

Question 30

A considerable variability in hierarchy definitions (or classifications) may lead to inconsistencies among the Guidelines that address the same topic.

Answer 30

Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group has been organized to deal with this issue. The GRADE working group Quality of evidence high, mod, low, very low The GRADE guidelines strong for, weak for, weak against, strong against

Question 31

RCTS help rate things high in GRADE but can be downgraded if....

Answer 31

Bias of study design and implementation Population, intervention, control, outcome issues Unexplained heterogeneity or inconsistent findings Very wide confidence intervals, imprecision Publication bias

Question 32

Perform an exhaustive literature search? Inclusion and exclusion criteria for studies? Evaluate the quality of studies? Have conclusions based on findings of the quality review?

Answer 32

Evaluating clinical practice guidelines (CPGs) with appropriate questions to ask about their design

Question 33

The appraisal of guidelines resarch and eval collaboration – guidelines rating system

Answer 33

AGREE

Question 34

The International standard for reporting the development and eval of CPGS, AGREE, has 6 domains (things to ask) . what are they?

Answer 34

1. Scope and purpose “overall aim of CPG, clinical focus, target population” 2. Stakeholder involvement “extent to which the CPG was developed by the appropriate stakeholders and represents the views of its intended users” 3. Rigor of development – the process used to gather & synthesize the evidence: Methods (search, selection, appraisal ) to formulate and update the recommendations 4. Clarity and presentation – language, structure and format of the guidelines 5. Applicability – the likely barriers and facilitators to implementation; strategies to improve uptake; resource implications of applying the guidelines 6. Editorial independence – formulation of recommendations not being unduly biased with competing interest

Question 35

how often should CPG's be updated?

Answer 35

every 3 years

Question 36

consider the 3 pillars of EBP when using CPG's

Answer 36

clinical Expertise, Best evidence, Patient values

Question 38

questions to ask about a CPG article

Answer 38

Perform an exhaustive literature search? Inclusion and exclusion criteria for studies? Eva8luate the quality of studies? Have conclusions based on findings of the quality review?

Question 39

CONSORT

Answer 39

Consolidated Standards of Reporting Trials Randomized trials N or 1 trials reporting of harms, pragmatic trials, non inferiority trials for RCTS

Question 40

RCTS use which reporting standards

Answer 40

CONSORT

Question 41

STROBE

Answer 41

strengthening the reporting of observational studies in epidemiology corhort studies, case control studies, cross sectional studies

Question 42

Observational studies like cohort studies, case control studies and cross sectional studies use which REPORTING standard

Answer 42

STROBE

Question 43

PRISMA

Answer 43

Preferred reporting items for systematic reviews and meta analyses systematic reviews and meta analyses, scoping reviews, improving harms

Question 44

systematic reviews and meta analyses scoping reviews improving harms which reporting standard would these things use?

Answer 44

PRISMA

Question 45

Standards for Reporting of Diagnostic Accuracy (STARD) Transparent Reporting of a multivariable Prediction model for individual Prognosis Or Diagnosis (TRIPOD)

Answer 45

Diagnostic accuracy and prognostic studies

Question 46

diagnostic accuracy and prognostic studies Standard reporting?

Answer 46

STARD/TRIPOD

Question 47

qualitative research reporting standards

Answer 47

SRQR ( standards for reporting qualitative research) COREQ (consolidated criteria for reporting qualitative research)

Question 48

SRQR

Answer 48

standards for reporting Qualitative research

Question 49

COREQ

Answer 49

consolidated criteria for reporting Qualitative research

Question 50

CASE reports reporting standard

Answer 50

CARE Consensus based clinical case reporting

Question 51

Consensus based clinical case reporting

Answer 51

CARE (for case studies)

Question 52

clinical practice guidelines (reporting standards?)

Answer 52

AGREE (appraisal of guidelines, research and eval) RIGHT (Reporting tool for practice guidelines in health care)

Question 53

Reporting tool for practice guidelines in health care

Answer 53

RIGHT (for CPG's)

Question 54

appraisal of guidelines, research and eval

Answer 54

AGREE for CPG's

Question 55

Study protocols (reporting standards)

Answer 55

SPIRIT (standard protocol items: recommendations for intervention trials) PRISMA - P (preferred reporting items for sys reviews and meta analysis protocols )

Question 56

preferred reporting items for sys reviews and meta analysis protocols

Answer 56

PRISMA - P (for study protocol standards)

Question 57

SPIRIT?

Answer 57

for study protocols standard protocol items: recommendations for intervention trials

Question 58

quality and economic guidelines (standards for reporting?)

Answer 58

SQUIRE (standards for quality improvement reporting excellence) CHEERS (consolidated health economic eval reporting standards)

Question 59

SQUIRE CHEERS for what ?

Answer 59

economic and quality guidelines

Question 60

journal editors role

Answer 60

editors assess submitted papers to determine if they fit the journal's scope and are suitable for peer review.

Question 61

peer reviewers role

Answer 61

A peer reviewer evaluates submitted research papers or scholarly works, providing feedback to improve the quality and validity of the manuscript before publication. They assess the validity, significance, and originality of the research, offering constructive criticism and suggestions for improvement. Reviewers also determine if the research aligns with the journal's scope and recommend whether the paper should be accepted, rejected, or revised.