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Year 2 Medicine > The Hierarchy of Evidence > Flashcards

The Hierarchy of Evidence Flashcards

1
Q

Hierarchy of Evidence

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2
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Hierarchy of Evidence

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3
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Assessing risk of bias

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4
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Assessing risk of bias

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5
Q

Assessing risk of bias

  • Quality appraisal tools are used
    • DURING …-… process – by authors to ensure high quality …
    • AFTER …-… process - by readers to … risk of bias within studies
  • Quality appraisal tools take the form of a … with a list of items that, for higher quality, should be included
    • Within the study itself
    • Within the report
  • Some tools give rise to a … score or … rating
  • Risk of bias can be assessed both
    • Within individual studies
    • Collectively acrossstudies
A
  • Quality appraisal tools are used
    • DURING write-up process – by authors to ensure high quality reporting
    • AFTER write-up process - by readers to review risk of bias within studies
  • Quality appraisal tools take the form of a checklist with a list of items that, for higher quality, should be included
    • Within the study itself
    • Within the report
  • Some tools give rise to a numerical score or categorical rating
  • Risk of bias can be assessed both
    • Within individual studies
    • Collectively acrossstudies
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6
Q

Assessing risk of bias

  • When are quality appraisal tools used?
A
  • Quality appraisal tools are used
    • DURING write-up process – by authors to ensure high quality reporting
    • AFTER write-up process - by readers to review risk of bias within studies
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7
Q

Assessing risk of bias

  • Risk of bias can be assessed both…
A
  • Within individual studies
  • Collectively acrossstudies
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8
Q

Assessing risk of bias

  • Quality appraisal tools take the form of a checklist with a list of items that, for higher quality, should be included
    • Within the study itself
    • Within the report
A
  • Within the study itself
  • Within the report
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9
Q

Case reports - Hierarchy of Evidence

  • Disadvantages:
    • Only …
    • Lack of g…
    • Uncontrolled
    • Uncertain … o../s
    • Changing features to preserve … could impact on usefulness
  • Advantages:
    • Can include …-… analyses/ experiential inquiries of person/ group in …-… setting
    • Utility in emerging epidemics and previously unrecognised syndromes
    • Fast and …
    • Good … tool
A
  • Disadvantages:
    • Only descriptive
    • Lack of generalisability
    • Uncontrolled
    • Uncertain future outcome/s
    • Changing features to preserve anonymity could impact on usefulness
  • Advantages:
    • Can include in-depth analyses/ experiential inquiries of person/ group in real-world setting
    • Utility in emerging epidemics and previously unrecognised syndromes
    • Fast and cheap
    • Good learning tool
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10
Q

Case reports - Hierarchy of Evidence

  • Disadvantages:
    • Only descriptive
    • … of generalisability
    • …
    • … future outcome/s
    • Changing features to preserve anonymity could impact on …
  • Advantages:
    • Can include in-depth analyses/ experiential inquiries of person/ group in real-world setting
    • Utility in emerging … and previously … syndromes
    • … and cheap
    • Good learning tool
A
  • Disadvantages:
    • Only descriptive
    • Lack of generalisability
    • Uncontrolled
    • Uncertain future outcome/s
    • Changing features to preserve anonymity could impact on usefulness
  • Advantages:
    • Can include in-depth analyses/ experiential inquiries of person/ group in real-world setting
    • Utility in emerging epidemics and previously unrecognised syndromes
    • Fast and cheap
    • Good learning tool
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11
Q

Animal trials - Hierarchy of Evidence

  • Disadvantages:
    • Not able to … all … features and …
    • Introduction e.g. of allergens, pathogens not like …-…
    • … between a given animal species and humans
    • Animal … and …
  • Advantages:
    • Possibilities considered unethical in human trials
    • Ability to control potential …
    • Vast commonalities in the biology of most mammals
    • Human diseases often affect other animal species
    • Mechanisms and treatment also commonly similar in major infectious and non-infectious diseases
A
  • Disadvantages:
    • Not able to mimic all human features and phenotypes
    • Introduction e.g. of allergens, pathogens not like real-life
    • Differences between a given animal species and humans
    • Animal protection and welfare
  • Advantages:
    • Possibilities considered unethical in human trials
    • Ability to control potential confounds
    • Vast commonalities in the biology of most mammals
    • Human diseases often affect other animal species
    • Mechanisms and treatment also commonly similar in major infectious and non-infectious diseases
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12
Q

Animal trials - Hierarchy of Evidence

  • Disadvantages:
    • Not able to mimic all human features and phenotypes
    • Introduction e.g. of allergens, pathogens not like real-life
    • … between a given animal species and humans
    • Animal … and …
  • Advantages:
    • Possibilities considered … in human trials
    • Ability to control potential confounds
    • Vast … in the biology of most mammals
    • Human … often affect other animal species
    • Mechanisms and treatment also commonly similar in … infectious and …-infectious diseases
A
  • Disadvantages:
    • Not able to mimic all human features and phenotypes
    • Introduction e.g. of allergens, pathogens not like real-life
    • Differences between a given animal species and humans
    • Animal protection and welfare
  • Advantages:
    • Possibilities considered unethical in human trials
    • Ability to control potential confounds
    • Vast commonalities in the biology of most mammals
    • Human diseases often affect other animal species
    • Mechanisms and treatment also commonly similar in major infectious and non-infectious diseases
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13
Q

Meta-analysis/Systemic reviews - Hierarchy of Evidence

  • Disadvantages:
    • Limited by … and amount of available …
    • Meta-analysis of different study type occupies same top pole
    • Limited inclusion of/ focus on … research
    • …-defined question
  • Advantages:
    • Summary of overall evidence area
    • … policy and clinical decision-making
    • Identify and test sources of variability
A
  • Disadvantages:
    • Limited by quality and amount of available evidence
    • Meta-analysis of different study type occupies same top pole
    • Limited inclusion of/ focus on qualitative research
    • Narrowly-defined question
  • Advantages:
    • Summary of overall evidence area
    • Guide policy and clinical decision-making
    • Identify and test sources of variability
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14
Q

Meta-analysis/Systemic reviews - Hierarchy of Evidence

  • Disadvantages:
    • Limited by quality and amount of available evidence
    • Meta-analysis of different study type occupies same top pole
    • … inclusion of/ focus on qualitative research
    • …-defined question
  • Advantages:
    • Summary of overall evidence area
    • Guide policy and … decision-making
    • Identify and test sources of …
A
  • Disadvantages:
    • Limited by quality and amount of available evidence
    • Meta-analysis of different study type occupies same top pole
    • Limited inclusion of/ focus on qualitative research
    • Narrowly-defined question
  • Advantages:
    • Summary of overall evidence area
    • Guide policy and clinical decision-making
    • Identify and test sources of variability
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15
Q

Evidence-based medicine (EBM)

  • “Evidence based medicine is the c…, e…, and judicious use of current best evidence in making decisions about the care of … patients” (David Sackett)
    • “(1) that our clinical and other health care decisions should be based on the best patient- and population-based as well as ..-based evidence;
    • (2) that the … determines the nature and source of evidence to be sought, rather than our habits, protocols or traditions;
    • (3) that identifying the best evidence calls for the integration of e… and b… ways of thinking with those derived from pathophysiology and our personal experience;
    • (4) that the conclusions of this search and critical … of evidence are worthwhile only if they are translated into actions that affect our patients;
    • (5) that we should continuously evaluate our … in applying these ideas.” (Sackett & Rosenberg)
A
  • “Evidence based medicine is the conscientious , explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (David Sackett)
    • “(1) that our clinical and other health care decisions should be based on the best patient- and population-based as well as laboratory-based evidence;
    • (2) that the problem determines the nature and source of evidence to be sought, rather than our habits, protocols or traditions;
    • (3) that identifying the best evidence calls for the integration of epidemiological and biostatistical ways of thinking with those derived from pathophysiology and our personal experience;
    • (4) that the conclusions of this search and critical appraisal of evidence are worthwhile only if they are translated into actions that affect our patients;
    • (5) that we should continuously evaluate our performance in applying these ideas.” (Sackett & Rosenberg)
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16
Q

EBM and hierarchies of evidence

  • EBM in practice:
      1. Setting the …
      1. Finding the …
      1. … the Evidence
      1. … the Evidence
      1. … Performance
  • A. Individual clinicians performing … appraisal of evidence as part of routine practice, using a … of evidence
  • B. Individual clinicians being guided by guidelines/evidence synthesis formulated through … appraisal and review
A
  • EBM in practice:
      1. Setting the Question
      1. Finding the Evidence
      1. Appraising the Evidence
      1. Applying the Evidence
      1. Evaluating Performance
  • A. Individual clinicians performing critical appraisal of evidence as part of routine practice, using a hierarchy of evidence
  • B. Individual clinicians being guided by guidelines/evidence synthesis formulated through hierarchical appraisal and review
17
Q

EBM and hierarchies of evidence

  • EBM in practice:
      1. Setting the Question
      1. Finding the Evidence
      1. Appraising the Evidence
      1. Applying the Evidence
      1. Evaluating Performance
  • A. Individual clinicians performing critical appraisal of evidence as part of routine practice, using a hierarchy of evidence
  • B. Individual clinicians being guided by guidelines/evidence synthesis formulated through hierarchical appraisal and review
A
  • EBM in practice:
      1. Setting the Question
      1. Finding the Evidence
      1. Appraising the Evidence
      1. Applying the Evidence
      1. Evaluating Performance
  • A. Individual clinicians performing critical appraisal of evidence as part of routine practice, using a hierarchy of evidence
  • B. Individual clinicians being guided by guidelines/evidence synthesis formulated through hierarchical appraisal and review
18
Q

EBM and evidence appraisal

  • Evidence … is the process of deciding whether, and to what degree, evidence (either from a … study or an … base of many studies) supports a ….
A
  • Evidence appraisal is the process of deciding whether, and to what degree, evidence (either from a single study or an evidence base of many studies) supports a claim.
19
Q

Hierarchy of evidence and health policy: Evidence-Based Policy (EBP)

  • Health policy is developed based on
    • Using the best … healthcare evidence overall
    • To ensure … and equitable access to most effective and …-… healthcare
  • Most research in medicine is produced by pharmaceutical and medical device companies – who want to later sell the product they make
  • … is not-for-profit international organisation, which only collaborates with non-commercial organisations (80% of NICE and WHO guidelines use … Reviews)
  • NICE guideline creation
    • Independence from … and …
    • …-… teams, stakeholder engagement and participatory process involving patients and carers
    • Evidence … and transparent processes
A
  • Health policy is developed based on
    • Using the best quality healthcare evidence overall
    • To ensure fair and equitable access to most effective and cost-effective healthcare
  • Most research in medicine is produced by pharmaceutical and medical device companies – who want to later sell the product they make
  • Cochrane is not-for-profit international organisation, which only collaborates with non-commercial organisations (80% of NICE and WHO guidelines use Cochrane Reviews)
  • NICE guideline creation
    • Independence from government and industry
    • Multi-disciplinary teams, stakeholder engagement and participatory process involving patients and carers
    • Evidence appraisal and transparent processes
20
Q

Hierarchy of evidence and health policy: Evidence-Based Policy (EBP)

  • Health policy is developed based on
    • Using the best quality healthcare … overall
    • To ensure fair and equitable access to most effective and cost-effective healthcare
  • Most research in medicine is produced by … and medical device companies – who want to later sell the product they make
  • Cochrane is not-for-profit international organisation, which only collaborates with non-commercial organisations (…% of NICE and WHO guidelines use Cochrane Reviews)
  • NICE guideline creation
    • Independence from government and industry
    • Multi-disciplinary teams, … engagement and participatory process involving patients and carers
    • Evidence appraisal and … processes
A
  • Health policy is developed based on
    • Using the best quality healthcare evidence overall
    • To ensure fair and equitable access to most effective and cost-effective healthcare
  • Most research in medicine is produced by pharmaceutical and medical device companies – who want to later sell the product they make
  • Cochrane is not-for-profit international organisation, which only collaborates with non-commercial organisations (80% of NICE and WHO guidelines use Cochrane Reviews)
  • NICE guideline creation
    • Independence from government and industry
    • Multi-disciplinary teams, stakeholder engagement and participatory process involving patients and carers
    • Evidence appraisal and transparent processes
21
Q

Hierarchy of evidence and health policy: Evidence-Based Policy (EBP)

  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of … versus …, whether net … are worth costs/resource use
      • F.. of the intervention
      • Q.. of evidence
    • Uncertainty or … in the values and preferences among stakeholders
      • Or l… factors influencing the translation of evidence into practice
    • Ease of implementation at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
A
  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of benefits versus harms, whether net benefits are worth costs/resource use
      • Feasibility of the intervention
      • Quality of evidence
    • Uncertainty or variability in the values and preferences among stakeholders
      • Or local factors influencing the translation of evidence into practice
    • Ease of implementation at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
22
Q

Hierarchy of evidence and health policy: Evidence-Based Policy (EBP)

  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of benefits versus harms, whether net benefits are worth costs/resource use
      • Feasibility of the …
      • Quality of evidence
    • Uncertainty or variability in the values and preferences among stakeholders
      • Or local factors influencing the translation of evidence into practice
    • Ease of … at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • … to existing policies
      • …-… values
      • … considerations
A
  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of benefits versus harms, whether net benefits are worth costs/resource use
      • Feasibility of the intervention
      • Quality of evidence
    • Uncertainty or variability in the values and preferences among stakeholders
      • Or local factors influencing the translation of evidence into practice
    • Ease of implementation at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
23
Q

Hierarchy of evidence and health policy: Evidence-Based Policy (EBP)

  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of benefits versus harms, whether net benefits are worth …/…. use
      • Feasibility of the intervention
      • Quality of evidence
    • Uncertainty or variability in the values and preferences among …
      • Or local factors influencing the translation of evidence into …
    • Ease of implementation at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
A
  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of benefits versus harms, whether net benefits are worth costs/resource use
      • Feasibility of the intervention
      • Quality of evidence
    • Uncertainty or variability in the values and preferences among stakeholders
      • Or local factors influencing the translation of evidence into practice
    • Ease of implementation at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
24
Q

Hierarchy of evidence and health policy: Evidence-Based Policy (EBP)

  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • … of benefits versus harms, whether net benefits are worth costs/resource use
      • Feasibility of the intervention
      • … of evidence
    • Uncertainty or variability in the values and preferences among stakeholders
      • Or local factors influencing the … of evidence into practice
    • Ease of implementation at the … level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
A
  • Factors that may inform decisions about the strength of recommendations for policy options:
    • Uncertainty about
      • Balance of benefits versus harms, whether net benefits are worth costs/resource use
      • Feasibility of the intervention
      • Quality of evidence
    • Uncertainty or variability in the values and preferences among stakeholders
      • Or local factors influencing the translation of evidence into practice
    • Ease of implementation at the systems level
      • Government, finance, implementation strategies and resources
    • Socio-political correctness
      • Relation to existing policies
      • Socio-political values
      • Economic considerations
25
Q

Asthma: The case of the not-very-EBP

  • Expert Panel Report 3- National Asthma Education Program USA: Guidelines for Diagnosis and Management**​
    • 1) Recommendation to encase mattresses in allergen-impermeable covers
      • Supporting references incl. an editorial, a study involving multiple allergens, and a study incl. some patients with no dust mite sensitivity. 5 trials showed no benefit for mattress encasings.
      • Did not cite Cochrane meta-analysis of 49 RCTs (2,733 patients) showing no effectiveness.
    • 2) Does not acknowledge that evidence-based recommendations for inhaled corticosteroids (ICS) in asthma apply exclusively to …-…
      • … tend to be excluded from many trials seeking FDA approval for ICS in asthma Other trial evidence suggested no benefit for ICS in …-…
    • 3) Recommendations to prescribe daily …-dose ICS for mild persistent asthma
      • Despite only one trial showing effectiveness with respect to severe asthma-related events, and which also suggested side effects of growth suppression in … (also shown in other studies).
A
  • 1) Recommendation to encase mattresses in allergen-impermeable covers
    • Supporting references incl. an editorial, a study involving multiple allergens, and a study incl. some patients with no dust mite sensitivity. 5 trials showed no benefit for mattress encasings.
    • Did not cite Cochrane meta-analysis of 49 RCTs (2,733 patients) showing no effectiveness.
  • 2) Does not acknowledge that evidence-based recommendations for inhaled corticosteroids (ICS) in asthma apply exclusively to non-smokers
    • Smokers tend to be excluded from many trials seeking FDA approval for ICS in asthma Other trial evidence suggested no benefit for ICS in non-smokers
  • 3) Recommendations to prescribe daily low-dose ICS for mild persistent asthma
    • Despite only one trial showing effectiveness with respect to severe asthma-related events, and which also suggested side effects of growth suppression in children (also shown in other studies).
26
Q

Asthma: The case of a certain uncertainty

  • NICE NG80: Asthma: diagnosis, monitoring and chronic asthma management
    • 1) November 2017
      • Recommended … the ICS dose as part of a self-management programme for children and young people with deteriorating asthma
    • 2) February 2020
      • Acknowledged the 2017 ICS … dose recommendation was based on limited evidence mainly in adults and new evidence did not support it
      • Although no evidence that … dose was harmful (incl. on child growth), therefore recommendation to increase ICS removed but no recommendation was made not to increase ICS
      • Therefore allowing … decision-making for CYP who have varied and changing support needs
A
  • NICE NG80: Asthma: diagnosis, monitoring and chronic asthma management
    • 1) November 2017
      • Recommended quadrupling the ICS dose as part of a self-management programme for children and young people with deteriorating asthma
    • 2) February 2020
      • Acknowledged the 2017 ICS quadrupled dose recommendation was based on limited evidence mainly in adults and new evidence did not support it
      • Although no evidence that quadrupled dose was harmful (incl. on child growth), therefore recommendation to increase ICS removed but no recommendation was made not to increase ICS
      • Therefore allowing individualised decision-making for CYP who have varied and changing support needs
27
Q

Allergy: The case of the cow milk protein allergy

  • Non-IgE mediated cow’s milk protein allergy in breastfed infants
    • Premise:
      • In an …-… infant, if a mother ingests cow’s milk, the child will develop an allergy
      • Either the mother needs to stop consuming dairy or the child should switch to a non-dairy formula
    • 2006-2016
      • NHS prescriptions for formula rose from 100,000 to over … annually
      • NHS spend from …% from £8.1m to over £60m annually
  • BUT: …..
      • Guideline endorsement; NICE 2011, Milk Allergy in Primary (MAP) Care guideline 2013, International iMAP guidelines 2017
A
  • Non-IgE mediated cow’s milk protein allergy in breastfed infants
    • Premise:
      • In an exclusively-breastfed infant, if a mother ingests cow’s milk, the child will develop an allergy
      • Either the mother needs to stop consuming dairy or the child should switch to a non-dairy formula
    • 2006-2016
      • NHS prescriptions for formula rose from 100,000 to over 600,000 annually
      • NHS spend from 700% from £8.1m to over £60m annually
      • Guideline endorsement; NICE 2011, Milk Allergy in Primary (MAP) Care guideline 2013, International iMAP guidelines 2017
    • BUT!! see slide attached
28
Q

Allergy: The case of the cow milk protein allergy (2)

  • Many more … allergy than … allergy guidelines – formula industry support e.g. 5/11 authors NICE 2011
  • Conflicts in medical education e.g. Allergy UK, British Society for Allergy and Clinical Immunology
  • Broad impacts of …-diagnosis
    • individual child and parent health, social and psychological issues
    • broader … and economic costs
    • mortality - near universal level of … could prevent 823 000 annual child deaths < 5 year
A
  • Many more milk allergy than food allergy guidelines – formula industry support e.g. 5/11 authors NICE 2011
  • Conflicts in medical education e.g. Allergy UK, British Society for Allergy and Clinical Immunology
  • Broad impacts of over-diagnosis
    • individual child and parent health, social and psychological issues
    • broader societal and economic costs
    • mortality - near universal level of breastfeeding could prevent 823 000 annual child deaths < 5 years
29
Q

Allergy: The case of the cow milk protein allergy

  • Guidelines suggest …-…% in non-breastfed infants
    • No good epidemiological evidence in breastfed infants
      • No indication of matching jump in prevalence
  • Basic evidence regarding non-IgE mediated allergy when only drinking breast milk is very … and quite …
    • Limited evidence of the … onset allergy – should be easier to detect
    • Just because breastfed, doesn’t mean … came from the breast milk
    • Non-specific and common symptoms
      • Test requires e…, d… and re-introduction
  • Encouragement of over-diagnosis in context of conflicts of interest
    • Capitalising on parenting …
A
  • Guidelines suggest 1-3% in non-breastfed infants
    • No good epidemiological evidence in breastfed infants
      • No indication of matching jump in prevalence
  • Basic evidence regarding non-IgE mediated allergy when only drinking breast milk is very limited and quite weak
    • Limited evidence of the rapid onset allergy – should be easier to detect
    • Just because breastfed, doesn’t mean allergen came from the breast milk
    • Non-specific and common symptoms
      • Test requires exclusion, delay and re-introduction
  • Encouragement of over-diagnosis in context of conflicts of interest
    • Capitalising on parenting attitudes
30
Q

Broad impacts of over-diagnosis (cow milk protein allergy)

  • individual child and parent …, social and … issues
  • broader … and … costs
  • mortality - near universal level of breastfeeding could prevent …,… annual child deaths < 5 years
A
  • individual child and parent health, social and psychological issues
  • broader societal and economic costs
  • mortality - near universal level of breastfeeding could prevent 823 000 annual child deaths < 5 years
31
Q

Allergy: The case of the cow milk protein allergy

Milk Allergy in Primary (MAP) Care guideline 2013→International iMAP guidelines 2017

  • Simple and accessible algorithms for UK primary care clinicians
  • Based on existing international consensus guidelines, not new evidence review
  • In 2018, guidelines were criticised for
    • Promoting … of CMPA
    • … impacting breastfeeding
    • … impact on guidelines
  • In 2019, guidelines were updated to
    • Reflect apparent prevalence of CMPA at 1.28% CMPA, half non-… mediated
    • Emphasise using … judgement when interpreting symptoms
    • Draw direct attention to danger of …
    • Emphasise need to … cow’s milk
    • Involve more … input from individuals and organisations with no industry ties
A
  • Simple and accessible algorithms for UK primary care clinicians
  • Based on existing international consensus guidelines, not new evidence review
  • In 2018, guidelines were criticised for
    • Promoting overdiagnosis of CMPA
    • Negatively impacting breastfeeding
    • Industry impact on guidelines
  • In 2019, guidelines were updated to
    • Reflect apparent prevalence of CMPA at 1.28% CMPA, half non-IgE mediated
    • Emphasise using clinical judgement when interpreting symptoms
    • Draw direct attention to danger of overdiagnosis
    • Emphasise need to reintroduce cow’s milk
    • Involve more stakeholder input from individuals and organisations with no industry ties
32
Q

Allergy: The case of the cow milk protein allergy

Milk Allergy in Primary (MAP) Care guideline 2013→International iMAP guidelines 2017

  • Simple and accessible algorithms for UK primary care clinicians
  • Based on existing international consensus guidelines, not new evidence review
  • In 2018, guidelines were criticised for
    • Promoting overdiagnosis of CMPA
    • Negatively impacting breastfeeding
    • Industry impact on guidelines
  • In 2019, guidelines were updated to
    • Reflect apparent prevalence of CMPA at …% CMPA, half non-IgE mediated
    • Emphasise using clinical judgement when interpreting …
    • Draw direct attention to danger of overdiagnosis
    • Emphasise need to reintroduce cow’s milk
    • Involve more stakeholder input from individuals and organisations with no … ties
A
  • Simple and accessible algorithms for UK primary care clinicians
  • Based on existing international consensus guidelines, not new evidence review
  • In 2018, guidelines were criticised for
    • Promoting overdiagnosis of CMPA
    • Negatively impacting breastfeeding
    • Industry impact on guidelines
  • In 2019, guidelines were updated to
    • Reflect apparent prevalence of CMPA at 1.28% CMPA, half non-IgE mediated
    • Emphasise using clinical judgement when interpreting symptoms
    • Draw direct attention to danger of overdiagnosis
    • Emphasise need to reintroduce cow’s milk
    • Involve more stakeholder input from individuals and organisations with no industry ties
33
Q

EBM and EBP: Hierarchy of evidence

  • Over-value of quantitative data/ analysis, … significance
  • Over-value of the idea of a single ‘…’
    • Choice between competing sets of concerns, and not just technical evaluations of effectiveness, may be more relevant
    • Multiplicity of evidence is best to support … - all levels of investigations needed for full understanding of disease/phenomenon
  • Over-value internal validity….(RCT, causal study design, bias appraisal)
  • …under-value external … (local and individual context)
    • Lack of consideration of importance of different outcomes and their primacy to patients e.g., morbidity, mortality, quality of life outcomes versus surrogate and other outcomes – hard-to-… outcomes
    • Less evidence for ‘…-life’ patients e.g. with comorbidities, long-term conditions, conditions/interventions less suited to quantitative study/RCTs
    • Under-value of … evidence
    • Under-value of … perspectives, doctor expertise and judgement, tailoring and individualised medicine
A
  • Over-value of quantitative data/ analysis, statistical significance
  • Over-value of the idea of a single ‘evidence’
    • Choice between competing sets of concerns, and not just technical evaluations of effectiveness, may be more relevant
    • Multiplicity of evidence is best to support causation - all levels of investigations needed for full understanding of disease/phenomenon
  • Over-value internal validity….(RCT, causal study design, bias appraisal)
  • …under-value external validity (local and individual context)
    • Lack of consideration of importance of different outcomes and their primacy to patients e.g., morbidity, mortality, quality of life outcomes versus surrogate and other outcomes – hard-to-measure outcomes
    • Less evidence for ‘real-life’ patients e.g. with comorbidities, long-term conditions, conditions/interventions less suited to quantitative study/RCTs
    • Under-value of mechanism evidence
    • Under-value of patient perspectives, doctor expertise and judgement, tailoring and individualised medicine
34
Q

Nonetheless… (hierarchy of evidence importance)

A
35
Q

… is the explicit process of searching, identifying, appraising and applying the best evidence in making decisions about (and with!) individual patients

A

EBM is the explicit process of searching, identifying, appraising and applying the best evidence in making decisions about (and with!) individual patients

36
Q

The hierarchy of evidence is… (2)

A
  • The hierarchy of evidence
    • Is a grading of what evidence we assess to have the most to the least risk of bias
    • Is used to inform health policy (EBP)
37
Q

…, like many other organisations elsewhere, create/update policy based on reviewing and synthesising available evidence paying attention to the hierarchy of evidence – and usually using … Reviews to inform guidelines

A

NICE, like many other organisations elsewhere, create/update policy based on reviewing and synthesising available evidence paying attention to the hierarchy of evidence – and usually using Cochrane Reviews to inform guidelines

38
Q

Some criticisms of …/… and hierarchy of … include the (over-) value placed on … validity and (under-) value on … validity

A

Some criticisms of EBM/EBP and hierarchy of evidence include the (over-) value placed on internal validity and (under-) value on external validity

Year 2 Medicine (162 decks)

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