Clinical Epidemiology for

Effective Clinical Practice

Online Tutorial

A Internet Self-Directed Learning Workbook 

IntensiveCare.com    EBM Resource Page    

This tutorial is currently under construction

(CME credit may be available in the future)

INDEX

Recommendations for Completing the ECP Tutorial

• Set aside sufficient time to complete each section. The time required will vary depending on your prior exposure to these concepts and how closely you follow the workbook. We have estimated the minimum time required to complete each section.
• Links to outside sites will open up a new browser window that you can close to return to the tutorial page.
• Start with the EBM Introduction and then go through Critical Appraisal I and Basic Statistics for Clinicians.
• Other sections discuss fundamental concepts required for Effective Clinical Practice.
  • They can be completed in any order.
  • Most of the links are to articles on the WWW and are classic articles (see WWW site links).

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Evidence Based Medicine Introduction

(Estimated Time = 2 hours)

• How does EBM differ from current practice? [1]
• 5 Steps to Practicing EBM
  • Identify a focused clinical question [2]
  • Efficiently track down the BEST evidence [7]
  • Critically Appraise that evidence [1]
    • Are the results valid?
    • What are the results?
    • Are the results helpful in caring for your patients?
  • Apply the evidence in practice [9]
  • Evaluate your performance [3]
• EBM: What it is and what it isn't by David Sackett [2]
• EBM Introducation - Self-Review

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How to Critically Appraise the Medical Literature (Part I)

(Estimated Total Time = 12 hours)

Please read the following 2 articles first

• Getting your bearings (deciding what the paper is about) [3]
• Assessing the methodological quality of published papers [3]

THERAPY (Estimated time 2 hours)

• Please read:  How to use an article about Therapy or Prevention [1]
• Now do the therapy tutorial [8]

PROGNOSIS (Estimated time 2 hours)

• Please read:  How to use an article about Prognosis [1]
• Now do the prognosis tutorial [8]

HARM

• Please read:  How to use an article about Risk or Harm [1]
• Now do the harm tutorial

DIAGNOSIS (Estimated time 4 hours)

• Please read:  How to use an article about Diagnosis [1]
• Now do the diagnosis tutorial which also covers Sensitivity, Specificity, Likelihood Ratios, and ROC curves. [8]

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Basic Statistics for Clinicians

(Estimated Time = 8 hours)

• Statistics for the non-statistician [3]
• Hypothesis testing & Statistical Significance [4]
• Confidence Intervals & Power [4]
  • Power Calculation Exercises (Power Analysis Calculator)
• Measures of Association [4]
  • Absolute Risk, Relative Risk and Relative Risk Reduction [4]
  • Odds Ratios [2]
  • Number Needed to Treat (NNT) [2]
  • Example of AR, RR, RRR, OR, NNT
• Sensitivity & Specificity [2]
• Correlation & Linear Regression [4]
• Basic Statistics - Self-Review

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Clinical Research Fundamentals

(Estimated Time = 8 hours)

• How do we discover truth?
  • Bias and confounding
  • Types of bias
• Formulating the question
• Identifying the population to study
  • Sources of sampling bias
• Choosing the appropriate design
  • Experimental versus observational research
  • Limitations of different study designs
• Collecting the data
  • Sources of bias in data collection
• Evaluating the results
  • Statistics: the study of stability in variation
  • Sources of bias during data analysis
• Reporting the results
• Clinical Research Fundamentals - Self-Review

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Finding the Evidence

(Estimated Time = 1 hour)

• Sources of evidence [1]
• Strategies for searching the medical literature [2]
  • The Medline database [3]
  • Medline definitions list [5]
  • Use of evidence repositories: the Cochrane Database of Systematic Reviews (CDSR)
  • Finding systematic review articles [6]
• Finding the Evidence - Self-Review

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Controversies Surrounding EBM

(Estimated Time = 2 hours)

• What it is and what it isn't by Dr. David Sackett [2]
• Evidence-Based Purchasing
  • Does EBM save $$$?
  • An example of an Evidence-Based Purchasing Initiative in the UK
  • Is clinical effectiveness a management issue? [3]
• The Value of Expert Clinicians
• Relating published evidence to individual patients- ethics and EBM [3]
• Clinical realities may limit research methods [3]
• Its time to stop squabbling over the "best" methods - Choosing the best research design for each question [3]
• Meta-analysis is not a panacea [3]

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How to Critically Appraise the Medical Literature (Part II)

(Estimated Time = 6 hours)

• How to use:
  • a Systematic Review [1]
  • an Economic Analysis of Clinical Practice [1]
  • a Clinical Decision Analysis [1]
  • a Clinical Practice Guideline [1]
• Applicability of Clinical Trials Results in Individual Patients

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Intermediate Statistics for Clinicians

(Estimated Time = 10 hours)

• Meta-Analysis
  • Principles and Procedures [3]
  • Beyond the Grand Mean [3]
  • Graphical Detection of Bias [3]
  • Observational Studies [3]
  • Unresolved Issues [3]
• Likelihood Ratios [2]
• Logistic Regression
• Receiver-Operator Characteristic (ROC) Curves
• Comparing a new test to a gold standard (Bland-Altman test)
• Converting a severity of illness score into mortality estimate
• Survival Curves
• Regression Toward the Mean

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How to Critically Appraise the Medical Literature (Part III)

(Estimated Time = 7 hours)

• How to use an article:
  • describing a Clinical Utilization Review or Audit [1]
  • about Outcomes Research [1]
  • describing a Survey
  • about Health-Related Quality of Life Measurements [1]
  • applying Qualitative Research Methods [3]

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Understanding Systematic Reviews

(Estimated Time = 8 hours)

• What is a Systematic Review? [3]
• Locating and appraising Systematic Reviews [6]
• The Relation between Systematic Reviews and Practice Guidelines [6]
• Quantitative Synthesis in Systematic Reviews [6]
• Limitations of Systematic Reviews
  • Bias in location and selection of studies [3]
  • Publication Bias
    • Unpublished trials [3]
    • Covert duplicate publication [3]
    • Delayed publication [3]
  • How to detect bias in meta-analysis [3]
  • Meta-analysis of observational studies [3]
• Meta-analysis: future directions [3]

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Tutorial Wrap-Up & Online Self-Examination

• Furthering your education
• Participating in ECP Initiatives
• Online self-examination a.k.a. "the Final Exam" (with answers)

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References to WWW Offsite Links

1. The Centres for Health Evidence.net  publishes the Users' Guides to the Medical Literature Series from JAMA on the WWW.

2. NHS (UK) Research and Development Centre for EBM

3. The British Medical Journal has made their series of articles on database searching, article appraisal, basic statistical principles, meta-analysis and other EBM topics available on the WWW.

4. Four articles published in the Canadian Medical Association Journal series cover basic statistics for clinicians.

5. Faculty of Medicine and Oral Sciences, University of Alberta also has the EBM Toolbox and clinical epidemiology definitions.

6. A full-text series in the Annals of Internal Medicine on systematic reviews.

7.   The Health Information Research Unit (HIRU) at McMaster University in Canada.

8.  An Introduction to Information Mastery by Mark H. Ebell, MD, MS, University of Michigan, Dept. of Family Practice.

9.  The WISDOM seminar series from the Wisdom Centre for Networked Learning, Sheffield, UK.

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Articles Not Available on WWW

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Copyright 1998 Adrienne G. Randolph, MD, MSc

Last revised 04/14/2000