Скачать презентацию Basic statistics www bradfordvts co uk EBM Скачать презентацию Basic statistics www bradfordvts co uk EBM

241d1175166b759f9dbb792f35abba96.ppt

  • Количество слайдов: 21

Basic statistics www. bradfordvts. co. uk Basic statistics www. bradfordvts. co. uk

EBM SKILLS - STATISTICS • CHANCE - p = 1 in 20 (0. 05). EBM SKILLS - STATISTICS • CHANCE - p = 1 in 20 (0. 05). • > 1 in 20 (0. 051) = not significant • < 1 in 20 (0. 049) = statistically significant • CONFIDENCE INTERVALS • what is the range of values between which we could be 95% certain that this result would lie if this intervention was applied to the general population

EBM SKILLS - A BASIC INTRODUCTION CHANCE, BIAS, CONFOUNDING VARIABLES EBM SKILLS - A BASIC INTRODUCTION CHANCE, BIAS, CONFOUNDING VARIABLES

TYPES OF STUDY - HYPOTHESIS FORMING • CASE REPORTS / CASE SERIES • CROSS TYPES OF STUDY - HYPOTHESIS FORMING • CASE REPORTS / CASE SERIES • CROSS SECTIONAL / PREVALENCE STUDIES measure personal factors & disease states - hypothesis FORMING - cannot indicate cause & effect • CORRELATIONAL / ECOLOGICAL / GEOGRAPHIC STUDIES. prevalence &/or incidence measurement in one population c/w another pop.

TYPES OF STUDY - HYPOTHESIS TESTING CASE CONTROL STUDIES TYPES OF STUDY - HYPOTHESIS TESTING CASE CONTROL STUDIES

CASE CONTROL EXAMPLE -SMOKING & LUNG CANCER DISEASE Cases Controls EXPOSURE Yes a b CASE CONTROL EXAMPLE -SMOKING & LUNG CANCER DISEASE Cases Controls EXPOSURE Yes a b EXPOSURE No c d Odds Ratio = ad/bc (1 = no association, > 1 = possible association, < 1 = protective effect) DISEASE Cases Controls EXPOSURE (smoking) Yes No (lung cancer) 56 7 230 246 The odds ratio would therefore be 56 x 246 = 13776 = 8. 6. 7 x 230 1610

TYPES OF STUDY - HYPOTHESIS TESTING • COHORT STUDIES TYPES OF STUDY - HYPOTHESIS TESTING • COHORT STUDIES

COHORT STUDIES OUTCOME Exposed Not exposed Yes a c No b d Attributable risk COHORT STUDIES OUTCOME Exposed Not exposed Yes a c No b d Attributable risk (absolute risk or risk difference) "What is the incidence of disease attributable to exposure" Answer = a - c. Relative risk "How many times are exposed persons more likely to develop the disease, relative to non-exposed persons? " i. e. the incidence in the exposed divided by the incidence in the nonexposed. This is expressed as a divided by a+b c c+d .

COHORT STUDY EXAMPLE Deep vein thromboses (DVT) in oral contraceptive users. (Hypothetical results). OUTCOME COHORT STUDY EXAMPLE Deep vein thromboses (DVT) in oral contraceptive users. (Hypothetical results). OUTCOME (DVT) Exposed ( on oral contraceptive ) Not exposed (not on o. c. ) 10009 Yes 41 7 No 9996 These results would give an attributable risk of 34 and a relative risk of 6 - significantly large enough numbers to indicate the possibility of a real association between exposure and outcome. However, the possibility of biases very often arises.

RANDOMISED CONTROLLED TRIALS RANDOMISED CONTROLLED TRIALS

RANDOMISED CONTROLLED TRIALS OUTCOME Yes No Comparison intervention a b Experimental intervention c d RANDOMISED CONTROLLED TRIALS OUTCOME Yes No Comparison intervention a b Experimental intervention c d Relative risk reduction: “ How many fewer patients will get the outcome measured if they get active treatment versus comparison intervention” a /a+b - c/c+d a/a+b Absolute risk reduction: “What is the size of this effect in the population” a/a+b - c/c+d

RCT EXAMPLE - 4 S STUDY • STABLE ANGINA OR MYOCARDIAL INFARCTION MORE THAN RCT EXAMPLE - 4 S STUDY • STABLE ANGINA OR MYOCARDIAL INFARCTION MORE THAN 6 MONTHS PREVIOUSLY • SERUM CHOLESTEROL > 6. 2 mmol/l • EXCLUDED PATIENTS WITH ARYHTHMIAS AND HEART FAILURE • ALL PATIENTS GIVEN 8 WEEKS OF DIETARY THERAPY • IF CHOLESTEROL STILL RAISED (>5. 5) RANDOMISED TO RECEIVE SIMVASTATIN (20 mg > 40 mg) OR PLACEBO • OUTCOME DEATH OR MYOCARDIAL INFARCTION (LENGTH OF TREATMENT 5. 4 YEARS ) WERE THE OUTCOMES

RCT EXAMPLE - 4 S STUDY OUTCOME (death) Yes No 256 1967 Comparison intervention RCT EXAMPLE - 4 S STUDY OUTCOME (death) Yes No 256 1967 Comparison intervention (placebo) 2223 Experimental intervention (simvastatin) 182 2221 2039 The ARR is (256/2223) - (182/2221) = 0. 115 - 0. 082 = 0. 033. The RRR is 0. 033/0. 115 = 0. 29 or expressed as a percentage 29%. 1/ARR = NUMBER NEEDED TO TREAT. 1/0. 033 = 30. i. e. if we treat 30 patients with IHD with simvastatin as per 4 S study, in 5. 4 years we will have prevented 1 death.

NNT EXAMPLES Intervention Outcome NNT NNT EXAMPLES Intervention Outcome NNT

Why are RCTs the “gold standard” Breast cancer mortality in studies of screening with Why are RCTs the “gold standard” Breast cancer mortality in studies of screening with mammography; women aged 50 and over (55 in Malmo study, 45 in UK)

SCREENING - WILSON & JUNGEN (WHO, 1968) • IS THE DISORDER COMMON / IMPORTANT SCREENING - WILSON & JUNGEN (WHO, 1968) • IS THE DISORDER COMMON / IMPORTANT • ARE THERE TREATMENTS FOR THE DISORDER • IS THERE A KNOWN NATURAL HISTORY & “WINDOW OF OPPORTUNITY” WHERE SCREENING CAN DETECT DISEASE EARLY WITH IMPROVED CHANCE OF CURE • IS THE TEST ACCEPTABLE TO PATIENTS • SENSITIVE AND SPECIFIC • GENERALISABLE • CHEAP / COST EFFECTIVE • APPLY TO GROUP AT HIGH RISK

SCREENING DISEASE PRESENT ABSENT TEST POSITIVE A B NEGATIVE C D Sensitivity = a/a+c; SCREENING DISEASE PRESENT ABSENT TEST POSITIVE A B NEGATIVE C D Sensitivity = a/a+c; Specificity = d/b+d; positive predicitive value = a/a+b; negative predicitve value = d/c+d.

Value of exercise ECG in coronary artery stenosis DISEASE PRESENT POSITIVE 137 11 NEGATIVE Value of exercise ECG in coronary artery stenosis DISEASE PRESENT POSITIVE 137 11 NEGATIVE TEST ABSENT 90 112 Sensitivity = a/a+c = 60%; Specificity = d/b+d = 91%; positive predicitive value = a/a+b = 93%; negative predicitve value = d/c+d = 55%.

Sensitivities and Specificities for different tests Alcohol dependency or abuse (as defined by extensive Sensitivities and Specificities for different tests Alcohol dependency or abuse (as defined by extensive investigations in medical and orthopaedic in patients) GGT MCV LFTs “Yes” to 1 or > of CAGE ? s “Yes” to 3 or > of CAGE ? s SENS 54% 63% 37% 85% 51% SPEC 76% 64% 81% 100%

MAKING SENSE OF THE EVIDENCE - ARE THESE RESULTS VALID i. e. should I MAKING SENSE OF THE EVIDENCE - ARE THESE RESULTS VALID i. e. should I believe them? • • Randomised (where appropriate)? Drop outs and withdrawals? Followup complete? Analysed in the groups to which randomised? “Intention to treat”.

MAKING SENSE OF THE EVIDENCE- ARE THESE RESULTS USEFUL? i. e. should I be MAKING SENSE OF THE EVIDENCE- ARE THESE RESULTS USEFUL? i. e. should I be impressed by them, are they relevant to my patients (GENERALISABLE) • How large was the treatment effect? • How precise was the estimate of treatment effect • Were all important clinical outcomes considered? • Do benefits outweigh risks?