EBP Flashcards
5 steps of EBP
- Ask
- Acquire
- Appraise
- Apply
- Assess
PICO
- Patient/problem
- Intervention
- Comparison Intervention
- Outcomes
Foreground question
very detailed questions that can best be answered with the information contained in published research studies.
4 types of clinical questions
- Diagnosis
- Prognosis
- Intervention
- Harm
Hierarchy of evidence
- N=1 RCT
- Systematic review of RCTs
- Multiple RCTs
- RCT
- Systematic review of below studies
- Observational cohort or case control studies, large case series
- Case reports, small case series
- Unsystematic clinical observations (expert opinion)
MCID
Minimal clinically important difference
*smallest change in score associated with a patient’s perception of change in health status
“Positive trials”
- rejecting null hypothesis
- focus on lower end of confidence interval
- if lower boundary of CI is GREATER than MCID, you can conclude it is a positive trial
“Negative” Trials
- focus on upper end of CI
- IF upper boundary of CI excludes any important benefit of treatment, you can conclude it is definitively negative
Pre-test probability
baseline probability of a certain condition pre-testing
Post-test probability
application of a clinical diagnostic test that alters the baseline probability (special tests)
Diagnostic process
- pattern recognition
- hypothesis generation
- logical reasoning (hypothetico-deductive reasoning)
- Other types - algorithm and exhaustive
Spectrum bias
lack of sufficient heterogeneity of subjects
Sensitivity
- proportion of patients with the condition who HAVE a positive result
- true positive rate
- tests w/ high sensitivity have few FALSE NEGATIVES
- SnNOUT
Specificity
- proportion of patients without the condition who have a NEGATIVE test result
- tests w/ high specificity have few FALSE POSITIVES
- True negative rate
- SpPin
Likelihood ratios
used to reduce uncertainty about a patient’s likelihood of having a target condition
Pre-test porbability + LR =
= post test probability
Positive Likelihood Ratio
- if a diagnostic test is POSITIVE - use PLR
- PLR always >1.0
Negative Likelihood Ratio
- if diagnostic test is NEGATIVE - use NLR
- NLR always <1.0
Where does pre-test probability come from?
- intuitive sense
- patient demo and nature of c/o
- clinical experience
- published prevalence rates
Positive Likelihood ratio magnitude
> 10 - large and conclusive
5-10 - moderate
2-5 small (sometimes important)
1-2 - small (rarely important)
Negative likelihood ratio magnitude
<0.1 - large and often conclusive
- 1-0.2 - moderate
- 5-0.2 - small (sometimes important)
- 5-1.0 - small (rarely important)
CPRs
Synonyms (CPGs, clinical decision rules, test item clusters)
- ID of cluster of diagnostic tests through multivariate method
- important to validate CPR with independent study or separate group
Diagnostic reasoning
- reasoning about what information to gather and how to interpret information from both the patient interview and physical exam
- DEDUCTIVE
Narrative reasoning
- asking open ended questions
- establishing and validating an understanding of the person who is the patient
- explicit integration of understanding into reasoning process and decisions made
- INDUCTIVE
Intervention procedures reasoning
- choice and administration of interventions
- reasoning related to choice of re-exam strategies
- both inductive and deductive
Interactive reasoning
- choices of approach and manner of interacting with patients
- establishing rapport
- inductive and deductive
Collaborative reasoning
- negotiation of a working relationship, including distribution of power in decision making
- consensual approach in interpretation of exam data, setting, and prioritization
- inductive and deductive
Reasoning about teaching/patient education
- directed towards approaches and strategies for educating patients
- deductive and/or inductive
Predictive reasoning
- process of developing a prognosis
- deductive and/or inductive
Deductive reasoning
development and systematic testing of hypotheses
Inductive reasoning
Coming to an understanding of the patient’s situation from his or her point of view through communication
Over focus on early/superficial recognition error
acceptance of the validity of a diagnosis/clinical pattern ID based on a presentation’s superficial similarity to another familiar case
Premature anchoring error
fixation on first impressions that is unaltered with new or conflicting information
Premature closure error
acceptance of a diagnosis without challenge through adequate consideration of likely alternatives
Framing effect error
Decision is influenced by the perception of relative risk, whether or not that risk if presented in a positive or negative light, and/or based on a tendency to avoid versus seek risk
Commission bias error
Deciding to do something regardless of evidence that would contradict the decision
Extrapolation error
Inappropriately choosing to do something that was done successfully in another dissimilar situation
Confirmation bias
Tendency to look for, notice, and remember only the information that fits with pre-existing expectations
Outcome bias
Tendency for an overreliance on outcome information to indicate accuracy or quality of the clinical reasoning that determined the choice of intervention
EBP
- evidence
- clinical experience/expertise
- Patient values
Over-generalization
application of research evidence to clinical practice when the information is not applicable/relevant
over-valuing a test finding
erroneous interpretation or unwarranted weighting of a “+” or “-“ clinical test finding when determining the likelihood of a specific diagnosis, prognosis, or intervention effectiveness
Omission of quality assessment of literature
focus on the results of the study without consideration of the relative quality of the study design
Lack of scrutiny for outcome measure choice
superficial or incomplete consideration when deciding which outcome measure to choose
Lack of confidence
undervaluing one’s own clinical experiences and expertise, inadequate confidence that clinical knowledge is sound and applicable
Over valuing clinical experiences
Over-inflating importance of past experiences and over confidence in one’s own clinical knowledge and skill set
Inappropriate clinical pattern recognition
misreading when general clinical patterns learned through clinical experience are appropriate for specific clinical patient case
Work up (verification) bias
If all patients don’t receive the gold standard test
95% confidence interval
95% certainty that the values will fall within a certain range
-NARROW IS BETTER
Efficacy
determine whether an intervention produces the expected result under ideal circumstances
Effectiveness
measure the degree of beneficial effect under “real world” clinical settings.
Type I Error
- incorrect rejection of a true null hypothesis
- detection of an effect that is not actually present
Type II Error
- incorrectly retaining a false null hypothesis
- failure to detect an effect that is actually present
Double blind
- in PT treatments you can’t usually blind both groups
- if you blind both patients and clinician than it is double blinded
Drop outs
->20% drop out rate is too much
Intention to treat
- based on the initial treatment assignment, not the actual treatment received
- intended to avoid misleading artifacts such as non-random participants or cross overs
- if no dropouts, then no need to perform ITT
