Midterm Flashcards
The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.
Evidence-based practice
What are the three essential components of EBCP?
External evidence, patient values and clinical expertise
Where do you get information?
Clinical observation, peers and experts, internet, books, popular press, peer-reviewed scientific publications
What is the relevance of EBCP?
Providers can use it to improve patient care and make referrals, patients use it to improve their health and government agencies use it to make policy decisions
What is at the top of the hierarchy of evidence?
Clinical practice guidelines
What are the two broad categories of health-related research?
Basic science, clinical
Basic or clinical science? Laboratory, usually not patients; investigates mechanisms, how treatment works
Basic science
Basic or clinical science? Treatment of patients; investigates clinical outcomes, shows effectiveness of treatment
Clinical science
The science (systematic study) of the factors that influence human health on the level of the population
Epidemiology
Health-related events do not depend on a single isolated cause, but develop as the result of complex interactions among factors
Web of causation
What is incidence?
The amount of new cases of the disease.
What is prevalence?
The existing cases of a disorder in a population at one point in time. Expressed as a number per 100,000 or a %.
What is primary research?
Investigators collect the data such as surveys, experiments with animals or humans and formal observations of animals or humans
What is secondary research?
Investigators use data that has already been collected such as narrative reviews, systematic reviews, meta-analyses and guidelines
What are the study design categories?
Observational and experimental
What type of study design is described? Investigators DO NOT control variables, often used for describing populations, best to use if there are many unknown factors
Observational
What type of study design is described? Investigators DO control variables, often used to investigation treatments, best for investigating effect of single factors
Experimental
What are the five A’s of EBCP?
Assess, ask, acquire, appraise, apply
General, broad questions
Background Questions
Questions specific to patients, focused, address diagnosis or therapy
Foreground Questions
What is an abstract?
Short summary, overview of methods and results
What is an introduction?
Background and purpose, establishes importance, includes relevant literature and identifies gaps in literature.
What is included in methods?
**Very important
Explains project’s study design, if sample is well described, procedures explained, outcome measures explained and justified and statistical analysis
What is included in results?
Summary of sample/groups. Compares groups to be sure they are equivalent in important characteristics and summary of outcomes with tables and figures at the heart of this section.
What is included in the discussion?
Limitations of the study (very important that this is included) and compare/contrast to other studies
What is included in the conclusion?
Conclusions of the results that should follow logically
What is included in references?
Establishes whether the authors have considered work of others. References older than 5 years should be minimal and references should apply directly to the study.
What are the two types of validity?
Internal and External
What is internal validity?
How well the study achieved it’s aim.
What is external validity?
“Generalizability” How well this could be applied to the outside world.
Internal or external validity?
Within the study only
Internal
Internal or external validity?
Generalizable to other groups of people, settings or interventions.
External
Internal or external validity?
If the results of the study are only applicable to it’s participants then this type of validity is lacking.
External
Internal or external validity?
If the intervention causes the outcome vs other variables which may have affected results.
Internal
Internal or external validity?
If outcomes are affected by bias.
Internal
Internal or external validity?
Related to the presence of extraneous variable and bias.
Internal
Bias, or _________ error in measurement, usually reproducible as it may be caused by faulty equipment or from mistakes in taking the measurement.
Systematic
This type of error occurs by chance.
Random
Excessive bias means the results of the study are __________.
Not trustworthy
Instruments/equipment may be non-standardized OR be used slightly differently by different investigators at different times.
Instrumentation bias or measurement bias
Measurements used should be both _____ and ______. (with references to support this)
Valid and reliable
Participants who are not representative of the population being studied create _________.
Selection bias
Groups who are unequal at baseline can also create __________.
Selection bias
Usually table number __ in an article will compare groups at baseline and discuss differences
1
__________ may occur when participants drop out and are lost to follow-up
Attrition bias
T/F A decrease in sample size may affect representativeness and outcomes, particularly if the cause of attrition is able to be determined.
False, particularly if the cause of attrition is NOT able to be determined it’s likely to affect representativeness.
_____% attrition probably doesn’t create bias.
<5%
_____% probably creates attrition bias
> 20%
What are three ways to appraise an article?
- Apply ABCD FIX mnemonic (only for therapy articles)
- Use a worksheet
- Use CONSORT checklist
What does ABCD FIX stand for?
Allocation concealed? Blinding? Comparable groups? Drop-outs? Follow-up? Intention to treat? X factor (other obvious source of bias)
What are the three purposes of diagnostic testing?
- To establish a diagnosis
- To provide prognostic information
- To monitor the response to treatment
What three things determine diagnostic test discrimination (accuracy)?
- Sensitivity and specificity
- Predictive value
- Likelihood ratios
T/F If a patient is very unlikely or very likely to have a disorder, there is probably no need for a test.
True
Accepted diagnostic procedure which identifies disorder with certainty
Gold standard
_________ may be riskier, more technically difficult, expensive or impractical than other diagnostic procedures.
Gold standard
T/F: Some disorders may not have a gold standard.
True
__________: probability that a person WITH a disorder will have a positive result
Sensitivity
__________: probability that a person WITHOUT a disorder will have a negative test result
Specificity
Positive disorder, positive test
True positive
Positive disorder, negative test
False negative
Negative disorder, negative test
True negative
Negative disorder, positive test
False positive
________: ability of a dx test to identify true disease without missing anyone who has it
Sensitivity
T/F: High sensitivity test has few false negatives so is effective at ruling conditions in.
False: effective at ruling conditions out. (SnNout)
T/F: High specificity test has few false positives so is effective in ruling conditions in.
True (SpPin)
________: ability of dx test to identify absence of disease without mislabeling anyone who does not have it.
Specificity
Prevalence is also known as a __________.
Pretest probability
What is a positive predictive value (PPV)?
The likelihood of having the dx when the test is +
What is the negative predictive value (NPV)?
The likelihood of not having the dx when the test is -
A likelihood ratio of _____ generates large and often conclusive changes from pre-test to post-test probability.
Greater than 10 or less than 0.1
A likelihood ratio of >10 is good for what?
Ruling the condition IN
A likelihood ratio of <0.1 is good for what?
Ruling the condition OUT
What are the four types of Nociceptive pain?
- Discogenic
- Facet
- SI joint
- Myofascial
What are the four types of neuropathic pain?
- Compressive radiculopathy
- Non-compressive radiculopathy
- Neurogenic claudication
- Central pain
_______ is the progressive resolution of or retreat of symptoms toward the midline
Centralization
What are the descriptive study types?
- Case report
- Case series
- Survey
What are the observational (analytic) study types?
- Cross-sectional
- Case-control
- Cohort studies
What are the experimental (analytic) study types?
- RCT
_________ studies are a slice of time that looks at prevalence. Not too expensive or time-consuming.
Cross-sectional
________ studies follow a group of individuals over time.
Cohort
The limitation of _________ studies is you can’t tell whether exposure preceded disease.
Cross-sectional
_______ studies often use surveys, which may have bias
Cross-sectional
______ studies start with exposure/risk factor and follow group over time to determine outcome
Cohort
_______ studies are used to assessing risk/harm/adverse events.
Cohort
What are the two types of cohorts?
Prospective and Retrospective
__________ cohort: with or without risk factor of interest followed forward in time to record outcome. Is more expensive.
Prospective
__________ cohort: usually uses secondary data, cohort is followed backward in time to examine risk factors present years in the past. Less expensive.
Retrospective
What is a case-control study?
Looks at the difference between group with the disease and one group without.
T/F: In case-control studies risk factors are compared.
True
T/F: In case-control studies “risk of outcome” can be assessed.
False, risk of outcome cannot be assessed, the outcome is already known.
T/F: Case-control studies are useful for rare conditions, such as the association between stroke and SMT.
True
T/F: Systematic reviews use secondary data.
True
Systematic review methods include 3 things which are?
- Eligibility criteria for articles
- Databases and search strategies detailed
- Evaluation of the quality of the literature.***
Primary evidence includes what?
RCTs, Observational studies (Case-control, cohort), expert opinion and case reports/series
Secondary evidence includes what?
Clinical practice guidelines, meta-analyses and systematic reviews
Observational or experimental study?
Who: People with specific condition/exposure; may be 2 groups.
Observational
Observational or experimental study?
Who: Sample 1+ comparison sample(s)
Experimental
Observational or experimental study?
Why: Evaluate the effect of an intervention using methods that minimize risk of bias.
Experimental
Observational or experimental study?
Why: Gather “real-world” evidence
Observational
Observational or experimental study?
There is no investigator-designed intervention
Observational
This type of study usually includes RCTs, cohorts and sometimes lower-level studies and is used to synthesize and evaluate the best evidence available on a very specific topic from multiple sources.
Systematic review
This type of study usually includes RCTs, cohorts and sometimes lower-level studies and is used to synthesize and analyze the best evidence available on a very specific topic COMBINING DATA from the included studies.
Meta-analysis
This type of study includes the generalized population and is used to make recommendations on best practices, based on best available evidence.
Clinical practice guidelines
What are some good databases to access?
- ) PubMed (legit)
- ) Index to Chiropractic Literature (ICL)
- ) CINAHL (whatever the heck that is lol)
This recent type of literature was developed to help busy clinicians apply evidence in their practice - often at the time of care
Pre-appraised literature
T/F: Many experts in EBP recommend using these pre-appraised sources first, before the primary literature.
True
T/F: Pre-appraised literature is not useful.
False: pre-appraised literature uses an explicit review process to find and appraise evidence, so the sources are appraised for you by experts.
What are pre-appraised databases we can use?
- Dynamed
2. UptoDate
What is also apparently considered pre-appraised?
- Cochrane library
2. Systematic reviews and meta-analyses
What are a couple special purpose resources for clinical practice guidelines?
- National guideline clearinghouse
2. Clinical practice guidelines database (this one is for Canada)….glad i know that now.
What does R3C stand for?
Rapid Response Resource Center
What is the R3C?
An open access online resource that summarizes and references current evidence on effectiveness and safety of chiropractic care
T/F: The R3C is organized by topic such as commonly seen conditions by DCs and procedures/practices commonly used by DCs.
True
T/F: Essentially the purpose of this R3C thing is to make searching easier because it gives you less irrelevant results to shuffle through compared to doing a Google or even PubMed search.
True
If you don’t have access to a pre-appraised source then use: ________.
Clinical practice guidelines, Systematic reviews, RCTs and cohort studies.
What is Type I error?
Alpha error… is a false positive
What is Type II error?
Beta error… is a false negative
Type I or II error?
Rejection of true null hypothesis, where a conclusion is drawn that the null hypothesis is false when, in fact, it is true. (false positive)
Type I
Type I or II error?
Retaining a false null hypothesis, where a conclusion is drawn that the null hypothesis is true when, in fact, it is false. (false negative)
Type II
Likelihood ratio score of 2-5 means what?
Small but sometimes important
Likelihood ratio score of 5-10 means what?
Moderate & usually important
Likelihood ratio score of 10+ means what?
Usually conclusive
Type I or II error:
The patient has a disease but the study says they don’t.
Type II (false negative)
Type I or II error: The patient does not have the disease but the study says they do.
Type I (false positive)
To avoid Type I error do this:
Significance testing
To avoid Type II error do this:
Power calculation
