The Hierarchy of Evidence Flashcards

Question 1

Q

Hierarchy of Evidence

Question 2

Q

Hierarchy of Evidence

Question 3

Q

Assessing risk of bias

Question 4

Q

Assessing risk of bias

Question 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

Answer

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

Question 6

Q

Assessing risk of bias

When are quality appraisal tools used?

Answer

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

Question 7

Q

Assessing risk of bias

Risk of bias can be assessed both…

Answer

A

Within individual studies
Collectively acrossstudies

Question 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

Answer

A

Within the study itself
Within the report

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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 …

Answer

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

Question 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)

Answer

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)

Question 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

Answer

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

Question 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

Answer

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

Question 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 ….

Answer

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.

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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).

Answer

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).

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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 …

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 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

Answer

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

Question 34

Q

Nonetheless… (hierarchy of evidence importance)

Question 35

Q

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

Answer

A

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

Question 36

Q

The hierarchy of evidence is… (2)

Answer

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)

Question 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

Answer

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

Question 38

Q

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

Answer

A

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