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Transcript of Ch1
TRANSITION SERIESTRANSITION SERIES
Topics for the Advanced EMTTopics for the Advanced EMT
CHAPTERCHAPTER
Research and EMSResearch and EMS
11
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
ObjectivesObjectives
• Explain the integration of research into EMS education and practice.
• Demonstrate that evidence-based research guides clinical decision making.
• Discuss analyzing and interpreting research, the types, and scientific theory.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Objectives (cont’d)Objectives (cont’d)
• Express the involvement of the Advanced EMT in clinical and EMS systems research.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
IntroductionIntroduction
• In EMS we spend nearly 3 billion dollars each year delivering care, but little of what we do has truly been evaluated.
• How do we know we are being helpful?• How do we know that the tools we use
are effective?
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Figure 1-1 Research guides the care we provide.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Evidence-Based ApproachEvidence-Based Approach
• Outcomes of therapies and interventions are carefully measured to ensure the intended results.
• When changes are made, decisions are based on clear indications and outcomes.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Evidence-Based Evidence-Based Approach (cont’d)Approach (cont’d)
• Quality research and the evidence based approach allows the EMS profession to:– Answer questions– Expand resources wisely– Avoid spending time and money on
ineffective therapies– Focus budgets on elements that mean
the most to patient care
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
EMS ResearchEMS Research
• Someone once said, “Not everything that is researched is true and not everything that is true has been researched.”
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Scientific MethodScientific Method
• General observations are turned into an unproven theory or hypothesis.
• Predictions are made based on the hypothesis.
• Predictions are tested to either prove or disprove the theory.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
BiasBias
• Occurs when research is influenced by prior inclinations, beliefs, or prejudices.
• Outcomes are manipulated to fit an expected outcome instead of being measured objectively against the hypothesis.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Prospective vs. RetrospectiveProspective vs. Retrospective
• Prospective research method– Designed to look forward and test
therapies/outcomes in the future.– Easier to control errors and prevent
bias.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Prospective vs. Retrospective Prospective vs. Retrospective (cont’d)(cont’d)
• Retrospective research method– Looks at events that have occurred in
the past, evaluating the outcome of therapies previously performed.
– Difficult to control and less valid.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
RandomizationRandomization
• The research study compares one therapy against another by randomly assigning a specific therapy to patients as opposed to having predetermined groups– Bias is controlled– Improves objectivity– Utilizes blinding to improve objectivity
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
BlindingBlinding
• Keeps the patient from knowing which therapy they are receiving.
• Makes it very difficult to influence outcomes thus improving objectivity.– Single blind: the researcher knows who
is getting what therapy– Double blind: neither the patient nor the
researcher knows who is getting what therapy
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Control GroupsControl Groups
• In medicine, a control group is commonly a known, or currently used therapy.
• Helps to better evaluate outcomes fairly.
• Comparison adds weight and value to the analysis.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Study Group SimilarityStudy Group Similarity
• When testing a new treatment, it is important that the subjects in the group have a degree of similarity.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Systematic ReviewSystematic Review
• A series of studies pertaining to a single question are evaluated
• Results are reviewed, summarized, and used to draw evidence-based conclusions.
• Made up of many different research experiments.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Randomized Controlled TrialsRandomized Controlled Trials
• The researcher randomly assigns eligible subjects into groups to receive or not receive the intervention being tested
• A placebo may be used:– Sugar pill which has no effect
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Cohort/Concurrent Control/Cohort/Concurrent Control/Case-Control Studies Case-Control Studies
• Two groups of therapies or patients are compared but they are not randomized.
• Frequently retrospective in nature.• Difficult to control all aspects of
similarity and methods among the groups.
• Prone to bias.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Case Series/Case ReportsCase Series/Case Reports
• Review the treatment of a single patient or a series of patients.
• Frequently report on unusual circumstances or outcomes.
• No control group.• Always retrospective.• Not as valid as randomized studies.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Meta-AnalysisMeta-Analysis
• Compilation of different studies looking at a single topic.
• Summarizes the work of others.• Often comments on outcomes.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Level of EvidenceLevel of Evidence
• The American Heart Association qualifies the validity of research in a linear fashion.
• Assigns varying levels of importance based on the way studies are conducted.
• Useful in evaluating the importance of data.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Level of Evidence (cont’d)Level of Evidence (cont’d)
• Can be used as a framework for considering the utility of a particular study.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Level of Evidence (cont’d)Level of Evidence (cont’d)
• Level of Evidence 1 – The most valuable set of data results from randomized control trials or meta-analyses of RCTs.
• Level of Evidence 2 – Studies using concurrent controls without true randomization.
• Level of Evidence 3 – Studies using retrospective controls.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Level of Evidence (cont’d)Level of Evidence (cont’d)
• Level of Evidence 4 – Studies without a control group.
• Level of Evidence 5 – Studies not directly related to the specific patient or population.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Reviewing ResearchReviewing Research
• Was the study randomized?• Was the randomization blinded?• If more than one group, were the groups
similar at the start of the trial?• Were all eligible patients analyzed?• If they were excluded, why?• Were the outcomes a result of the
therapy?• Is the outcome relevant?
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
Figure 1-2 Read and evaluate research
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
You and EMS ResearchYou and EMS Research
• As an ALS provider of the future, you will be on the front line of conducting research.
• Strong documentation will help improve future studies.
• Your service, local hospital, or region may participate and enroll patients in a specifically-designed experiment.
• You may take part in designing a study.
Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD
SummarySummary
• EMS research is an important part of the future of our profession.
• It is imperative to understand the basic concepts of research as well as know how to read and evaluate research literature.
• Being involved in research development offers a rewarding pathway for enlightened providers.