So much evidence 1
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Transcript of So much evidence 1
So Much Evidence
What is Next
Process of Randomisation ParticipantsParticipants
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Intervention GroupIntervention Group
Control GroupControl Group
Follow-upFollow-up
Follow-upFollow-up
Intervention Intervention GroupGroup
Control Control GroupGroup
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Assessed for eligibility (n= 245)
Excluded (n= 15)
Not meeting inclusion criteria (n=7)
Refused to participate (n=5)
Social reasons (n=3)
Received IUI (110)
Analyzed (n=110)
Cycles cancelled (n=5)
Inadequate response (n=4)
Hyper-response (n=1)
Group I (n=115) received Merional + CC
Cycles cancelled (n=8)
Inadequate response (n=6)
Hyper-response (n=2)
Group II (n=115) received Merional alone
Received IUI (107)
Analyzed (n=107)
Allocation
Analysis
Follow-Up
Enrollment
Randomized (n=230)
The best evidence for different types of question
Level Treatment Prognosis Diagnosis
I Systematic Review of …
Systematic Review of …
Systematic Review of …
II Randomised trial
Cohort Cross sectional
III
systematic reviews
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New protocols
Existing protocols
New reviews
Updated reviews
Existing reviews, not incl updates
Reviews and protocols for reviews on The Cochrane Database of Systematic Reviews
Issue 1/2005Alderson, 2005
Too much information
0
500000
1000000
1500000
2000000
2500000
Biomedical MEDLINE Trials Diagnostic?
Med
ical
Art
icle
s p
er Y
ear
5,000?per day
1,500 per day
55 per day
OBGYN in Pubmed
• 563 meta-analysis • 7184 RCT
Ready Made EBOG
• RCOG• SOGC• Cochrane Library• UpTodate
“I don’t know…”
“I don’t really care about all of this research stuff…”
“I just want to take care of patients…”
Unnamed Ob-Gyn Resident
Still There is a Problem
Many “Leaks” from research to practice
Aware Accept Target Able Recall Agree Done
ValidResearch
If 80% achieved at each stage then0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21
(a*+) (b+)
(c*) (d)
Minimum clinicalImportant difference
No difference
Another Problem : Which are (i) statistically significant * and (ii) Clinically significant +?
So
• Too many information• Little applied
Individual
EBP
The EBM Model
BestEvidence
Client Values and Expectations
Practitioner’s IndividualExpertise
Sackett et al., 1997
EBP Model
Institution state and
circumstances
Clinical Expertise
Client Preferences and actions
ResearchEvidence
But still
Knowledge needs to be managed
much more effectively than it
has been in the past
“Evidence Base” Community
• “The purchase of treatments and services that have been scientifically confirmed to improve outcomes.” (Lehman et al, 2004)
“Evidence Base” Community
• Evidence mapping• Mining the Research• Missing Pieces: Identifying the Gaps in
Evidence
Unexplained InfertilityIUI alone IUI + O.I
Timed intercourse O.I alone
Spontaneous intercourse??
Ines TrialIUI + O.I
IVF + sET
NC IVF
Timing of IUI
24hs32hs40hs
No Difference on Pregnancy rate
(Aboulgeit et al,2010)
“Evidence Base” Community
• engaging patients in research• working with guideline developers• Reporting and discussing practice guidelines• Podcasting as a Dissemination Strategy• funding for Knowledge Translation and
Dissemination
Moving Methodology Forward
• prognostic evidence in systematic reviews of interventions
• Revise current statistical analysis• There’s Nothing Constant but Change
Steps For Evidence Base Community Implementation
Information sharing with decision Makers
Organization & Fund raising
Clinical Care ImprovementTraining on EBP’s, supervision, consultation and support
Engagement Strategic planFocus on outcomes that clients value.
Improved Women Health
Clinicians, consumers, Stakeholers
Feedback :Efficiency & Effectiveness
Elements Important (Fixsen et al, 2005)
• Commitment of leadership to the implementation process.
• “unfreezing” current organizational practices.• Resources for extra costs, effort, materials, recruiting,
access to expertise, retraining.
So
• There is a need for an authorised body to handle these tasks
• To communicate with decision makers• To cooperate with existing societies • To gather interested people: doctors and
consumers
Hence
• International society• Open to every one• Starting activity from September 2010• Cooperate with different societies involved in
women health