Journal club MPH March 2010

Journal Club Meeting, MPH: 

Journal Club Meeting, MPH POINT-OF-CARE C-REACTIVE PROTEIN TESTING AND ANTIBIOTIC PRESCRIBING FOR RESPIRATOTY TRACT INFECTIONS: A RANDOMIZED CONTROLLED TRIAL Cals JWL, Schot MJC, de Jong SAM, Dinant GJ, Hopstaken RM. Ann Fam Med 2010;8:124-133 By Dr. E.K Mutunzi, Mafikeng Provincial Hospital, March 2010

Critical Appraisal of Literature: 

Critical Appraisal of Literature Intended to enhance the clinician’s skill to determine whether the results reported in an article were likely to be . . . . . . . true . . . important . . . applicable to their patients!

Critical appraisal provides useful tools for: : 

Critical appraisal provides useful tools for: Systematically evaluating scientific literature. Deciding which papers are going to influence what you do in your daily work Breaking down barriers between research (pure science) and practice (applied science) Supporting the development of Evidence Based Practice (EBP).

Slide 4: 

When you come across a research study in a journal how do you decide whether its is worth reading and whether you can believe what it says? Worth reading? Believable?

Understanding the concepts: 

Understanding the concepts RCT A Experimental study in which people are allocated at random (by chance alone) to receive one of several clinical interventions( intervention vs. control) Random assignment, usually with blinding; eg: randomised clinical trials, such as drug trials. Gold standard of experimental design . Every participant has an equal chance of being assigned to either group. MedicineNet.com

Slide 6: 

Open individually randomized study : the researcher knows the full details of intervention, and so does the patient. Visual analogue scale (VAS): is the standard tool for rating pain, severity of illness… allocation concealment: The process by which the person determining randomization is blinded to a study participant’s group allocation

Slide 7: 

Mann-Whitney (Wilcoxon) U test: is sometimes used for comparing the efficacy of two treatments in clinical trials Logistic regression: A form of regression analysis that models an individual’s odds of disease or some other outcome as a function of a risk factor or intervention. www.bmj.com

Slide 8: 

confidence interval : the range of values calculated from data such that there is a level of confidence, or certainty, that it contains the true value (95% or 99%). P value: The probability (ranging from 0 to 1) that the results observed in a study could have occurred by chance if the null hypothesis( no difference) was true. A p value of 0.05 is often used as a threshold to indicate statistical significance.

Slide 9: 

Intention to treat : The use of data from a RCT in which data from all randomized patients are accounted for in the final results. Number needed to treat (NNT): An estimate of how many persons need to receive a treatment before 1 person would experience a beneficial outcome. www.ncbi.nlm.nih.gov/bookshelf/br.fcgi

Slide 10: 

Epidemiological studies Observational studies Experimental studies Descriptive studies Analytic studies Ecological RCT Cross-sectional Field Trials Case-control Community Trials Cohort

Slide 11: 

Relative Risk (Case-control) Or rate ratio= incidence rate for the disease in the population exposed divided by the incidence rate of disease in the non-exposed population. RR=1: the exposure did not affect the risk of disease. RR>1: the risk of disease is increased by the exposure. RR<1: the risk of disease is decreased by the exposure Ann Bowling Research Methods in Health,3 rd ed. 2009

Slide 12: 

Odds Ratio ( Cohort) = the odds (chance) of outcome occurring in exposed persons divided by the odds of outcome occurring in unexposed persons. OR=1: the odds of outcome occurrence is unaffected by exposure. OR>1: the odds of outcome occurrence is increased by the exposure. OR<1: the odds of outcome occurrence is decreased by the exposure

Slide 13: 

Statistical significance – the P – value is less than then preset value.(0.05) P- value < 0.05 – reject Ho (there is an association) - i.e. the role of chance is too little P-value > 0.05 – do not reject Ho (there is no association) - i.e the role of chance is too big. t–test for numerical data and Chi-square for categorical data

READER acronym : 

READER acronym RELEVANCE EDUCATION APPLICABILITY DISCRIMINATION EVALUATION REACTION

RELEVANCE : 

RELEVANCE This article deal with general practice, family medicine and PHC Explore the issue of overprescribing antibiotics for clients with LRTI and Rhino sinusitis The article has considerable practice input in family medicine practice, PHC. The authors are well known academics, with high qualification,3 out of 5 authors holding a PhD.

EDUCATION: 

EDUCATION This article reiterate our knowledge about rational use of Antibiotics In doing so, the findings are practically useful in term of rational, efficient and cost-effective use of ATB

APPLICABILITY: 

APPLICABILITY This type of research can be done in our district (Ngaka Modiri Molema district) or country- theatrically yes Practically, NO. ?Availability of the CRP rapid test

DISCRIMINATION: 

DISCRIMINATION It is about the scientific quality of the research, from it methodology, validity and reliability. Title design problem Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A randomized Controlled Trial. Sound Great! Highest level of evidence

Slide 19: 

Study design: RCT, gold standard of experimental study ? Weakness: open RCT, no blinded Figure 1. Trial profile Table 1. Characteristics of Randomized Patients

Slide 20: 

Setting of the study – The Netherlands Multicenter research. Reporting, information bias? Motivation of doing the research: product promotion? (conflict of interest) source of findings: Orion diagnostica (Finland) Manufacturer of the Quick Read point-of-care C-reactive testing device

Slide 21: 

The principal researcher has received travel funds from the testing device companies

Slide 22: 

Selection criteria > 18 years old Current episode of LRTI and Rhinosinusitis Exclusion criteria Immediate requirement of admission No understanding of Dutch language Immunocompromized… data collection by different GPs and setting

Validity issues : 

Validity issues

Slide 24: 

Table 2: Mean and Media C-Protein Values at Index Consultation and Number of Patients Within CRP Categories Table 3. Effects of Intervention on Antibiotic Use After the Index Consultation (by CRP Category) and Within a 28-Day Follow-up. Exploratory Data on Antibiotic Use Per Respiratory Tract Infection.

Slide 25: 

Figure 2. Median symptom scores per group during first week after index consultation Table 4. Effects of Interventions on Patient-Reported Recovery and Secondary Outcomes (Assessed After the Index Consultation)

EVALUATION: 

EVALUATION The research is relevant The findings can be incorporated into practice with caution This research should not be considered seriously – has poor score

SCORING SYSTEM: 

SCORING SYSTEM Criteria score Relevance Not relevant to general practice 1 Allied to general practice 2 Only relevant to special general practice 3 Broadly relevant to all general practice 4 Relevant to me 5 Education Would certainly not influence my practice 1 Could possible influence behaviour 2 Would cause reconsideration of behaviour 3 Would probably alter behaviour 4 Would definitely change behaviour 5

Slide 28: 

Applicability Impossible in my practice 1 Fundamental changes needed 2 Perhaps possible 3 Could be done with reorganisation 4 I could do that tomorrow 5 Discrimination Poor, descriptive study 1 Moderately good, descriptive study 2 Good descriptive study but method not reproducible 3 Good descriptive study with sound methodology 4 Single blind with attempts to control 5 Controlled single blind study 6 Double blind, controlled study with methodology problem 7 Double blind, controlled study with statistical deficiency 8 Sound scientific paper with minor faults 9 Scientifically excellent paper 10

REACTION: 

REACTION The score given is 17/25. This mean that a paper can be kept in library...

END: 

END AKISANTI SANA! THANK YOU VERY MUCH! MERCI BEAUCOUP! MURAKOZE! SIYABONGA!!

Journal Critic 2: 

Journal Critic 2 Why do patients choose to consult homeopaths? An exploratory study Mclnton CDD and Ogunbanjo GA. SA Fam Pract 2008

Why this topic?: 

Why this topic? In other words,… ‘ Why do patients cheat from their doctors/FP?’ Similarity… ‘why do wife/husband cheat from their husband/wife? Report suggested that patients choose to consult homeopaths without informing…

READER acronym : 

READER acronym RELEVANCE EDUCATION APPLICABILITY DISCRIMINATION EVALUATION REACTION

RELEVANCE : 

RELEVANCE This article deal with general practice Explore the consultation issues and the patient-doctor relationshi The authors are well known academics in the South Africa scientific circle The article has considerable practice input

EDUCATION: 

EDUCATION This article help doctors to have an understanding why patients do choose to consult homeopath In doing so, the doctors can be able to change their behaviour vis a vis to their patients – Good practice

APPLICABILITY: 

APPLICABILITY This type of research can be done in MPH practice (Polyclinic, Gateway clinic, and others departments)

DISCRIMINATION: 

DISCRIMINATION This is a qualitative, descriptive study 8 free-attitude interviews were conducted using the exploratory question: ‘ why do you choose to consult a homeopath?’ Homeopath setting in Gauteng province Interview were done in English only-limitation -bias?=weakness of the study

Slide 40: 

Triangulation of data was done by audio-recording of the interviews, and transcribed notes and field notes collected during interviews =strength of the study Saturation reached at 8 th interview The article were published in a peer reviewed journal – SA Fam Practice 2008

EVALUATION: 

EVALUATION The research is relevant and can change the practice behaviour The findings can be incorporated into practice This research should be considered seriously – has good score

REACTION: 

REACTION The score given 19/25. This mean that although not fulfilling all the criteria, a paper may be of interest. The article can be stored in the library for the public.

SCORING SYSTEM: 

SCORING SYSTEM Criteria score Relevance Not relevant to general practice 1 Allied to general practice 2 Only relevant to special general practice 3 Broadly relevant to all general practice 4 Relevant to me 5 Education Would certainly not influence my practice 1 Could possible influence behaviour 2 Would cause reconsideration of behaviour 3 Would probably alter behaviour 4 Would definitely change behaviour 5

Slide 44: 

Applicability Impossible in my practice 1 Fundamental changes needed 2 Perhaps possible 3 Could be done with reorganisation 4 I could do that tomorrow 5 Discrimination Poor, descriptive study 1 Moderately good, descriptive study 2 Good descriptive study but method not reproducible 3 Good descriptive study with sound methodology 4 Single blind with attempts to control 5 Controlled single blind study 6 Double blind, controlled study with methodology problem 7 Double blind, controlled study with statistical deficiency 8 Sound scientific paper with minor faults 9 Scientifically excellent paper 10

Summery: results of the study: 

Summery: results of the study Approach of mainstream doctors they described the rushed, impersonal nature of the consultation – ’ They push number’, ‘very quickly’, ‘let me se 40, 50 patients very quickly’; short consultation- ’10, 15 minutes ’ doctors acted as if the ‘ knew everything ’, often did not explain things about illness, the treatment,… The mainstream medical approach was perceived to be reductionist and mechanistic- ‘ the way that I’ve been treated, and compartmentalized, that kind of thing, and dehuminised’… mainstream doctors being unapproachable and judgemental- …doctors forever telling me that it was all in my head’.

2. Approach of homeopath: 

2. Approach of homeopath The relationship they had with their homeopath was far more important than what type of medication was used. Respect, person-to-person conversation, punctuality at work, allowing more time… = quality in homeopaths Homeopaths were found to be caring, interested and empathic. They were perceived being very supportive, holistically, being available telephonically and providing regular follow up. ‘ …it looks at people at multiple levels, at multiple layers… from the physical to the spiritual to the emotional to the psychological to the social’. ‘So they kind of get context before rushing to tell you what’s wrong’.

3. Risks of mainstream medicine and safety of homeopathy: 

3. Risks of mainstream medicine and safety of homeopathy Side effects of ‘ harmful chemical’ medications ‘ my Asthavent, it gives me such bad heart palpitations…’ Homeopathic medicine, which considered ‘natural’ and is often prepared from plants, was considered as not having side effects and being safer in overdose.