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So much evidence 1

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So much evidence 1

  1. 1. So Much Evidence What is Next
  2. 2. P articipants I ntervention Group (IG) & C omparison Group (CG) O utcome I G CG + - + - D C B A R epresentative? Allocation? Selection? Maintenance of allocation? VALIDITY M aintenance? treated equally? compliant? M easurements b lind subjective? OR o bjective? QUESTION: A llocation? Randomised? comparable groups? Measurement of outcomes? DESIGN:
  3. 3. Process of Randomisation Participants R a n d o m l y A s s i g n e d Intervention Group Control Group Follow-up Follow-up Intervention Group Control Group O u t c o m e C o m p a r e d
  4. 4. 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 )
  5. 5. 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
  6. 6. systematic reviews Alderson, 2005
  7. 7. Too much information 5,000? per day 1,500 per day 55 per day
  8. 8. OBGYN in Pubmed <ul><li>563 meta-analysis </li></ul><ul><li>7184 RCT </li></ul>
  9. 9. Ready Made EBOG <ul><li>RCOG </li></ul><ul><li>SOGC </li></ul><ul><li>Cochrane Library </li></ul><ul><li>UpTodate </li></ul>
  10. 10. “ 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
  11. 11. Many “Leaks” from research to practice If 80% achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21 Aware Accept Target Able Recall Agree Done Valid Research
  12. 12. (a*+) (b+) (c*) (d) Minimum clinical Important difference No difference Another Problem : Which are (i) statistically significant * and (ii) Clinically significant +?
  13. 14. So <ul><li>Too many information </li></ul><ul><li>Little applied </li></ul>
  14. 15. Individual
  15. 16. The EB M Model Sackett et al., 1997 EBP Best Evidence Client Values and Expectations Practitioner’s Individual Expertise
  16. 17. EB P Model Institution state and circumstances Clinical Expertise Client Preferences and actions Research Evidence
  17. 18. But still Knowledge needs to be managed much more effectively than it has been in the past
  18. 19. “ Evidence Base” Community <ul><li>“ The purchase of treatments and services that have been scientifically confirmed to improve outcomes.” (Lehman et al, 2004) </li></ul>
  19. 20. “ Evidence Base” Community <ul><li>Evidence mapping </li></ul><ul><li>Mining the Research </li></ul><ul><li>Missing Pieces: Identifying the Gaps in Evidence </li></ul>
  20. 21. Unexplained Infertility Spontaneous intercourse?? IUI alone IUI + O.I Timed intercourse O.I alone
  21. 22. Ines Trial IUI + O.I IVF + sET NC IVF
  22. 23. Timing of IUI <ul><li>24hs </li></ul><ul><li>32hs </li></ul><ul><li>40hs </li></ul><ul><li>No Difference on Pregnancy rate </li></ul><ul><li>(Aboulgeit et al,2010) </li></ul>
  23. 24. “ Evidence Base” Community <ul><li>engaging patients in research </li></ul><ul><li>working with guideline developers </li></ul><ul><li>Reporting and discussing practice guidelines </li></ul><ul><li>Podcasting as a Dissemination Strategy </li></ul><ul><li>funding for Knowledge Translation and Dissemination </li></ul>
  24. 25. Moving Methodology Forward <ul><li>prognostic evidence in systematic reviews of interventions </li></ul><ul><li>Revise current statistical analysis </li></ul><ul><li>There’s Nothing Constant but Change </li></ul>
  25. 26. Steps For Evidence Base Community Implementation Information sharing with decision Makers Organization & Fund raising Clinical Care Improvement Training on EBP’s, supervision, consultation and support Engagement Strategic plan Focus on outcomes that clients value. Improved Women Health Clinicians, consumers, Stakeholers Feedback :Efficiency & Effectiveness
  26. 27. Elements Important (Fixsen et al, 2005) <ul><li>Commitment of leadership to the implementation process. </li></ul><ul><li>“ unfreezing” current organizational practices. </li></ul><ul><li>Resources for extra costs, effort, materials, recruiting, access to expertise, retraining. </li></ul>
  27. 28. So <ul><li>There is a need for an authorised body to handle these tasks </li></ul><ul><li>To communicate with decision makers </li></ul><ul><li>To cooperate with existing societies </li></ul><ul><li>To gather interested people: doctors and consumers </li></ul>
  28. 29. Hence
  29. 30. <ul><li>International society </li></ul><ul><li>Open to every one </li></ul><ul><li>Starting activity from September 2010 </li></ul><ul><li>Cooperate with different societies involved in women health </li></ul>

Notas

  • Enrollment - Treatment Allocation - Follow-up - Data Analysis
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