Graphic Appraisal Tool for Epidemiology 1991 2015 3 1 picture 2 formulas amp 3 acronyms GATE Graphic Appraisal Tool for Epidemiology Graphic Architectural Tool for Epidemiology ID: 448157
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GATE:
Graphic Appraisal Tool for Epidemiology
1991 - 2015
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1 picture, 2 formulas & 3 acronymsSlide4
GATE:
Graphic Appraisal Tool for
Epidemiology
Graphic
Architectural Tool
for
Epidemiology
Graphic
Approach To Epidemiology
making epidemiology accessible
4Slide5
4
th
year medical students 1991Slide6
Jerry Morris
n
umerator denominator
epidemiology =
In: Uses of Epidemiology 1977
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p
resentation outline
GATE is a framework for:
study design
study analysis
study error
practicing EBM
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1 picture, 2 formulas & 3 acronymsSlide9
1Slide10
GATE: a framework for study design
1 picture
10
every epidemiological
study can be hung on the GATE frame
1
picture
, 2 formulas & 3 acronymsSlide11
cohort
of British doctors
non-smokers
smokers
lung cancer events counted
yes
no
followed
for 10 years
smoking status allocated by measurement
(
observation)
cohort
/
longitudinal
/
follow-up study
11
1
picture: GATE frame
1
picture
, 2 formulas & 3 acronymsSlide12
British doctors
placebo
aspirin
MI
yes
no
5 years
r
andomly allocated to aspirin or placebo
12
1
st
acronym: PECOT
Participants
Comparison
Exposure
Outcomes
Time
P
E
C
O
T
r
andomised controlled trial
1 picture, 2 formulas & 3
acronymsSlide13
m
iddle-aged Americans
‘normal’ weight
overweight
d
iabetes status measured in all participants
yes
no
b
ody mass index measured
c
ross-sectional (prevalence) study
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P
E
C
O
TSlide14
m
iddle-aged American women
b
reast cancer
m
ammogram negative
yes
no
receive mammogram screening test
d
iagnostic
test (prediction) study
m
ammogram positive
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P
E
C
O
TSlide15
m
iddle-aged American women
m
ammogram
test
no breast cancer
positive
negative
Gold Standard
d
iagnostic (test accuracy) study
b
reast cancer
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P
E
C
O
TSlide16
non-smokers
smokers
l
ung cancer
yes
no
smoking status measured
c
ase-control study
16
P
E
C
O
T
cases
controls
(all nested in virtual cohort studies)Slide17
£100Slide18
2Slide19
GATE: a framework for study analysis:
1
st
formula: occurrence = outcomes ÷ population
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the numbers in epidemiological studies can be hung on the GATE frame
1 picture, 2
formulas
& 3 acronymsSlide20
British doctors
non-smokers
smokers
Lung cancer
yes
no
10 years
smoking status measured
20
1
st
formula
: occurrence of outcomes =
n
umber of outcomes ÷ number in population/group
Participant Population
Comparison Group
Exposure Group
Outcomes
Time
P
EG
CG
O
T
a
bSlide21
British doctors
non-smokers
smokers
Lung cancer
yes
no
10 years
smoking status measured
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Population
Comparison Group
Exposure Group
Outcomes
Time
P
EG
CG
O
T
Exposure Group Occurrence (EGO) = a
÷
EG
= number of outcomes (a) ÷ number in exposed population (EG)
a
bSlide22
British doctors
placebo
aspirin
MI
yes
no
5
years
r
andomly allocated
22
Population
Comparison Group
Exposure Group
Outcomes
Time
P
EG
CG
O
T
a
b
Comparison Group Occurrence (CGO) = b
÷
CG
= number of outcomes (
b
) ÷ number in comparison population (CG)Slide23
yes
no
23
E
pidemiology =
N
umerator ÷
D
enominator
Participant Population
Comparison Group
Exposure Group
Outcomes
Time
P
EG
D
O
T
a
N
m
iddle-aged American women
b
reast cancer
m
ammogram negative
receive mammogram screening test
m
ammogram positiveSlide24
British doctors
non-smokers
smokers
Lung cancer
yes
no
10 years
smoking status measured
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t
he goal of all epidemiological studies is to calculate
EGO and CGO
P
EG
CG
O
T
a
b
EGO:
Occurrence (risk) of cancer in smokers
C
GO:
Occurrence of cancer in non-smokersSlide25
Middle-aged Americans
Low BMI
High BMI
EGO:
Average blood glucose in EG
high
low
Body Mass Index (BMI) measured
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P
EG
CG
O
C
GO:
Average blood glucose in CGSlide26
Middle-aged Americans
Low BMI
High BMI
b
lood glucose
high
low
Body Mass Index (BMI) measured
c
ross-sectional study with numerical measures
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P
E
C
O
TSlide27
Middle-aged American women
mammogram
no Breast cancer
positive
negative
Gold Standard
Breast cancer
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P
E
C
O
T
EGO:
likelihood of a positive mammogram if breast cancer
C
GO:
likelihood of a positive mammogram if no breast cancerSlide28
EGO ÷ CGO
= Relative
Risk (RR
)
EGO – CGO
= Risk Difference
(RD)
i
ts all about EGO and CGO
measures of occurrence
: risk; rate; likelihood; probability; average; incidence; prevalence
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1
st
formula:
occurrence
= outcomes ÷ populationSlide29
3Slide30
GATE: framework
for
nonrandom error
2
nd
acronym: RAMBOMAN
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R
ecruitment
A
llocation
M
aintenance
B
lind
O
bjective
M
easurements
AN
alyses
1 picture, 2 formulas & 3
acronymsSlide31
R
AMBOMAN
Recruitment of participants
‘who
are the findings
applicable to?’
P
P
Study setting
Eligible population
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r
ecruitment process Slide32
EG CG
O
T
RCT: a
llocated by
randomisation
(
e.g
to drugs
)
EG CG
O
T
Cohort: a
llocated
by measurement
(e.g. smoking)
R
A
MBOMAN:
‘
were participants well
Allocated
to exposure & comparison groups?’
EG & CG similar at baseline?
w
as
Allocation
to EG & CG successful?
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E & C measures accurate?Slide33
RA
M
BOMAN
EG CG
O
T
‘were Participants well
Maintained
in the groups they were allocated to?’
P
completeness
of follow-up
c
ompliance
c
ontamination
c
o
-
interventions
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RAM
B
O
M
AN
EG
CG
O
T
‘were
outcomes
well
Measured
?’
w
ere they measured
Blind
to whether participant was in EG or CG
?
P
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RAMB
OM
AN
EG
CG
O
T
‘were
outcomes
well
Measured
?’
w
ere they measured
Objectively
?
P
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RAMBOM
AN
EG
C
CG
C
O
T
P
36
EG
A
CG
A
a
b
‘were the
ANalyses
done well
?’
If RCT were
I
ntention
T
o
T
reat (ITT)
analyses done?Slide37
RAMBOM
AN
EG CG
O
T
‘were the
ANalyses
done well
?’
P
a
djustment for baseline differences / confounding?
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GATE
:
random error:
2
nd
formula:
random error = 95% confidence interval
38
There is about a 95% chance that the true
value in
the underlying
population
lies
within
the 95% CI (assuming no non-random error)
EGO ± 95% CI
C
GO ± 95% CI
1 picture, 2
formulas
& 3 acronyms
s
ample from a population Slide39
GATE
:
a framework for error in systematic reviews & meta-analyses:
3
rd
acronym: FAITH
1 picture, 2 formulas & 3
acronyms
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study sources
s
tudies appraised & allocated:
included
excluded
s
tudies summarised
& pooled if homogeneous
systematic review: a study
of studies
studies
screened
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study sources
s
tudies appraised & allocated:
included
excluded
s
tudies summarised
& pooled if homogeneous
studies
screened
critical appraisal of SR:
FAITH
Find
Appraise
Include
Total
H
eterogeneity?
1 picture, 2
formulas
& 3 acronyms
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GATE: framework for the 4 steps of EBP
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t
he steps of EBP:
A
sk
Acquire
3. Appraise
4. Apply & Act
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yes
no
45
1. Participants
3. Comparison
2. Exposure
4. Outcomes
5. Time
P
E
C
O
T
EBP Step 1:
ASK
- turn your question into
a focused 5-part PECOT question Slide46
EBP Step
2:
ACQUIRE
the evidence – use
PE
COT
to help choose search terms
46
yes
no
Participants
Comparison
Exposure
Outcomes
Time
P
E
C
O
TSlide47
P
E
C
O
T
P
E
C
O
T
R
ecruitment
A
llocation
M
aintenance
b
lind
o
bjective
M
easurements
AN
alyses
47
EBP Step 3:
APPRAISE
the evidence – with the picture, acronyms & formulas
Occurrence = outcomes ÷ population
Random error = 95% Confidence Interval Slide48
APPLY
the evidence by AMALGAMATING the
relevant information &
making
an
evidence-based decision:’
the X-factor
©
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e
pidemiological evidence
p
atient’s clinical circumstances
s
ystem features
v
alues & preferences
X-factor: making evidence-based decisions
Practitioner
e
X
pertise
: ‘putting it all together’
- the
art of practice
e
conomic
legal
political
person
family
community
practitioner
social
p
hysical health
psychological
Clinical expertise in the era of evidence-based medicine and patient choice. EBM 2002;736-8 (March/April)
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GATE critically appraised topic (CATs) formsSlide52
GATE CAT –
4-
sheet workbook (in Excel)
sheet 1: GATE-Ask &
Acquire
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GATE CAT – 3-sheet workbook (in Excel)
sheet 2: GATE-Appraise
(with calculator)Slide54
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GATE CAT – 3-sheet workbook (in Excel)
sheet 3: GATE-ApplySlide55Slide56Slide57
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