critically appraising research in pain management making sense of the evidence m.sc. the nature of...
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Critically appraising research in pain management
Making sense of the evidence
M.Sc. The nature of pain and its’ management, 2006
• Why do we need to appraise the literature on pain ?
• What is the current state of the art ?
• How do we go about it ?
• What are good sources of information ?
Critical Appraisal
The process of “weighing
up” the evidence to assess
how useful it is in making
decisions about clinical
care
Some “drivers” promoting critical review of research literature
• Evidence based practice
Clinical effectiveness > guidelines, standards and pathways
• Continuing Professional Development (CPD)
• Modernisation Agenda eg. patient choice
• Research – asking the right questions
Types of Evidence
• Primary
Generated from first hand experience
eg. diaries, letters, research reports
• Secondary (synthesis of others work)
eg. narrative and systematic literature reviews, scholarly papers
Information explosion
c. 20.000 journals, 2 million papers p.a.
Pain Management – The Evidence
• Meta-analyses, RCT’s• Systematic reviews• Cohort studies• Case studies• Narrative reviews• Updates• Reports, editorials, working papers, product
updates• Conference proceedings, abstracts• Dissertations etc.
Traditional Hierarchy of EvidenceQuantitative Research
Which research has most “weight” ?
• Meta-analysis, systematic review
• High quality RCT
• Controlled study without randomisation
• Observational study eg. case control study
• Descriptive study
• Expert consensus
• Clinicians and clients/patients views
Systematic review
- The “sharp end” of critical appraisal- Used for development of clinical guidelines
Many stages including:
• Development of a protocol• Systematic selection of studies• Data Extraction• Quality assessment• Statistical or other synthesis of findings• Rating of the overall body of evidence
NICE • Cox II selective inhibitors are not recommended
for routine (regular) use in patients with rheumatoid arthritis or osteoarthritis (2001, Guidance 27)
• Current evidence on the safety and efficacy of percutaneous disc decompression using coblation for lower back pain does not appear adequate to support the use of this procedure without special arrangements for consent and for audit or research (Consultation Document, 25 May 2004)
• Adalimumab, etanercept and infliximab for the treatment of ankylosing spondylitis (in progress, due Feb. 2007)
Assessing the quality “critical appraisal”
a) Quality of individual publications
• Checklists• Guidelines/reading guides• Questionnaires• Frameworks,• Criterion based scoring tools
b) Quality of bodies of evidence
• Grading schemes• hierarchies
Quality Evaluation Tools
• Many “off-the-shelf” tools available for different types of studieseg. Jadad, Delphi, Maastricht, SIGN
• Debate on scales v scores v weighting
• Few have been properly validated and the criteria for validation are unknown
• Move towards customised checklists
• Critical Appraisal Skills Programme
http://www.phru.org.uk/-casp/
• Scottish Intercollegiate Guidelines Network
http://www.sign.ac.uk/guidelines
• Jadad et. al. (1996) Control Clin Trials 17:1–12
• Newcastle Ottawa Observational Study checklist http://www.ohri.ca/programs/clinical _epidemiology/oxford.htm
Quality in quantitative research eg. RCT’s
Emphasis on issues such as: Random allocation of subjects, “blinding”Allocation concealmentSimilarity at baselineStandard, reliable and valid outcome assessmentDrop-outs Intention to treat analysis (ITT)
ValidityReliability
Quality in qualitative research • Dependability (reliability) eg. - justification of methods - audit trail - providing information about the researcher
- member checking, inter-researcher comparisons, triangulation • Credibility eg. - providing raw quotes - reference to accepted procedures for analysis - discussion of how researcher may have effected outcomes
- clear distinction between data and interpretation
• Transferability eg. - detail about participants and context
- identifying differences between individual participants and participants and researcher
CASP – Qualitative Studies
Rigour: has a thorough and appropriate approach been applied to key research methods in the study?
Credibility: are the findings well presented and meaningful?
Relevance: how useful are the findings to you and your organisation?
http://www.phru.nhs.uk/casp/casp_qualitative_tool.pdf
Structure of a research paper
• Title, author• Abstract: summary of what the paper is about• Introduction: Background including previous
research, aims, research question/hypothesis, ethics
• Methods: patients, methods, equipment, data analysis
• Results• Discussion (may include results in qualitative
research)• Conclusion, recommendations for clinical
practice and further research
General questions for any study• Are the aims clearly stated ?• Was it ethical ?• Does the design match the aims ?• Was the sample size justified ?• Sufficient methodological detail eg. drop outs ?
Missing data ?• Are the measurements/outcomes valid and
reliable ? (NB. study population)• Are statistical methods/data analysis described ?• Are the main findings explicit ?• Are important effects considered ?• Are results/findings compared with previous
work?• Are implications for practice discussed ?
Papers for review:
Effects of pool-based and land-basedaerobic exercise on women with fibromyalgia/
chronic widespread muscle painJentoft et alArthritis Care and Research, 2001, 45:42-47
In the system: the lived experience of chronic back pain from the perspectives of those
seeking help from pain clinicsWalker et alPain, 1999, 621-628
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