Bulletin for Evidence-Based Health Care Programme

November 14, 2015

In the Bulletin this term . . .

Lead Article

Bias – alive and kicking
Dr Kamal Mahtani, Deputy Director Centre for Evidence Based Medicine and co-coordinator of Knowledge into Action

As the risk of bias increases, so does the likelihood that the results a particular study do not reflect the truth. So what types of  bias should we be looking for?  Read more . . .

Upcoming Events

Evidence Live
22 – 24 June 2016, Radcliffe Observatory Quarter (ROQ) campus, Oxford. Read more . . .

Peer Update

Steve Langton (DPhil student and MSc Alumnus) – The ‘two week rule’ in head and neck cancer, 2000-2014; a systematic literature review  Read more . . .
Moses Mulimira (PGDip Alumnus) – The role of a health partnership: Development of a Centre for Evidence Based Medicine in Uganda  Read more . . .

Events Catch-up

Preventing Overdiagnosis – Co-sponsored by the Centre for Evidence-Based Medicine at the University of Oxford in Bethesda, Maryland, USA, 1 – 3 September 2015. Read more . . .

Harms in Healthcare – Alumni Weekend, 19 September 2015. Read more . . .

Ben Goldacre on flaws in bad trials – Oxford University Continuing Education Open Day, 25 September 2015 (Visit link to watch video broadcast) Read more . . .

What good are the Humanities?11 November 2015
Dr Kamal Mahtani is part of panel debating the question ‘What good are the Humanities?’ Read more . . .

Speed bumps research wins Ig Nobel Prize

EBHC Programme Module talks

Recent Publications

by the Nuffield Department of Primary Health Care Sciences

Programme Update and News

The EBHC Programme welcomes several new Module Coordinators this year.

Prof Trish Greenhalgh and Dr Kamal Mahtani – Knowledge into Action (9 – 13 May 2016)
Dr Emma Ogburn – Clinical Trial Management (11 – 15 April 2016)
Dr Jason Oke – Introduction to Statistics for Health Care Research (online – 18 January – 26 March 2016 and 16 May – 22 July 2016)
Read more . . .

Welcome from Amy Price, Student Representative for the EBHC DPhil programme

Roger Bailey – New Student Representative for the MSc Programme

Review of The History & Philosophy of Evidence-Based Health Care

Second cohort on the Academic Health Science Network (ASHN) join the MSc in EBHC programme.

Clinical Trial Management Module – Recommended by student Lucia Ramirez-Montesinos

Upcoming Modules

Featuring a few of the modules offered in Hilary Term which still have some places available.

Curriers’ Millennium Healthcare Bursary

This bursary, worth up to £10,000 over two years, is to enable primary healthcare professionals to enhance the helathcare of disadvantaged individuals and families in inner London. Closing date for applications must be received by 31st March 2016. Follow link for more information.

Lead Article

Bias – alive and kicking

Dr Kamal Mahtani, Deputy Director Centre for Evidence Based Medicine and co-coordinator of Knowledge into Action

Definition of bias
‘Any process at any stage of inference which tends to produce results or conclusions that differ systematically from the truth’.
(Adapted from Murphy. The Logic of Medicine. Baltimore: John Hopkins University Press. 1976.)

One of the key steps in evidence based medicine, and sadly one that is often forgotten, is to appraise evidence before making a decision as to whether to use it.  Skills in critical appraisal involve a systematic evaluation of research in order to establish, amongst other things, whether the results of a particular study are valid both internally (reflecting how well the study was conducted) and externally (reflecting how generalizable the results are).  Internal validity is determined by the extent to which the study is free from bias. As the risk of bias increases, so does the likelihood that the results a particular study do not reflect the truth.

So what types of bias should we be looking for?

For randomized controlled trials, the Cochrane handbook defines a common classification scheme for sources of bias, summarized below:

The handbook also points out other potential sources of bias, such as in the study design (e.g. a carry over effect from a cross-over RCT) or a “contamination” effect whereby participants in one arm, adopt the intervention in the other.

Many researchers use the Cochrane tool for assessing the risk of bias in reviews, which has generally been found to be very acceptable by users.

But does all this searching and assessment for bias make a real difference?

Simply put…yes it does.

Take “Reporting bias” for example – differences between reported and unreported findings, which itself incorporates several types:

Empirical evidence has shown that trials showing positive findings are more likely to be published, and often quicker, than trials with negative findings.

So imagine this – you are doing a systematic review of clinical trials on a healthcare question relevant to your patient or population. You find your relevant included studies, you systematically analyze, summarize and find a clear benefit. Great.

How would you feel though if after all the time and effort you put in to do your review, your results were totally hampered by bias and you never even realized it  –  because you only had access to published trials which were more likely to show a positive finding?

The Cochrane handbook describes ways of addressing reporting biases, such as searching for data from multiple sources, including grey literature and searching for unpublished studies.

But wouldn’t it be nice to have a consensus agreement that every clinical trial done should be registered and every result within it reported?  Think how much stronger your review would be. Think how much stronger the clinical decisions we make that affect patient care would be.

If your answer is yes (and it should be) then you should have a look, then sign up to the AllTrials campaign, because that’s exactly what they have been calling for.

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Upcoming Events

Stem cells – The answer for all our ills?
Thursday 19 November 2015, 18:15  Public lecture at the Nuffield Orthopaedic Centre – Lecture Theatre Level 1 sponsored by the Oxford Biomedical Research Centre.Professor Zameel Cader, Consultant Neurologist and Director of the Oxford Headache Centre and Director of Stembancc, University of Oxford will talk about how the world continues to face major challenges in providing effective therapies for disabling and degenerative neurological disorders.

Diseases such as Alzheimer’s have no effective treatments whilst other prevalent and disabling conditions such as chronic migraine have inadequate treatments.

Stem cell technology may offer hope for new ways of finding better drugs or even regenerating lost brain cells. In this talk, the promise of stem cells will be examined against the real challenges ahead to deliver this promise. Free tickets can be obtained here.

Innovation in the NHS
Monday, 30 November 2015, 18.00 – 20.00 John Radlciffe Hospital – Lecture Theatre 2, Oxford

This free symposium is hosted by Innovation Forum Oxford. Full details including Free tickets can be found here.

Workshop: Virtues and Vices in Evidence Based Clinical Practice
Wednesday 27 January 2016, 10:00 – 16:00 Abraham Lecture Theatre, Green Templeton College, OxfordThis workshop will bring together doctors, philosophers and social scientists to discuss how they might develop the interdisciplinary study of virtues and vices in evidence-based clinical practice.

Much has been written about the research-practice gap. The question of why clinicians don’t follow guidelines has been dominated by behaviourist models. It is time to refocus the analysis on philosophical and psychological aspects of this issue. How humans behave is underpinned by how they think, and thinking styles are in turn influenced by intellectual character traits – both virtues (e.g. open-mindedness, criticality, carefulness) and vices (e.g. dogmatism, prejudice). Clinicians are also influenced by their professional virtues (e.g. integrity, altruism) and vices (e.g. a tendency to close ranks).

The workshop, which is supported by a grant from Green Templeton College, will be led by Professor Trish Greenhalgh (Medicine, Oxford) and Professor Qassim Cassam (Philosophy, University of Warwick). Prof Cassam has a particular interest in intellectual vices and is the author of Self Knowledge for Humans (OUP 2014). Also speaking will be Iona Heath (past President, Royal College of General Practitioners). Free tickets can be obtained here.
Evidence Live
22 – 24 June 2016, Radcliffe Observatory Quarter (ROQ) campus, Oxford

This event includes three days of workshops, speakers & fringe events and brings together leading speakers in evidence-based medicine from all over the world, from the fields of research, clinical practice and commissioning. Evidence Live is the place for learning about the latest advances in evidence-based healthcare and finding out how they can be best applied in clinical practice.At the Evidence Live conference researchers, clinicians and professionals, working with evidence at different stages in the healthcare chain, learn about important issues in healthcare. The programme is designed to showcase the most innovative ideas, processes and best practices that form the foundations of an evidence-based approach. The conference aims to provide a thought-provoking environment that offers an opportunity for delegates to learn first-hand from leading experts in evidence-based healthcare.

“ Our programmes for Evidence Live events are designed to be thought-provoking, practical and entertaining. Delegates get an amazing opportunity to learn first-hand how leading world experts in evidence-based medicine are helping to shape healthcare for the better. ”
Dr Carl Heneghan, Director Centre Evidence Based Medicine, University of Oxford

“ The evidence movement is always advancing and there are new challenges, new technologies and new methodologies to discuss but at the same time people want to learn how to apply them in their every day work. The Evidence Conference combines debate about the latest issues with educational, practical skills development. ”
Fiona Godlee, Editor in chief, The BMJ

Who should attend?

  • Front-line healthcare professionals.
  • Regional and national policy makers involved in the implementation of evidence.
  • Methodologists and researchers.
  • Teachers and trainers of evidence-based practice.
  • Commissioners of evidence-based interventions and resources.
  • Budget holders who need to assess the cost-effectiveness of evidence-based interventions.
  • Developers of evidence-based healthcare resources, tools and materials.
  • Students interested in learning about evidence-based practice.
  • Allied healthcare professionals and others with an interest in using evidence in their practice.

Read more including Registration guidance

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Peer Update

If you would like to feature in this section, please contact cpdhealth@conted.ox.ac.uk

The ‘two week rule’ in head and neck cancer, 2000-2014; a systematic literature review

Steve Langton (DPhil student and MSc Alumnus)

I completed the MSc in EBHC 2014. The course provided everything I’d hoped for, and more! One of the many attractions of the course is that the modules and assignments allow you to study EBHC principles in relation to your own professional expertise. As a head and neck cancer surgeon, I was therefore able, in most instances, to develop assignments in relation to aspects of head and neck cancer which, apart from being extremely valuable, made the course even more enjoyable.
The systematic review from my dissertation, which was about the UK fast-track cancer referral system in head and neck cancer, has recently been accepted for publication as ‘The ‘two week rule’ in head and neck cancer, 2000-2014; a systematic literature review’ by the British Journal of Oral and Maxillofacial Surgery.
Having now been ‘hooked’ by EBHC, I am starting my DPhil and I plan to examine in greater depth the evidence base for fast-track suspected cancer referral from primary to specialist care.

Watch for Steve’s article in the December issue of the British Journal of Oral and Maxillofacial Surgery – Ed.

The role of a health partnership: Development of a Centre for Evidence Based Medicine in Uganda

Moses Mulimira (PGDip Alumnus)

The past few decades have been marked by unprecedented interest in evidence based medicine (EBM), and a focus upon the use of innovative methods and protocols to provide valid and reliable information for healthcare (Greenhalgh, 2010). Evidence based healthcare has been indicated to be the most appropriate way of ensuring that patients receive the most effective care possible (Greenhalgh, 2010). Consequently, healthcare decisions are increasingly being based on research derived evidence, rather than expert opinion or clinical experience alone (Greenhalgh, 2010).(Image: The UK team after meeting with Professor James Tumwine (in the centre) at Makerere University College of Health Sciences)

The use of evidence based healthcare treatments in low income countries can be viewed as controversial, because treatments are typically developed and transported from high resource, “Western” countries or contexts, which are culturally and contextually distinct (World Health Organization, 2010). However, it’s also arguable that efforts to address the treatment gap in low income countries should build and benefit from evidence in other settings, including treatments developed in high resource countries.

To adequately address the substantial health treatment gap in low income countries, there is a need to encourage scientific research that evaluates the efficacy of health treatments in low income countries, according to the criteria of EBM. If this could be achieved, we would have strong supporting evidence for the treatment of health disorders, which revolves chiefly around well controlled clinical trials, including placebo controlled trials (World Health Organization, 2010).

Given the need for both fidelity and adaptation when implementing evidence based treatments in low income countries, it could be critical to work collaboratively with several stakeholders in both high and low income countries, so that the EBM paradigm applied is still culturally specific.

The above argument was the thinking behind the development of a Centre for Evidence Based Medicine at Makerere University College of Health Sciences in Uganda, formed in partnership with the Royal Society of Medicine, the Uganda Diaspora Health Foundation (UDHF), and the Centre for Evidence Based Medicine at Oxford University—and supported by the Tropical Health & Education Trust (THET). The overall objective of this partnership is to assess the need for a collaborative training programme aimed at improved EBM knowledge and skills among students and faculty at Makerere University College of Health Sciences. The partnership also hopes to find ways to address any gaps innovatively and by building on student led partnership.

The project will be implemented under two phases, including; (1) Enhancing research skills training through the “Training of Trainers” model. There will also be a pilot project, which gives tablets to medical students to improve their communication skills and access to evidence based research during the Community Based Education and Services programme—an off-campus learning course, which combines educational and clinical/community objectives, and which provides real life experiences for students.

Tablet devices will give them remote access to e-resources; to practice protocols for common conditions; to reference information that can assist with diagnostic and intervention approaches; and access to platforms for supervision, so that students can communicate with faculty even when in remote areas.

The second phase will be the monitoring and evaluation of the project objectives and goals. Our funders THET value our planned EBM project, commenting that “THET’s experience shows that partnership projects, such as this one, are an effective means to exchange professional experiences and approaches. Drawing on the expertise available in the UK and Uganda, peer to peer collaboration can play a crucial role in assessing organisational capacities and point to innovative ways to address gaps.”

Blog submitted to BMJ and published online on 28 April 2015 – Ed.

More blogs from students, alumni and tutors can be found here.

Send a contribution to the EBHC Bulletin

Events Catch-up

Preventing Overdiagnosis
1 – 3 September 2015

Preventing Overdiagnosis is a gathering of likeminded scientists coming together to share opinions, ideas and solutions to the growing problem of overdiagnosis and overtreatment and how best to tackle the burden of overdiagnosis in today’s Health Care system. The 2015 event took place in Bethesda, Maryland and was co-sponsored by Oxford’s Centre for Evidence-Based Medicine (CEBM). Dr Carl Heneghan was among the over 350 delegates to this event and chaired several sessions.

For abstracts and videos, visit this website. Also, CEBM has placed several videos from the event on their YouTube channel.

Next year’s event will take place 20 – 22 September 2016 in Barcelona, Spain.

Harms in Healthcare
Alumni Weekend, 19 September 2015

Better evidence and communication are needed to avoid worrying harms in healthcare, according to a distinguished group of speakers from Oxford University’s Nuffield Department of Primary Care Health Sciences.

The failure to deliver the best treatment, the risks of overdiagnosis, and the proliferation of rogue online pharmacies were all emphasised during the talk during Oxford University’s Alumni Weekend. Read more . . .

Ben Goldacre on flaws in bad trials
25 October 2015
Dr Annette Pluddemann

As part of the Department for Continuing Education’s recent Open Days, Ben Goldacre spoke about the flaws in bad trials to a full house in Rewley House’s lecture theatre.  In his 45 min talk he covered key problems in trials. Talking about dodgy comparators, he highlighted the problems of using incorrect or unusual doses. For example, in schizophrenia trials of newer agents unusually high doses of haloperidol were used in the comparator group resulting in more side effects –   making the new drug seem better than it really was.

One other key example of switching the main outcome discussed was the 329 study of paroxetine for major depression in adolescents; if you’re not aware of this study, have a look at Carl Heneghan’s blog in the BMJ (Carl Heneghan: 329 trial restoration highlights need to restore public trust in trials) – something everyone with an interest in EBM, and methods, should know about.

Ben’s subgroup analyses analogy, which stuck in my mind, was the X-raying of a X-mas pudding to find out where the most coins are. If you then cut the cake in a very complex way you can get a piece with more coins, but that doesn’t mean anything. The coins are still randomly distributed in the pudding, and what you found does not represent the rest of the pudding.

Also emphasized in his talk were the substantial problems that surrogate outcomes cause along with issues of external validity, giving the example of the ALLHAT trial of statins (Debate: The slippery slope of surrogate outcomes) . Carl has also written a good blog on surrogate outcomes, have a look at it (Obsessed with surrogates?). Importantly, this is not really about how bad pharma is (and is not a plug for the book) but more about how permissive we are in letting all of this happen. In closing Ben reminded us that all we really need, for a good trial, is for it to present a fair test compared to the best currently available treatment, with real world outcomes.

You can view Ben Goldacre’s full presentation here.

What good are the Humanities?
11 November 2015
Dr Kamal Mahtani, Fellow in Evidence-Based Medicine, was part of the panel debating the question ‘What good are the Humanities?’  In this inaugural Humanities Seminar, Kellogg Fellows from across the Humanities and the Medical Sciences were asked to respond to the question in turn and then the subject was opened up for debate and discussion.

Speed bumps research wins Ig Nobel Prize
Dr Helen Ashdown ( PG Diploma in Health Research alumna) and team were awarded the international Ig Nobel prize for research involving appendicitis and speed bumps. Read more . . .

Module Talk podcasts
Don’t forget that there are a series of podcasts available to you through the Centre for Evidence-Based Medicine podcast series. Most of these podcasts come from talks given as part of the Postgraduate programme in Evidence-Based Health Care. More podcasts will be added throughout the year so check regularly for updates.

The following podcasts have been added since the Trinity Term Bulletin:

Theorising with narrative: How careful analysis of stories can help us reise above the ontological desert of ‘behaviour change’ research – Professor Trish Greenhalgh

What has EBM done for healthcare? – Professor Carl Heneghan

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Programme Update and News

New Module Coordinators

Prof Trish Greenhalgh – Earlier this year Trish joined the Nuffield Department of Primary Care Health Sciences as Professor of Primary Care Health Sciences and will be coordinating the Knowledge into Action module (9 – 13 May 2016) along with Dr Kamal Mahtani. Read more about Trish here.

Dr Kamal Mahtani – Kamal is Deputy Director of the Centre for Evidence-Based Medicine and is already an integral part of the EBHC Programme. He will coordinate the Knowledge into Action module (9 – 13 May 2016) along with Prof Trish Greenhalgh. Read more about Kamal here.

Dr Emma Ogburn – Emma, as Senior Clinical Trials Manager at the Nuffield Department of Primary Care Health Sciences, wll coordinate the Clinical Trial Management module (11 – 15 April 2016). Read more about Emma here.

Dr Jason Oke – Jason actually took over as Module Coordinator for the online module Introduction to Statistics for Health Care Research (18 January – 26 March 2016 and 16 May – 22 July 2016) near the end of the past academic year after being the tutor for the same course earlier. Read more about Jason here.

Welcome! – Amy Price, Student Representative for the DPhil Programme
As we are entering the new academic year I want to introduce myself and welcome you. Congratulations for getting this far!  I am Amy Price your student rep for the EBHC DPHIL programme. If you have innovative ideas, practical support ideas, issues you would like to share or something you would like to see us do as a group, please contact me. If you come across great resources or things to recommend like an encouraging video, software please email me and I will get the message to all of us.

We have the FAQ’s on the forum that will show you things like how to use the department printer, how to get in the building with your student card and alert you to perks like you can punt for free, use a bike owned by Kellogg, use the community Kellogg locker and make yourself a beverage at Kellogg College, Rewley House, or the department. You may not know that as a member of Kellogg you can apply for bursaries and travel grants offered by the college and you get three free lunches every term.  If your FAQs are not the ones on the paper just email me at amy.price@kellogg.ox.ac.uk and I will try to get you information you need or direct you to someone who can.  I am always happy to meet up for a coffee or a meal when I am in Oxford or London so let’s stay in touch.

As a group we can think of great ways to grow Evidence-Based Health Care so your ideas are definitely wanted. As your rep I take those ideas and present them to key people or at meetings so our voice is heard. Oxford has been very responsive and we can now apply for CUREC ethics by email and take workshops tailor made to our DPHILs.  We have a place where we can have a page that shows us as DPHIL students at the University of Oxford and where we can showcase our research progress. We are working on making publication in journals easier, getting digital copies of past thesis plus providing some alternatives to WebLearn or at least making it easier to use. We have started to hold alumni weeks twice a year where we present, get skills training and just have fun with each other. In the next year we want to provide more advance notice to events and work on ways that we can grow EBHC as a powerful group above and beyond our DPHILs.

Roger Bailey – New Student Representative for the MSc Programme
I am delighted to be able to join Lawrence [Dawson] as a student representative for the MSc in EBHC course. My background is as a medical General Practice principal. I now work in Northamptonshire and Bedfordshire as a part-time GP, an appraiser of GP Continuing Professional Development, and in Medical Law with the Judiciary. I have previously studied at Charing Cross Hospital Medical School (now part of Imperial College, London), the University of Durham and the University of Manchester Law School. My childhood was spent following my seafaring father around the world, and my wife and I have spent some time living and working overseas and have enjoyed experiencing other cultures and languages. I also enjoy bridge, tennis and skiing. I look forward to meeting you all and getting to know you, and to working with Lawrence to represent you and your views at the Program/Course Committee meetings and with the Course Director and course organisers, and representatives of the Departmental Committees.

Second Cohort of AHSN Fellows Join MSc in EBHC Programme
Six more Academic Health Science Network (AHSN) Fellows join the seven who began last academic year to become Masters in Evidence-Based Health Care. Their journey has been made possible through a unique collaboration between the Oxford AHSN, Health Education Thames Valley and the Centre for Evidence-Based Medicine.

See here for more information about this year’s cohort and here for information about the students who began last year. More information about the Fellowship can be found here. The recruitment process for the third intake begins next month.

Review of The History & Philosophy of Evidence-Based Health Care
Student Michael Wilde, recipient of The History & Philosophy of Evidence-Based Health Care Career Enhancement Scholarship 2014-15, has written a review of the course in The Reasoner — a monthly digest “highlighting exciting new research on reasoning, inference and method broadly construed”.

Michael writes, “It was an informative and enjoyable week, and I recommend it to those interested in the philosophy of evidence-based medicine.” Read here for his full account in the July 2015 edition of The Reasoner.

Clinical Trial Management Module – Recommended by student Lucia Ramirez-Montesinos
Recipient of the Clinical Trial Management Career Enhancement Scholarship in 2014-15 Lucia Ramirez-Montesinos has this to say about the course:

I would recommend this course to my colleagues if they are looking for a course about the management of clinical trials and especially if they want to know more about the regulations involved in clinical trials, in particular clinical trials of medicinal products.

I have found the course very interesting as a whole but if I had to choose one single aspect of it, I would say that what was most useful and interesting to me was learning about all the regulations involved in conducting trials. Most importantly, knowing where to find the regulations required for your particular trial. I think it is important to know where to find this information as it is very difficult to know all the regulations for every possible trial. As long as you know the principles and where to find the specific regulations that your study needs to address, that is enough. This was well covered in the course.

I have learnt many things through the lectures as well as the homework (Good Clinical Practice course) and assignment. I am already using some of the skills learnt in my own PhD study. For example, I am now writing the protocol to submit and I am aware of all the documents that I need to submit. In the future and as part of my clinical practice I think that once I finish my PhD and with the help of this course I will be able to give advice and offer consultancy work in how to manage clinical trials in my field, Midwifery.

See Upcoming Modules below for more information about the Clinical Trial Management module taking place in April 2016.

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Introduction to Statistics for Health Care Research

18 January – 26 March 2016

Take your first steps to unlock the power of statistics

Closing date for applications is 5pm Friday 18th December 2015.

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