A systematic review of interventions for children with cerebral palsy: state of the evidence Rohini R Rattihalli 19.11.13
Why this paper Relevant to practice Good learning points re: practical aspects of EBM
Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence Treatment benefits: Systematic review of randomized trials or n-of-1 trials Randomized trial or observational study with dramatic effect Non-randomized controlled cohort/follow-up study Case-series, case-control studies, or historically controlled studies Mechanism-based reasoning
Grading of Recommendations, Assessment, Development and Evaluations (GRADE) GRADE score: high (4), moderate (3), low (2), or very low quality (1 or less) Quality of evidence on • outcome of interest • in our population of interest. Initial score based on type of evidence +4 RCTs/ SR of RCTs, +/– other types of evidence +2 Observational evidence (e.g., cohort, case-control)
Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Quality: Based on Blinding and allocation process, Follow-up and withdrawals, Sparse data, Other methodological concerns (e.g., incomplete reporting, subjective outcomes) 0 No problems –1 Problem with 1 element –2 Problem with 2 elements –3 Problem with 3 or more elements Similar +/- regarding Consistency, Directness, Effect size
ICF World Health Organization’s International Classification of Functioning, Disability and Health Classification of health and health-related domains body functions and structure (BF), activity (A) Participation (P), environmental factors (E), Personal factors (P)
Background: Interventions in CP 40% no reported evidence- based 20% ineffectual, unnecessary, or harmful.
Methods Inclusion criteria • Level 1 preferred • Level 2 to 4 only if • No level 1 • New level 2 after most recent level 1 Full search strategy available on request
CASP • Did the review ask a clearly focused question? • Clear, but not focused (but this was intentional) 2. Did the authors look for the appropriate sort of papers? • Full description of search strategy not available in the paper, but assumed to be “yes”.
CASP 3. Do you think important relevant studies were included? • Yes (assumed) 4. Did the review’s authors do enough to assess the quality of the included studies? • Yes (GRADE recommendations) 5. If the results of the review have been combined, was it reasonable to do so? • NA
CASP 6. What are the overall result of the reviews? • Majority of the interventions in CP were “Amber”. This was mainly due to no sufficient evidence. 7. How precise are the results? • Precise within the constraints of information available to the authors.
CASP 8. Can the results be applied to the local population? • Yes 9. Were all important outcomes considered? • Yes (and divided as per WHO International Classification of Functioning) 10. Are the benefits worth the harms and costs? • NA
Bottom line • Green and Red interventions helpful, but majority of interventions are Amber: • Evidence of inadequate effect OR Lack of evidence • What is the realistic possibility of having Level 1, Strong High quality, strong recommendation evidence for all interventions? So what is the solution?