Evidence-based Medicine Toolkit

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32 Evidence-based Medicine ToolkitOdds: what they are and why they’re usedIn measuring the efficacy of a therapy, odds can be used todescribe risk. The odds of an event are the probability of it occurringcompared to the probability of it not occurring. So, odds of 1means that an event has a 50/50 (or 50%) chance of occurring.Statisticians like odds because they are more amenable to metaanalytictechniques than other measures of risk.Is this odds ratio or relative risk clinically important?Because odds ratios and relative risks are relative measures of efficacy,they can’t tell us how many patients are likely to be helpedby the regimen. We need absolute measures of benefit to derivean NNT.To do this, we need to get an estimate of baseline risk (or odds),then multiply that by the relative risk (or odds ratio) from the review.For more help with this, see http://www.cebm.net and p. 74 onapplying the evidence to particular patients.Logarithmic oddsOdds ratios are usually plotted on a log scale to give an equal linelength on either side of the line of ‘no difference’. If odds ratios areplotted on a log scale, then a log odds ratio of 0 means no effect,and whether or not the 95% confidence interval crosses a verticalline through zero will lead to a decision about its significance.Binary or continuous dataBinary data (an event rate: something that either happens or not,such as numbers of patients improved or not) is usually combinedusing odds ratios. Continuous data (such as numbers of days, peakexpiratory flow rate) is combined using differences in mean valuesfor treatment and control groups (weighted mean differences orWMD) when units of measurement are the same, or standardizedmean differences when units of measurement differ. Here the differencein means is divided by the pooled standard deviation.
Appraising systematic reviews 33How precise are the results?The statistical significance of the results will depend on the extentof any confidence limits around the result (see p. 31). The reviewshould include confidence intervals for all results, both of individualstudies and any meta-analysis.Further readingAltman D. Practical Statistics for Medical Research. Edinburgh: ChurchillLivingstone, 1991.Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison ofresults of metaanalyses of randomized control trials and recommendationsof clinical experts. J Am Med Assoc 1992;268:240–8.Cohen M, Demers C, Gurfinkel EP et al. Low-molecular-weight heparins innon-ST-segment elevation ischemia: the ESSENCE trial. Efficacy and safetyof subcutaneous enoxaparin versus intravenous unfractionated heparin,in non-Q-wave coronary events. Am J Cardiol 1998;82(5B):19L–24L.Glasziou P. Systematic Reviews in Health Care: A practical guide. Cambridge:Cambridge University Press, 2001.NHS Centre for Reviews and Dissemination: http://www.york.ac.uk/inst/crd/Oxman AD, Cook DJ, Guyatt GH, for the Evidence-Based Medicine WorkingGroup. Users’ Guides to the Medical Literature VI: How to use an overview.J Am Med Assoc 1994;272(17):1367–71.Sackett DL, Straus SE, Richardson WS, Rosenberg WMC, Haynes RB. Evidence-BasedMedicine: How to practice and teach EBM, 2nd Edn. NewYork: Churchill Livingstone, 2000.Seers K. Systematic review. In: Dawes M, Davies P, Gray A, Mant J, Seers K,Snowball R (eds) Evidence-Based Practice: A primer for health care professionals.Edinburgh: Churchill Livingstone, 1999, pp. 85–100.Antman EM, McCabe CH, Gurfinkel EP, Turpie AG, Bernink PJ, Salein D,Bayes De Luna A, Fox K, Lablanche JM, Radley D, Premmereur J, BraunwaldE. Enoxaparin prevents death and cardiac ischemic events in unstableangina/non-Q-wave myocardial infarction. Results of the thrombolysisin myocardial infarction (TIMI) 11B trial. Circulation 1999;100(15):1593–601.
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