Introduction to Clinical

Introduction to Clinical Epidemiology

Epidemiology
•Module
Module
Introduction 1 –2: Video
to 5Clinical
| Video 2: Asking
Critical appraisal Questions
of RCTs – Was there a fair start?

Epidemiology
Module 10| Video 1: Overuse and
underuse of medical services

Presented By SYDNEY MEDICAL SCHOOL

Dr Fiona Stanaway | Fiona.Stanaway@Sydney.edu.au

SYDNEY MEDICAL SCHOOL

DrDrFiona
Fiona Stanaway
Stanaway
Fiona.Stanaway@sydney.edu.au
Fiona.Stanaway@sydney.edu.au

1
Overuse and underuse
– What do we mean?
Overuse
- Inappropriate or unnecessary
- Harms > Benefits
- Can be: Overtesting
Overtreatment
Underuse
- Failure to deliver medical services
that have proven effectiveness
- Benefits > Harms

Figure 2

The Lancet DOI: (10.1016/S0140-6736(16)32585-5)

Copyright © 2017 Elsevier Ltd Terms and Conditions

2
The Lancet DOI: (10.1016/S0140-6736(16)32585-5)
Copyright © 2017 Elsevier Ltd Terms and Conditions

Overuse and underuse

Overuse
- Is common
- Exposes patients to unnecessary risks
- Wastes resources
Frequently coexists with underuse!

Underuse
- Can be due to delay in adopting
new evidence-based interventions

3
 Figure 3

The Lancet DOI: (10.1016/S0140-6736(16)30946-1)

Copyright © 2017 Elsevier Ltd Terms and Conditions

Reducing overuse and underuse

Know the evidence!
- Avoids use of tests or treatments
with evidence showing no benefit
- Increases adoption of new tests and
treatments

Stay up to date
- Evidence Alerts
(http://plus.mcmaster.ca/EvidenceAlerts)
- Trip Database (tripdatabase.com)

4
Reducing overuse and underuse
Consider benefit to harm trade-off
- Some tests and treatments have
clear universal benefit
- Some tests and treatments are
clearly ineffective
BUT. . . .
- For many tests and treatments
the benefit to harm trade off varies

Benefit to harm trade-off

for diagnostic tests

Testing Treatment
Happy to
threshold threshold
do Happy to
nothing treat

Patient
disease
probability

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Benefit to harm trade-off
for diagnostic tests
How serious is
Testing Treatment the disease?
threshold threshold
What is the
treatment like?

Patient values
and preferences

Baseline risk
of disease

Benefit to harm trade-off

for diagnostic tests

Testing Treatment
threshold threshold

Patient Better LR leads to

disease greater change
probability

6
 RR = 0.3

Control
Treatment
Incidence of stroke %

12
10
10
Risk difference
8 = 10 - 3 = 7%
6
4 3
3 = 0.3 x 10 Risk difference
2 1 = 1 - 0.3 = 0.7%
0.3
0 0.3 = 0.3 x 1

High risk Low risk

Greater benefit Less benefit

Patient values and preferences

- Have an impact on the benefit to harm
trade-off
- Clinicians are not good at guessing
what they are
- Discussing decisions with patients
helps avoid
• Providing aggressive therapy that is not
wanted
• Withholding therapy that the patient might
consider worthwhile