1. Speaker ：R1吳師豪 Supervisor：VS吳孟書 2008-08-27
Journal reading
Speaker ：R1吳師豪
Supervisor：VS吳孟書

2. Randomized controlled trial of asthma education after discharge from an emergency department
MSR Khan, et al.
J. Paediatr. Child Health
(2004)40, 674–677
Sydney Children’s Hospital at Randwick,
Sydney, New South Wales, Australia

3. Meta-analysis Forest plot
The Evidence Pyramid
Animal research
In vitro (test tube) research
Case series/ Reports
Ideas, Editorials, Opinions
Case Control Studies
Cohort studies
Randomized Controlled
Studies
Randomized Controlled Double Blind Studies
Meta - analysis
Meta-analysis Forest plot
Hierarchy of evidence that arranges study designs by their susceptibility to bias.

4. Grade of Recommendation Level of Evidence Therapy
Systemic review of RCTs 1b
Single RCT 1c
‘All-or-none’
[B] 2a
Systemic review of cohort studies 2b
Cohort study or poor RCT 2c
‘Outcomes’ research 3a
Systemic review of case-control studies 3b
Case-control study
[C] 4
Case series
[D] 5
Expert opinion, physiology, bench research
Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. David L. Sackett, Sharon E. Straus, W. Scott Richardson, William Rosenberg, R. Brian Haynes. Churchill Levingstone. 2000, p

5. Background (1)
The importance of patient education and recommend the use of written asthma action plans during exacerbations.
Lack of parental knowledge and lack of use of a written asthma action plan during an emergency has been associated with increased admissions and ED visits.

6. Background (2)
However, the Cochrane review by Haby and her colleagues of children who had attended the ED with asthma found that education to their parents or to them neither reduced subsequent ED visits, hospital admissions nor unscheduled doctor visits.

7. Background (3)
The aim of this study was to determine whether education provided by telephone soon after discharge from the ED with asthma improves asthma management and control.

8. Methods (1) Design and setting Time frame and Participants
This was a randomized, single blinded, controlled trial.
At the Emergency Department of Sydney Children’s Hospital
Time frame and Participants
16 October 2000 ~ 28 February 2002.

9. Methods (2) Inclusion Criteria: Exclusion criteria
Those who were discharged from the Emergency Department of Sydney Children’s Hospital with asthma
Exclusion criteria
Parents whose English was inadequate to complete the questionnaires and conduct the telephone consultation in English.

10. Methods (3) Information were collected at baseline and 6 months later
symptoms,
parental asthma knowledge,
parental quality of life and
use of asthma action plans and preventer therapy.

12. Methods (4)
The primary outcome measure was number of days of wheezing in the last 3 months.
Intermediate outcomes were
possession and use of a written asthma action plan during a crisis,
use of preventer medication,
increased asthma knowledge scores and
parental quality of life scores.

13. Methods (5) Other secondary measures were
number of visits to GP/paediatricians,
Number of attendances at ED and
admissions to hospital with asthma in the previous 6 months.

14. Methods (6) Comparisons were made using as appropriate. χ2
Mann–Whitney U,
Wilcoxon-signed rank, or
McNemar’s tests

15. Result (1) Baseline data:
50.3% of controls, 56.1% of intervention group with infrequent episodic asthma or a first attack.
54.2% in control and 57.4% in intervention had a written asthma action plan
The control group children were more likely to use preventers than the intervention group (55.5% vs 43.9%).

16. Results (2)

17. Result (3)

18. Results (4)

19. Results (5)

20. Conclusions
Reinforcement by telephone consultation did not improve the primary outcome of wheeze in the last 3 months.
However, it increased the possession and regular use of written asthma action plans in the intervention group.

21. Discussion Was the intervention ineffective?
It is possible that the large improvement in both groups represented a seasonal effect and that this might have swamped any possible positive effects.

22. Critical Appraisal Skills VIP
Valid: 研究方法的探討
Important: 結論的分析
Practice: 如何運用來照顧病人
RCT / Cohort study / Case-control study

23. Critically Appraising the Evidence-1
Validity (closeness to the truth)
Was the assignment of patients to treatment randomized? Yes
Was follow-up of patients sufficiently long and complete (follow-up > 80%) ? Yes
Were all patients analyzed in the groups to which they were randomized? Yes

24. Critically Appraising the Evidence-2
Were patients and clinicians kept blind to treatment? No, only single blind
Were groups treated equally, apart from the experimental therapy? Yes
Were the groups similar at the start of the trial? Yes

25. Critically Appraising the Evidence-3
Validity:
Selection bias: No
Information bias: No
Confounding: Inter-observer bias: No
Reliability of measurement:
Intra-observer: Yes
internal consistency Yes

26. Critically Appraising the Evidence-4
Impact (size of the effect, clinical importance
NNT (number needed to treat) = 1/ARR (absolute risk reduction)
NNH (number needed to harm) = 1/ARI (absolute risk increase)
Applicability (usefulness in our clinical practice)
Integrating the evidence with our clinical expertise and patients’ values and preferences.

27. 範例說明

28. Written asthma action plan between intervention and control patients
Control Event Rate ( CER) = 72.3%
Experimental Event Rate ( EER) = 87.5%
Relative Risk = 87.5%/72.3% = 1.21
Relative Risk Reduction = |1 – RR| = 0.21
Absolute Risk Reduction ( ARR)= |72.3% %| = 15.2%
Number Need to Treat( NNT) = 1/ARR = 1/1% = 6.58
Written asthma action plan
Present
Absent
Intervention group
119 17
Control group 94 36

29. Conclusion: Integrate with our clinical practice
Is reinforcement by telephone consultation efficacy for increased the possession and regular use of written asthma action plans in the intervention group ?
NNT: 6.58
(efficacy of written asthma action plan between intervention and control patients)

30. The primary outcome of wheeze in the last 3 months between intervention and control patients
Control Event Rate ( CER) = 2.31%
Experimental Event Rate ( EER) = 1.47%
Relative Risk = 1.47%/2.31% =
Relative Risk Reduction = |1 – RR| =
Absolute Risk Reduction ( ARR)= |2.31% %| = 0.84%
Number Need to Harm( NNH) = 1/ARR = 1/0.84% =
outcome of wheeze
Present
Absent
Intervention group 2
134
Control group 3
127

31. Conclusion: Integrate with our clinical practice
Is reinforcement by telephone consultation efficacy to improve the primary outcome of wheeze in the last 3 months in the intervention group ?
NNH: (negative)
(The primary outcome of wheeze in the last 3 months between intervention and control patients)

32. Thanks for your attention!!