Epidemiological Research Designs

Epidemiological research is conducted to study the risk factors leading to disease or prevention (here, I use the word disease generically, as it could also mean a condition, such as low back pain). Epidemiologic designs are used because some questions cannot be answered by conducting clinical trials. For example, the best way to determine if smoking causes lung cancer would be to devise a clinical trial in which we randomize people into 2 groups, one who will smoke 3 packs of cigarettes per day for 5 years and one that does not smoke. At the end of the study, we could then compare cancer rates. But of course this is not ethical in any possible way. Rather, the epidemiological designs observe people as they live their lives, looking to see whether or not a risk factor may lead to a disease (or perhaps, in some case, to prevention. For example, does being active reduce the risk of heart disease).

There are three designs that are used in such studies. In order of increasing complexity, they are cross-sectional studies, case-control studies and cohort studies. They each work differently.

Cross-sectional studies: These look at the association of risk to disease. This kind of study is conducted at one point in time, the present. The most common form of cross-sectional study is a survey, in which we might ask a group of people if, for example, they have low back pain. Some percentage will say yes. We can also ask if they have a short leg. Some will say yes. What we cannot say is that these two are related in any way; this would require a more complex study. But we can demonstrate an association.

Case-control studies: Here, we begin with two groups of people in a population: those who have a condition of interest (i.e. cirrhosis) known as cases, and those who do not, known as controls. We then go “backward in time” reviewing their medical history to see if there is a higher exposure to a risk factor (i.e. heavy drinking) in the cases compared to the controls. In such studies, we can calculate an odds ration; that is, a comparison of the odds of developing a condition in the exposed group to the unexposed group. We cannot calculate risk because risk involves newly diagnosed cases, and we begin here with people already diagnosed.

Cohort studies: In the final and most complex kind of study, a cohort study follows a population of people forward in time to determine whether or not an exposure to a risk factor leads to a higher rate of a condition of interest. An example of a cohort study is the famous Framingham study, in which the people of Framingham, MA have been followed for nearly half a century to study the risk factors for cardiovascular disease. At the outset, no one has the condition; over time, as people live their lives, some will develop it. We then look at exposure to risk and compare the rate of disease in the group that was exposed to the group that was not. Because we are now looking for new diagnoses of disease, we can calculate actual risk rates and thus also a risk ratio: the risk of developing the condition in the exposed group divided by the risk in the unexposed group. This also allows us to determine incidence (number of new cases per population).

All of these designs are elegant in their own way, are less often seen in chiropractic, but are powerful tools for studying the relationship between risk and disease.

After Break Special: Three New Papers

Given we are all just returning from spring break, here are three new papers for you to peruse.

Oliver K, Innvar S, Lorenc T, Woodman J, Thomas J. A systematic review of barriers to and facilitators of the use of evidence by policymakers. BMC Health Services Research 2014, 14:2  doi:10.1186/1472-6963-14-2

ABSTRACT

Background: The gap between research and practice or policy is often described as a problem. To identify new barriers of and facilitators to the use of evidence by policymakers, and assess the state of research in this area, we updated a systematic review.

Methods: Systematic review. We searched online databases including Medline, Embase, SocSci Abstracts, CDS, DARE, Psychlit, Cochrane Library, NHSEED, HTA, PAIS, IBSS (Search dates: July 2000 - September 2012). Studies were included if they were primary research or systematic reviews about factors affecting the use of evidence in policy. Studies were coded to extract data on methods, topic, focus, results and population.

Results: 145 new studies were identified, of which over half were published after 2010. Thirteen systematic reviews were included. Compared with the original review, a much wider range of policy topics was found. Although still primarily in the health field, studies were also drawn from criminal justice, traffic policy, drug policy, and partnership working. The most frequently reported barriers to evidence uptake were poor access to good quality relevant research, and lack of timely research output. The most frequently reported facilitators were collaboration between researchers and policymakers, and improved relationships and skills. There is an increasing amount of research into new models of knowledge transfer, and evaluations of interventions such as knowledge brokerage.

Conclusions: Timely access to good quality and relevant research evidence, collaborations with policymakers and relationship- and skills-building with policymakers are reported to be the most important factors in influencing the use of evidence. Although investigations into the use of evidence have spread beyond the health field and into more countries, the main barriers and facilitators remained the same as in the earlier review. Few studies provide clear definitions of policy, evidence or policymaker. Nor are empirical data about policy processes or implementation of policy widely available. It is therefore difficult to describe the role of evidence and other factors influencing policy. Future research and policy priorities should aim to illuminate these concepts and processes, target the factors identified in this review, and consider new methods of overcoming the barriers described.

Kloek CJJ, Tol J, Veenhof C, van der Wulp I, Swinkels ICS. Dutch General Practitioners’ weight management policy for overweight and obese patients. BMC Obesity 2014, 1:2  doi:10.1186/2052-9538-1-2

ABSTRACT

Background: General practitioners (GPs) can play an important role in both the prevention and management of overweight and obesity. Current general practice guidelines in the Netherlands allow room for GPs to execute their own weight management policy.

Objective: To examine GPs’ current weight management policy and the factors associated with this policy.

Methods: 800 Dutch GPs were asked to complete a questionnaire in December 2012. The questionnaire items were based on the Dutch Obesity Standard for GPs. The data were analyzed by means of descriptive statistics and multiple linear regression analyses in 2013.

Results: In total, 307 GPs (39.0%) responded. Most respondents (82.9%) considered weight management as part of their responsibility for providing care. GPs aged <48 25="" 47.7="" a="" average="" bmi="" comorbidities="" compared="" dietitian="" discussed="" frequent.="" frequently="" gps="" is="" kg="" less="" m="" management="" moderately="" next="" obese="" of="" on="" or="" overweight="" patients.="" patients="" preferably="" professional="" refer="" reported="" sup="" the="" to="" weight-related="" weight="" with="" without="" years="">2

were less likely to refer obese patients. In addition, GPs who had frequent contact with a dietitian were more likely to refer obese patients. Conclusions: In the context of General Practice and preventive medicine, GPs’ discussion of weight and the variety of obesity-determinants with their moderately overweight patients deserves more attention, especially from younger GPs. Strengthening interdisciplinary collaboration between GPs and dietitians could increase the referral percentage for dietary treatment.

McClymont H, Gow J, Perry C. The role of information search in seeking alternative treatment for back pain: a qualitative analysis. Chiropr Man Ther 2014, 22:16  doi:10.1186/2045-709X-22-16

ABSTRACT

Background: Health consumers have moved away from a reliance on medical practitioner advice to more independent decision processes and so their information search processes have subsequently widened. This study examined how persons with back pain searched for alternative treatment types and service providers. That is, what information do they seek and how; what sources do they use and why; and by what means do they search for it?

Methods: 12 persons with back pain were interviewed. The method used was convergent interviewing. This involved a series of semi-structured questions to obtain open-ended answers. The interviewer analysed the responses and refined the questions after each interview, to converge on the dominant factors influencing decisions about treatment patterns.

Results: Persons with back pain mainly search their memories and use word of mouth (their doctor and friends) for information about potential treatments and service providers. Their search is generally limited due to personal, provider-related and information-supply reasons. However, they did want in-depth information about the alternative treatments and providers in an attempt to establish apriori their efficacy in treating their specific back problems. They searched different sources depending on the type of information they required.

Conclusions: The findings differ from previous studies about the types of information health consumers require when searching for information about alternative or mainstream healthcare services. The results have identified for the first time that limited information availability was only one of three categories of reasons identified about why persons with back pain do not search for more information particularly from external non-personal sources.

 

The Purpose and Processes of Evaluation

In Mary Weiner’s book “Learner-Centered Teaching” (1) there is a chapter that addresses the purpose and processes of evaluation. It notes that, as has always been the case, grading students is necessary and that students place great importance upon their grades. This is not surprising. But perhaps we need to look at this from a slightly different perspective: this may be an opportunity to help students learn. We should acknowledge the importance of grades, but harness their power to help in learning. To that end, Weimer offers some thoughts.

1.       First she suggests we harness the power of grades to motivate students. She notes that grades energize students. And she notes we can use that motivation for productive outcomes. We can do this be letting students know that learning matters more than grades. They still call the person who graduated last in your class “Doctor.” Meaning, later in life, whether you got an A or a B in a class may mean little.

2.       She next suggests we make the evaluation experience less stressful. The ability to harness grades to advance learning can be seriously diminished by increasing the stress associated with earning them. If I overhear one complaint in walking through the halls, it is about the stress people anticipate when facing certain examinations in the program. While stress can be good and useful for motivation, too much can be counterproductive to learning.

3.       She then states that evaluation should be used only to assess learning. It should not be used to help advance personal hidden agendas. An example of a hidden agenda is writing a harder test simply because you do not feel your students are taking your class seriously enough. If more than half a class fails an examination, it likely means the instructor is not doing a good job at explaining material, may not know how to write a good test, or that the test is simply be used for something other than enhancing learning.

4.       A final recommendation is to focus more on formative feedback. Are we suing our tests for this purpose. We may cover them in class, but are we doing so to meet a KPA or to truly help students understand what they missed and learn from that? How do we use the test to help them learn, fi we do not discuss it at all?

This is just food for thought and another way to look at an important question.

References

1.       Weimer M. Learner-centered teaching, second edition. San Francisco, CA; JOssey-Bass, 2013

New from Biomed Central

Nousiainen P, Merras-Salmio L, Aalto K, Kolho K. Complementary and alternative medicine use in adolescents with inflammatory bowel disease and juvenile idiopathic arthritis. BMC Compl Alternative Med 2014, 14:124 doi:10.1186/1472-6882-14-124

ABSTRACT

Background: The use of complementary alternative medicine (CAM) is potentially prevalent among paediatric patients with chronic diseases but with variable rates among different age groups, diseases and countries. There are no recent reports on CAM use among paediatric patients with inflammatory bowel disease (IBD) and juvenile idiopathic arthritis (JIA) in Europe. We hypothesized that CAM use associates with a more severe disease in paediatric IBD and JIA.

Methods: A cross-sectional questionnaire study among adolescent outpatients with IBD and JIA addressing the frequency and type of CAM use during the past year. The patients were recruited at the Children's Hospital, University of Helsinki, Finland.

Results: Of the 147 respondents, 97 had IBD (Crohn's disease: n = 46; median age 15.5, disease duration 3.4 years) and 50 had JIA (median age 13.8, disease duration 6.9 years). During the past 12 months, 48% regularly used CAM while 81% reported occasional CAM use. Compared to patients with JIA, the use of CAM in IBD patients tended to be more frequent. The most commonly used CAM included probiotics, multivitamins, and mineral and trace element supplements. Self-imposed dietary restrictions were common, involving 27.6% of the non-CAM users but 64.8% of all CAM users. Disease activity was associated with CAM use in JIA but not in IBD.

Conclusions: CAM use is frequent among adolescents with IBD and JIA and associates with self-imposed dietary restrictions. Reassuringly, adherence to disease modifying drugs is good in young CAM users. In JIA, patients with active disease used more frequently CAM than patients with inactive disease. As CAM use is frequent, physicians should familiarise themselves with the basic concepts of CAM. The potential pharmacological interaction or the toxicity of certain CAM products warrants awareness and hence physicians should actively ask their patients about CAM use.

Muller A. Teaching lesbian, gay, bisexual and transgender health in a South African health sciences faculty: addressing the gap. BMC Med Educ 2013, 13:174 doi:10.1186/1472-6920-13-174

ABSTRACT

Background: People who identity as lesbian, gay, bisexual and transgender (LGBT) have specific health needs. Sexual orientation and gender identity are social determinants of health, as homophobia and heteronormativity persist as prejudices in society. LGBT patients often experience discrimination and prejudice in health care settings. While recent South African policies recognise the need for providing LGBT specific health care, no curricula for teaching about LGBT health related issues exist in South African health sciences faculties. This study aimed to determine the extent to which LGBT health related content is taught in the University of Cape Town’s medical curriculum.

Methods: A curriculum mapping exercise was conducted through an online survey of all academic staff at the UCT health sciences faculty, determining LGBT health related content, pedagogical methodology and assessment.
Results: 127 academics, across 31 divisions and research units in the Faculty of Health Sciences, responded to the survey, of which 93 completed the questionnaire. Ten taught some content related to LGBT health in the MBChB curriculum. No LGBT health related content was taught in the allied health sciences curricula. The MBChB curriculum provided no opportunity for students to challenge their own attitudes towards LGBT patients, and key LGBT health topics such as safer sex, mental health, substance abuse and adolescent health were not addressed.

Conclusion: At present, UCTs health sciences curricula do not adequately address LGBT specific health issues. Where LGBT health related content is taught in the MBChB curriculum, it is largely discretionary, unsystematic and not incorporated into the overarching structure. Coordinated initiatives to integrate LGBT health related content into all health sciences curricula should be supported, and follow an approach that challenges students to develop professional attitudes and behaviour concerning care for patients from LGBT backgrounds, as well as providing them with specific LGBT health knowledge. Educating health professions students on the health needs of LGBT people is essential to improving this population’s health by providing competent and non-judgmental care.

Clar C, Tsertsvadze A, Coiurt R, Lewando Hundt G, Clarke A, Sutcliffe P. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies 2014, 22:12 doi:10.1186/2045-709X-22-12

ABSTRACT

Background: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive? or 'negative? evidence rating or were not covered in the report.

Methods: A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

Results: 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive? or 'moderate? evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

Conclusions: Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

 

Videos for Online Teaching

This term I have begun adding videos to my course on evidence-based chiropractic practice. I know this is not a radical idea, and the videos I am using come from youtube, where there are a plethora of useful clips available. But today, as our students evolve and as technology develops, online content is becoming more and more important. Blending in-class work with online content, the blended classroom model, is becoming more important. And now it is easier than ever to create your own videos, so they can be precisely made for your course. You need not simply select youtube clips.

First, we need- and I as guilty of this as anyone- to move away from PowerPoint slides using bullet points. I know that I can read faster than you can talk, so I have already read the slide before you are done discussing it. Instead, think of people whose presentations resonate with you. Often, they do not use word slides, but graphic slides. Think TED talks, for example.

If you do intend to use videos, they must serve the educational purpose of the class. They require some consideration to make them work effectively at transmitting their ideas, points and concepts. A vide clip needs to have a purpose and it has to be a purpose a student understands.  An article by John Orlando in the new issue of Online Cl@ssroom (1) suggests that you limit videos to no more than 5-10 minutes, since any longer will have your students losing interest.  In this case, we could create a video that has a voiceover talking over a set of images. This might allow students to take the main points of your classroom lecture home to replay as needed. Orlando suggests you create the audio first, either scripted or not, and for which you should speak in an animated but normal voice. He suggests the use of Audacity as a free, open-source program for recording audio (http://audacity.source-forge.net.download/). You can save the voice file as an mp3 or wav file.

Now you can move to a video editor to make the actual clip. There are several you might consider using. One is youtube’s own editor (www.youtube.com/watch?v=A3ypVoN4NVM&feature=youtu.be), another is WeVideo (www.wevideo.com/) and the last is Camtasia, which we have access to here on campus. These programs will allow you to add graphic images to play under your recorded audio. The images you select should be ones that resonate with the watcher, and there are many free sites where you can obtain such images.

Clearly, there is more here than meets the eye. A fine book that I think provides a good overview of creating resonant slides is by Reynolds, “Presentation Zen.” (2)

References

1.       Orlando J. Using videos for online teaching. Online Cl@ssroom 2014;14:4-5

2.       Reynolds G. Presentation Zen. Berkeley, CA; New Riders, 2008

ACC-RAC 2014

Below is a sumamry of Palmer College personnel involvment in ACC-RAC. Once again, we did a superb job of representing our college.

Plenary

Dennis Marchiori. Opening and welcome

 Platform

Prize Paper: William Reed, Randall Sozio, Joel Pickar, Cynthia Long. Spinal manipulation can increase trunk mechanical thresholds of lateral thalamic neurons

Prize Paper: Rodger Tepe, Chabha Tepe. Development of psychometric evaluation of an information literacy self-efficacy survey and an information literacy knowledge test.

Heather Bowyer, Melissa Ferranti, Michelle Gingras, Philip Afghani. Student understanding and attitudes toward proper documentation, billing practices, and medico-legal concepts in chiropractic clinical education

Anna Walden, Stacie Salsbury, William Reed, Dana Lawrence. Self-reported bladder and bowel symptoms among adults attending an academic chiropractic clinic: a 1-month point-prevalence study

Prize Paper: Niu Zhang, Charles Henderson. Can formative quizzes improve summative exam performance?

John Stites, Greg Snow, Healther Bowyer, Robert Rowell, Tammi Clark, Barbara Mansholt, Kimberly Keene. Development of an introductory program for field practitioners on evidence-based clinical practice

Makani Lew. Time to numbness in response to five different cyrotherapy applications
Makani Lew. Comparison of subjective and objective pain sensitivity in a healthy population

John Stites, Greg Snow, Heather Bowyer, Robert Rowell, Tammi Clark, Barbara Mansholt, Kimberly Keene. Development of an introductory program for field practitioners on evidence-based clinical practice

Robert Cooperstein, Morgan Young. The location of the upright inferior angle of the scapula in relation to the spine: a systematic review of the literature
Robert Cooperstein, Anthony Lisi, Andrew Burd. Manual therapy approaches to over-active bladder: a narrative literature review

Maruti Ram Gudavalli, Robert Vining, Stacie Salsbury, Christine Goertz. Training doctors of chiropractic in delivering manual cervical traction forces

Barbara Mansholt, Robert Vining. Survey of clinical decision-making rationale for chiropractic analysis procedures among doctors of chiropractic and students

Dan Weinert, Dustin Derby, Kevin Paustian. Impact of unionization on faculty resistance to change, justice, trust, conflict and climate for innovation

Elissa Twist, Dana Lawrence, Stacie Salsbury, Cheryl Haw. Do informed consent documents for chiropractic clinical research studies meet readability level recommendations and contain required elements: a descriptive study

Christopher Roecker, Cynthia Long, Robert Vining, Dana Lawrence. Attitudes and use of evidence-based clinical practice within chiropractic: a survey of doctors of chiropractic with diplomate training on orthopedics

Roger Hynes, Alana Callender, Rachelle Hynes, Don Gran. Preceptor doctors’ assessment of the clinical skills of Palmer College externs

Marsha Hardacre. Student confidence level of preparedness and alumni performance level of preparedness for business success

Dustin Derby, Amy Everetts, Julie Schard, Charles Davis. Transformations abroad: transformative learning captured within a chiropractic humanitarian program

Barbara Mansholt, Robert Vining. Factors affecting treatment decisions during the first phase of clinical education

 Shawn He. The comparison of the validity and reliability between digital radiographic imaging systems and manual method in measuring the Cobb angle

Christopher Roecker. Diagnosis and management of myofascial pain: a narrative review of the literature

Liang Zhang. Physiological TNF may mediate spinal manipulation therapy: a literature re-examination

Poster

Robert Cooperstein, Anthony Lisi Lis, Andrew Burd. Overactive bladder in association with symphysis pubis subluxation: a novel mechanical approach

Dustin Derby. How do you assess cocurriculars? An assessment framework part and parcel for institutional effectiveness.

James DeVocht. Extracting information from visually identified points on excel plots

 Stephen Grand, Kenice Grand, Rod Floyd, Shane Carter. Chiropractic intern attitudes, beliefs, and intentions with regard to health promotion, wellness, and preventive services

Kenice Grand, Stephen Grand. Can vegans have healthy bones?

Todd Hubbard, Kali Gillen. Correlation between the fossa temperature difference and the Blair upper cervical atlas misalignment

Katie Malley, Matthew Richardson, Marie Williams, Leila McKenzie. Calcinosis cutis in the foot of a 26 year old retired female competitive ice skater: a case report

Henry Mueller, Laurie Mueller. Integrating functional medicine methodologies in the chiropractic clinical setting to improve outcomes for a patient with diabetes, obesity, high blood pressure, chronic sinusitis, and adult onset asthma: a case study

Dewan Raja, Bahar Sultana. Frozen shoulder, its pathogenesis, natural course, and treatment modalities

Robert M. Rowell, Kathy Murphy, Linda Carlson, Jody Bell. Does video use by students in an X-ray positioning class improve performance? A pilot study and survey of student attitudes

Michael Tunning, Michael VanNatta, Robert Rowell, Thomas Brozovich. A survey of student perceptions following 2 different formats for neuromusculoskeletal skills assessment

Michael VanNatta, Thomas Brozovich, Michael Tunning. Enhancing learning for students with the addition of podcasts

Morgan Young, Jessie Young. Conservative care for pediatric acquired torticollis: two cases of muscular origin

Workshop

John Stites, Ron LeFebvre, Bill Watson. The Art of Facilitation: Making Teams Effective

Alberto L. Rivera-Rentas, Mitch Hass, Cynthia Long Research-Training and Career Development Opportunities for Individuals and Institutions in the Chiropractic Profession

Judy Bhatti, Michael Van Natta, Mary Frost, Paul Wanless, Tom Brozovich, Michael Tunning. Leadership in the classroom: reaching students through web-based technology

Lisa Bloom, Karen Bobak, Ezra Coehn, Lisa Killinger. Leadership strategies for ethical decision making

Brian Gleberzon, Charles Blum, Christopher Roecker, Scott Cuthbert, David Sikorski. The interface between clinical practice and clinical research in chiropractic technique: bridging the gap between knowledge transfer and knowledge utilization

Teresa Brennan, James LaRose, Troy Tatum, Eva Elsangak. Engaging the learner in critical thinking: team-based learning model for use on Monday

Stu Kinsinger, Dana Lawrence. Professional ethics and academic dishonesty: approaches to disclipline

Learning Management Systems: An Update

Over the past few months, I have been engaged in leading an ad hoc committee that is examining possible learning management systems (LMS) for the entire college community, across all campuses. Our committee began its work by asking other faculty members about what kinds of things they would like to see in an LMS. From that, we began looking at many different vendors, to see if those systems had the capabilities our faculty wanted. In addition, the committee includes members of CTL and IT from all campuses, since clearly IT infrastructure is one key element of the decision process.

Based on the initial work we did, we narrowed our field down to three companies to look at in more detail. This remains in process, and could clearly change as we learn more, but if you wish to look at some information about these companies you can do so at:

Canvas: www.instructure.com

Desire2Learn: www.desire2learn.com

BlackBoard: www.blackboard.com

I believe all three sites have trial sites where you can look around and get a sense of the possibilities.

This is a short post for this week, as many people will be leaving for ACC-RAC later this week. I will be one of them.