Introduction to Research: Introduction to Research: What is it? What is it?

Why should homeopathic clinicians care? Why should homeopathic clinicians care?

Janet Kahn, PhD, LMT Janet Kahn, PhD, LMT

6th Annual Joint American Homeopathic Conference

April 8th, 2011

Alexandria, VA

AgendaAgenda Review the meaning of evidence-based practice and how to Review the meaning of evidence-based practice and how to

apply research to your clinical practiceapply research to your clinical practice

Define ResearchDefine Research

Explore types of research and uses of eachExplore types of research and uses of each

Explore how clinicians can engage in meaningful researchExplore how clinicians can engage in meaningful research Clinical case reportsClinical case reports Basic quantitative researchBasic quantitative research

Generate research topics from your clinical experience and learn how to turn them into researchable questions

?????? ?????? Your Questions Your Questions ????????????

Evidence-based practiceEvidence-based practice

Sackett et al. (2000) offered a tripartite structure for EBP saying, “Evidence based medicine is the integration of best research evidence with clinical expertise and patient values.”

So what is the best research evidence??

What is research?What is research?

Systematic inquiry…Systematic inquiry…using orderly, agreed using orderly, agreed upon methods toupon methods to

answer questions, answer questions, test hypothesestest hypotheses solve puzzles, solve puzzles, learn more about something, learn more about something, generate theorygenerate theory

Why research important to homeopathy?Why research important to homeopathy?

Uses for an individual clinician – Uses for an individual clinician – e.g. best e.g. best practices, successful marketing techniques…practices, successful marketing techniques…

Uses for the profession as a whole – Uses for the profession as a whole – Surveys, Surveys, insurance claims research…insurance claims research…

Uses for other types of clinicianUses for other types of clinician Uses for patientsUses for patients Uses for policymakers – Uses for policymakers – CERCER

Its all about the questionIts all about the question

What do you want to know?What do you want to know?

How do you plan to use the information?How do you plan to use the information?

Now, what do you really want to know?Now, what do you really want to know?

Types of ResearchTypes of Research

2 basic types of research2 basic types of research

Quantitative QualitativeQuantitative Qualitative

Deals with things that can be measured

Experimentation Observation

Deals with meaning and processes

Types of Quantitative ResearchTypes of Quantitative Research

SurveysSurveys Basic Science (bench science)Basic Science (bench science) Clinical trials – including CERClinical trials – including CER Literature ReviewsLiterature Reviews Case ReportsCase Reports

Survey – non-experimental research that focuses on obtaining Survey – non-experimental research that focuses on obtaining information about activities, beliefs, attitudes, etc. of people information about activities, beliefs, attitudes, etc. of people through direct questioning.through direct questioning.

Unconventional medicine in the United States. Prevalence, costs, and patterns of use. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. N Engl J MedN Engl J Med. 1993 Jan 28;328(4):246-52. 1993 Jan 28;328(4):246-52. .

Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RCKessler RC. . JAMAJAMA. 1998 Nov 11;280(18):1569-75. . 1998 Nov 11;280(18):1569-75.

Courses involving complementary and alternative medicine at US medical schools. Wetzel MS, Eisenberg DM, Kaptchuk TJ. Wetzel MS, Eisenberg DM, Kaptchuk TJ. JAMAJAMA. 1998 Sep 2;280(9):784-7. . 1998 Sep 2;280(9):784-7.

Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Cramer E, Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Cramer E, Milliman B, Booker J, Mootz R, Barassi J, Kahn JR, Kaptchuk TJ, Eisenberg Milliman B, Booker J, Mootz R, Barassi J, Kahn JR, Kaptchuk TJ, Eisenberg DM. DM. J Am Board Fam Pract. 2002 Sep-Oct;15(5):378-90.

Clinical TrialClinical Trial

An experiment designed to test the An experiment designed to test the safety / safety / effectiveness / efficacy / cost / etc.effectiveness / efficacy / cost / etc. of a of a specific treatment (or intervention).specific treatment (or intervention).

Key design issues focus on the Key design issues focus on the intervention, intervention, the expected outcomes, the expected outcomes, populationpopulation other important factors (variables).other important factors (variables).

EfficacyEfficacy - - In a healthcare context, efficacy indicates the capacity for beneficial change (or therapeutic effect) of a given intervention (e.g. a medicine, medical device, surgical procedure, or a public health intervention) under controlled conditions.

EffectivenesEffectivenesss is the capacity for beneficial change under typical conditions of practice – or real world effectiveness.

Comparative Effectiveness ResearchComparative Effectiveness Research (CER) (CER) is the direct comparison of existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. The core question of comparative effectiveness research is which treatment works best, for whom, and under what circumstances.

RCTRCT

Brigo B, Serpelloni G, Homoeopathic Treatment of Migraine Berlin Journal on Research in Homoeopathy, 1, 2, March, 1991, 98-106. In this randomised, placebo controlled double blind study, 60 people suffering from migraine were treated using constitutional homoeopathy over a period of 4 months. Those patients in the control group experienced a reduction in migraine frequency from 9.9 attacks per month to 7.9 per month, while those in the treatment group reduced their monthly attack rate from 10 to between 1.8 and 3 per month.

Literature ReviewsLiterature Reviews

Narrative ReviewNarrative Review Meta-analysis Meta-analysis Systematic ReviewSystematic Review

Meta-analysisMeta-analysis A technique for quantitatively combining and thus A technique for quantitatively combining and thus

integrating the results of multiple studies on a given integrating the results of multiple studies on a given topic.topic.

Very challenging to do because…Very challenging to do because…

Barnes J., Resch K-L., Ernst E. Homoeopathy for Post-Operative Ileus: A Meta-Analysis. Journal of Clinical Gastroenterology, 1997, Dec, 25, 4, 628- 633. 7 separate trials examining the effects of homoeopathic treatment for post-operative ileus after abdominal or gynaecological surgery when compared with placebo, specifically, for the time to first flatus after surgery. Subsequent analysis showed that homoeopathy provided superior results to placebo.

Systematic ReviewSystematic Review

A summary of the literature on a particular topic, using A summary of the literature on a particular topic, using explicit methods to perform a explicit methods to perform a thorough literature searchthorough literature search and and critical appraisal of individual studiescritical appraisal of individual studies and and appropriate statistical techniques to combineappropriate statistical techniques to combine the valid the valid studies. studies.

www.cochrane.org/reviews

Kassab S, Cummings M, Berkovitz S, van Haselen R, Fisher P. Homeopathic Medicines for Adverse effects of Cancer Treatments. Cochrane Database Systematic Review. 2009 Apr 15;(2):CD004845.

Research about researchResearch about research

Refining the methodsRefining the methods Investigating researcher effectsInvestigating researcher effects Etc.Etc.

Journal of Bodywork and Movement Therapies (]]]]) ], ]]]–]]]

The attitudes toward massage (ATOM) scale: Reliability, validity, and associated findingsChristopher A. Moyer, Ph.D.a,, James Rounds, Ph.D.b Summary: Despite the key role of attitudes in guiding behavior, no systematicexamination of attitudes toward massage has been conducted and no standardassessments have been created. We developed the attitudes toward massage (ATOM) scale, a nine-item measure of an overall attitude toward massage that includes two distinct subscales assessing the attitudes of Massage as Healthful and Massage as Pleasant. These subscales are reliable (a4.70 and 4.80, respectively), covary with major personality traits and dispositional sensitivities, and are positively correlated with broader attitudes toward complementary and alternative medicine. Clinical evidence suggests that these attitudes change in response to receiving massage, though further research is needed. Supplemental items administered with the ATOM illustrate a general preference for female massage therapists while also showing this preference to be stronger in men. Attitudes pertaining to massage and sexual arousal, which may stand in the way of trying massage for some persons, are also examined. With or without the supplemental items, the ATOM scale is an easily administered measure for assessing attitudes toward massage that can be used in research or practice settings.

Quantitative researchQuantitative research

It’s It’s all about the question, all about the question, a a theorytheory, ,

specific specific hypotheseshypotheses, and , and relationships between relationships between variablesvariables

Theory – an abstract generalization that presents a Theory – an abstract generalization that presents a systematic explanation (often not yet fully tested) systematic explanation (often not yet fully tested) about relationships among phenomena.about relationships among phenomena.

Hypothesis – a statement of predicted relationships Hypothesis – a statement of predicted relationships between variablesbetween variables

VariablesVariables

An attribute of a person or object that varies An attribute of a person or object that varies (takes on different values). Almost anything (takes on different values). Almost anything can be a variable:can be a variable: Physiological characteristicsPhysiological characteristics – weight, blood – weight, blood

pressure, soft tissue elasticity, degree of allergic pressure, soft tissue elasticity, degree of allergic response to goldenrod…response to goldenrod…

BehaviorBehavior – average daily caffeine intake, seat belt – average daily caffeine intake, seat belt usage, hours spent sleeping, charitable donation usage, hours spent sleeping, charitable donation patterns…patterns…

AttitudesAttitudes – views on CAM, support for health care – views on CAM, support for health care reform, preference for spicy or non-spicy food…reform, preference for spicy or non-spicy food…

Places and things also have variablesPlaces and things also have variables

% of US households using OTC homeopathic % of US households using OTC homeopathic remedies for pediatric applicationsremedies for pediatric applications

# of rainy days per year Alexandria, VA# of rainy days per year Alexandria, VA

Research inquires about the relationship between Research inquires about the relationship between variablesvariables and and good research inquires about the good research inquires about the relationships between well-chosen and well-relationships between well-chosen and well-defined variablesdefined variables..

Kinds of VariablesKinds of Variables

ContinuousContinuous – values can be represented on a – values can be represented on a continuum, e.g. agecontinuum, e.g. age

DiscreteDiscrete – have a finite number of values – have a finite number of values between any two points, e.g. the number of between any two points, e.g. the number of children you havechildren you have

CategoricalCategorical – have a small number of values – have a small number of values that do not inherently represent a quantity, e.g. that do not inherently represent a quantity, e.g. gender.gender.

Clinical Case ReportsClinical Case Reports

A case report is a systematic, in-depth A case report is a systematic, in-depth description and discussion of a single case. description and discussion of a single case.

Functions of a Case ReportFunctions of a Case Report It can call attention to something new, surprising, It can call attention to something new, surprising,

unexplained …unexplained … Identification of AIDS began with the case report of a single

unexplained case of Kaposi’s Sarcoma in a young man.

A case report is a teaching toolA case report is a teaching tool A case report is a time-honored tool of medical education, from daily A case report is a time-honored tool of medical education, from daily

ward presentations to grand rounds to published clinical case reports. ward presentations to grand rounds to published clinical case reports. Through having to report on cases they have admitted to hospital, new Through having to report on cases they have admitted to hospital, new residents learn to observe carefully and report accuratelyresidents learn to observe carefully and report accurately

A clinical case report is form of conversationA clinical case report is form of conversation Through it, one clinician speaks to others about what s/he has noticed Through it, one clinician speaks to others about what s/he has noticed

and believes is important. It is an integral part of medical culture, and believes is important. It is an integral part of medical culture, relied upon “...to enrich professional experience, relied upon “...to enrich professional experience, lead to better clinical lead to better clinical reasoning,reasoning, and prompt further research.” (Milos Jenicek, Clincial Case and prompt further research.” (Milos Jenicek, Clincial Case Reporting in Evidence-based Medicine, 1999, p7.)Reporting in Evidence-based Medicine, 1999, p7.)

Why is a Case Report Why is a Case Report Not an Anecdote?Not an Anecdote?

A clinical case report advances knowledge A clinical case report advances knowledge through:through: careful description, careful description, relevant detail, relevant detail, a thorough literature search, a thorough literature search, a compelling rationale, and a compelling rationale, and by analyzing potential implications for decision by analyzing potential implications for decision

making in clinical practice.making in clinical practice.

What is the Purpose of What is the Purpose of a Case Report?a Case Report?

Case reports also help advance knowledge by:Case reports also help advance knowledge by:

generating new theories and hypothesesgenerating new theories and hypotheses refuting old theories and hypothesesrefuting old theories and hypotheses recognizing and describing new diseases/conditions or …recognizing and describing new diseases/conditions or … novel treatment approachesnovel treatment approaches unusual or confusing combinations of conditions or eventsunusual or confusing combinations of conditions or events unusual or unexpected outcomesunusual or unexpected outcomes adverse responsesadverse responses personal impactpersonal impact

What from your clinical What from your clinical practice might you want to practice might you want to

report on?report on?

???????????? QUESTIONSQUESTIONS????????????