Introduction to Research: What is it? Why should homeopathic clinicians care?

1
Introduction to Research What is it? Why
should homeopathic clinicians care?

• Janet Kahn, PhD, LMT
• 6th Annual Joint American Homeopathic Conference
• April 8th, 2011
• Alexandria, VA

2
Agenda

• Review the meaning of evidence-based practice and
  how to apply research to your clinical practice
• Define Research
• Explore types of research and uses of each
• Explore how clinicians can engage in meaningful
  research
• Clinical case reports
• Basic quantitative research
• Generate research topics from your clinical
  experience and learn how to turn them into
  researchable questions

3
?????? Your Questions ??????
4
Evidence-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??
5
What is research?

• Systematic inquiryusing orderly, agreed upon
  methods to
• answer questions,
• test hypotheses
• solve puzzles,
• learn more about something,
• generate theory

6
Why research important to homeopathy?

• Uses for an individual clinician e.g. best
  practices, successful marketing techniques
• Uses for the profession as a whole Surveys,
  insurance claims research
• Uses for other types of clinician
• Uses for patients
• Uses for policymakers CER

7
Its all about the question

• What do you want to know?
• How do you plan to use the information?
• Now, what do you really want to know?

8
Types of Research

• 2 basic types of research
• Quantitative Qualitative

Deals with things that can be measured Experimen
tation Observation
Deals with meaning and processes
9
Types of Quantitative Research

• Surveys
• Basic Science (bench science)
• Clinical trials including CER
• Literature Reviews
• Case Reports

10
Survey non-experimental research that focuses
on obtaining information about activities,
beliefs, attitudes, etc. of people 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. N Engl J Med. 1993 Jan
  28328(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, Kessler RC.
  JAMA. 1998 Nov 11280(18)1569-75.
• Courses involving complementary and alternative
  medicine at US medical schools. Wetzel MS,
  Eisenberg DM, Kaptchuk TJ. JAMA. 1998 Sep
  2280(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, Milliman B, Booker J, Mootz R, Barassi J, Kahn
  JR, Kaptchuk TJ, Eisenberg DM. J Am Board Fam
  Pract. 2002 Sep-Oct15(5)378-90.

11
Clinical Trial

• An experiment designed to test the safety /
  effectiveness / efficacy / cost / etc. of a
  specific treatment (or intervention).
• Key design issues focus on the
• intervention,
• the expected outcomes,
• population
• other important factors (variables).

12

• Efficacy - 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.
• Effectiveness is the capacity for beneficial
  change under typical conditions of practice or
  real world effectiveness.
• Comparative Effectiveness Research (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.

13
RCT

• 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.

14
Literature Reviews

• Narrative Review
• Meta-analysis
• Systematic Review

15
Meta-analysis

• A technique for quantitatively combining and thus
  integrating the results of multiple studies on a
  given topic.
• 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.

16
Systematic Review

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

17
Research about research

• Refining the methods
• Investigating researcher effects
• Etc.

18
Journal of Bodywork and Movement Therapies ()
, The attitudes toward massage (ATOM)
scale Reliability, validity, and associated
findings Christopher A. Moyer, Ph.D.a,, James
Rounds, Ph.D.b Summary Despite the key role
of attitudes in guiding behavior, no
systematic examination of attitudes toward
massage has been conducted and no
standard assessments 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.
19
Quantitative research

• Its all about the question,
• a theory,
• specific hypotheses, and
• relationships between variables
• Theory an abstract generalization that presents
  a systematic explanation (often not yet fully
  tested) about relationships among phenomena.
• Hypothesis a statement of predicted
  relationships between variables

20
Variables

• An attribute of a person or object that varies
  (takes on different values). Almost anything can
  be a variable
• Physiological characteristics weight, blood
  pressure, soft tissue elasticity, degree of
  allergic response to goldenrod
• Behavior average daily caffeine intake, seat
  belt usage, hours spent sleeping, charitable
  donation patterns
• Attitudes views on CAM, support for health care
  reform, preference for spicy or non-spicy food

21
Places and things also have variables

• of US households using OTC homeopathic remedies
  for pediatric applications
• of rainy days per year Alexandria, VA
• Research inquires about the relationship between
  variables and good research inquires about the
  relationships between well-chosen and
  well-defined variables.

22
Kinds of Variables

• Continuous values can be represented on a
  continuum, e.g. age
• Discrete have a finite number of values between
  any two points, e.g. the number of children you
  have
• Categorical have a small number of values that
  do not inherently represent a quantity, e.g.
  gender.

23
Clinical Case Reports

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

24
Functions of a Case Report

• It can call attention to something new,
  surprising, unexplained
• Identification of AIDS began with the case report
  of a single unexplained case of Kaposis Sarcoma
  in a young man.
• A case report is a teaching tool
• A case report is a time-honored tool of medical
  education, from daily ward presentations to
  grand rounds to published clinical case reports.
  Through having to report on cases they have
  admitted to hospital, new residents learn to
  observe carefully and report accurately
• A clinical case report is form of conversation
• 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, relied
  upon ...to enrich professional experience, lead
  to better clinical reasoning, and prompt further
  research. (Milos Jenicek, Clincial Case
  Reporting in Evidence-based Medicine, 1999, p7.)

25
Why is a Case Report Not an Anecdote?

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

26
What is the Purpose of a Case Report?

• Case reports also help advance knowledge by
• generating new theories and hypotheses
• refuting old theories and hypotheses
• recognizing and describing new diseases/conditions
  or
• novel treatment approaches
• unusual or confusing combinations of conditions
  or events
• unusual or unexpected outcomes
• adverse responses
• personal impact

27
What from your clinical practice might you want
to report on?

28

• ?????? QUESTIONS??????