Statistics you can use practical use of statistics in reading medical research literature
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Statistics you can use: Practical use of statistics in reading medical research literature. PAS 610 June 21, 2005 Robert D. Hadley PhD, PA-C. The basics:. “There are three kinds of lies: lies, damned lies, and statistics.” Benjamin Disraeli, British politician (1804 - 1881).

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Statistics you can use practical use of statistics in reading medical research literature

Statistics you can use:Practical use of statistics in reading medical research literature

PAS 610

June 21, 2005

Robert D. Hadley

PhD, PA-C


The basics
The basics:

  • “There are three kinds of lies: lies, damned lies, and statistics.”

    • Benjamin Disraeli, British politician (1804 - 1881)


The value of statistics
The value of statistics:

  • Four economists are going to a meeting on the same train as four statisticians. The economists can't help noticing that the statisticians only buy a single ticket, where they bought four. When they inquire, the statisticians say, "Don't worry, you'll see."

  • They get on the train, and when the conductor starts in their car the four statisticians all lock themselves in the WC. When the conductor knocks on the WC door and yells "TICKET", they slide the ticket out under the door, and the conductor stamps it and slides it back. After he's gone, the statisticians emerge.


  • At the station on the way back from the meeting, the economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • As the conductor approaches their car, the economists all pile in the nearest WC and lock the door. One of the statisticians goes and knocks on the door; the economists slide the ticket out. The statisticians take the ticket and lock themselves in the WC at the other end of the car, repeating their maneuver of the previous trip. The economists get thrown off the train.

  • Moral: Don't use statistical methods you don't understand.


Practical vs sta 570
“Practical” vs. STA 570 economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Ways to represent data

    • Sample vs. population

  • Ways to compare data

    • e.g. Chi-square, Student’s t-test, ANOVA/ ANCOVA, Odds ratios and CI, Cox proportional hazard model, Spearman ranked correlation coefficients, multivariate regression analysis

  • Appropriateness of test for the way data were collected


Terms basics

Mean economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

Median

Quartiles, tertiles, etc.

Mode

Rank

Nominal

Ordinal

Population

Sample

Variance

Standard deviation

Normal distribution

Z-scores, T-scores

Correlation

Parametric vs. Nonparametric

Hypothesis testing

1- vs. 2-tailed

Significance levels

Confidence intervals

Statistical power

Terms: basics


Terms medical literature specific
Terms: medical literature-specific economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Intention to treat

  • Kaplan-Meier curves

  • ROC curves

  • Meta-analysis representations

  • Odds ratios/Relative Risk

  • Risk reduction

  • Number needed to treat

    • Over what time period?

    • For what outcome?

  • Number needed to harm


Concepts
Concepts economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Descriptive vs. inferential statistics

  • Type I and II errors


Descriptive economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

Statistics

Inferential

Statistics

  • Includes

  • Making inferences

  • Hypothesis testing

  • Determining

    relationships

  • Making predictions

  • Includes

  • Collecting

  • Organizing

  • Summarizing

  • Presenting

    data


Inferential errors

Type I ( economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“alpha)

Incorrectly reject the null hypothesis

Infer that something is significant when it is not

Type II (beta)

Incorrectly accept the null hypothesis

Infer that something is not significant when it really is

Inferential errors

So, which is better to do?

Which way does “intention to treat” skew the inference?


Study design
Study design economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Ask the right question in the right way


Statistical power
Statistical power economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Choose the appropriate sample size


Standard deviation and z scores
Standard deviation and Z-scores economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

Note: “normal” range for lab tests is ± 2 s.d.


Z and t scores in medicine
Z and T scores in medicine economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Bone density data are reported as T-scores and Z-scores. T-scores represent the number of SDs from the normal young adult mean bone density values, whereas Z-scores represent the number of SDs from the normal mean value for age- and sex-matched control subjects.

  • Results showing Z-scores of −2.0 or lower may suggest a secondary cause of osteoporosis.


Osteoporosis drug treatment
Osteoporosis drug treatment economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“


Data representation
Data Representation economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Relative risk, odds ratios, likelihood ratios, hazard ratios

  • Odds ratios in meta-analyses


Relative risk
Relative risk economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

What do unequal CI bars mean?


Meta analyses
Meta-analyses economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • “Gold standard” is randomized, placebo-controlled, multi-center, double blind clinical trial

  • “Platinum standard” is a meta-analysis of multiple “gold standard” trials by different investigators addressing the same question (rarely available)

  • Can make use of small studies that by themselves do not achieve statistical significance


Meta analyses1
Meta-analyses economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • How it’s done:

    • Search on a specific topic

    • Use predefined inclusion/exclusion criteria for studies that relate to topic

      • e.g. must be RCT, must measure same specific outcome (like cardiovascular events), etc.

    • Combine all studies that meet criteria

    • Use statistics appropriate to the way data were gathered in the included studies

    • Arrive at a conclusion that was impossible with the individual studies that were included


  • Other anti-platelet drug economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

    • (Reg. 1)

  • Aspirin

    • (Reg. 2)


Antiplatelet therapy for cvd
Antiplatelet therapy for CVD economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

BMJ 2002; 324:71-86


Data representation1
Data Representation economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Kaplan-Meier survivorship, and cumulative incidence of events

  • Both are a cumulative measure of something happening


Kaplan meier
Kaplan-Meier economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

Bortezomib or High-Dose Dexamethasone for Relapsed Multiple Myeloma

N Engl J Med 2005;352:2487-98


Use of quintiles to choose cutoff points
Use of quintiles to choose cutoff points economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“


Ascot lla trial stopped nearly 2 years early

36% RRR nonfatal MI + fatal CHD economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

(P =.0005)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

ASCOT-LLA: Trial Stopped Nearly 2 Years Early

Atorvastatin 10 mg No. of events: 100

Placebo (diet and exercise only) No. of events: 154

4

3

All patients counseled on

diet and exercise

Cumulative incidence (%)

2

What is approximate NNT for 1 year?

1

0

Years

Sever PS et al. Lancet. 2003;361:1149-1158.


Data representation2
Data Representation economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • 2x2, PPV, Chi-Square

  • ROC curves


ROC economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Receiver operator characteristic curves

    • Radar operators’ ability to distinguish signal from noise

  • Higher area under curve (AUC), higher reliability for a given test

  • Plot true positives vs. false positives


ROC economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“


ROC value: 0.65 (0.61-0.70) economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“


Data representation3
Data Representation economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Correlation

    • many statistical methods


Correlation of clinical data
Correlation of clinical data economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“


Correlation of clinical data1
Correlation of clinical data economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Is r=0.16 a strong correlation?

  • Can we conclude that CRP and LDL are related?


Box plots not common
Box plots (not common) economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

25th percentile, median and 75th percentile indicated in each box


Other interesting data representation
Other interesting data representation economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Neater than a true scatter plot

  • Simple to interpret

    Nissen et al, N Engl J Med 2005;352:29-38


An example
An example: economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • Peterson RC, Thomas RG, Grandman M, Bennet D, Doody R, Ferris S, et al. Vitamin E and Donepezil for the Treatment of Mild Cognitive Impairment. N Engl J Med 2005;352:2379-88.

  • Available at: http://content.nejm.org/cgi/content/full/352/23/2379


Questions
Questions: economists buy only one ticket, but they can't help noticing that the statisticians don't buy any. When they inquire, the statisticians say, "Don't worry, you'll see.“

  • What kind of study is this?

  • How large is the study?

  • What are the inclusion/exclusion criteria?

  • What is the outcome measured?

  • What is the intervention?

  • What are the statistical tests, and are they appropriate?

  • What data representations are used?

  • Is the result statistically significant?

  • Is the result clinically significant?

  • How does this knowledge affect my practice?


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