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    Establishing causal effects

    Necessary conditions for establishing causal effects

    Experiments require random selection and random assignemnt

    Everyone conducting research is looking for associations between predictor, confounding, and outcome variables. People will often talk about wanting to know the correlation, relationship, or effects between variables.  These types of research questions are answered using observational research designs.

    However, when researchers are attempting to explain causal effects, there are certain criteria that have to be met.  

    1. An experimental design is the only method by which a causal effect can be inferred. This means that study participants are selected at random and randomly assigned to treatment groups. Any differences at baseline are thought to occur by chance with random selection and random assignment (whereas with observational designs they are due to selection and observation biases).  

    2. Analyses have to be conducted in an "intention-to-treat" fashion. This means that all study participants are analyzed in the original groups that they were randomly assigned to at the beginning of the study.

    3. Blinding can bolster the validity of causal effects, but is not necessary for establishing causal effects. Blinding can reduce observational biases that can occur in experiments where human beings are studied.    

    4. As much as possible, all pertinent demographic, clinical, and confounding variables related to the association between the primary predictor and primary outcome variable should be accounted for in experiments. True causal effects (in reality and practice) are always multivariate in nature. Clinicians do not make treatment decisions based on one form of evidence, they want as many forms of evidence as possible. The statistics that establish the efficacy of treatments should reflect the multivariate nature of treatment decisions.

    5. There has to be a sufficient amount of time or follow-up for an outcome. True causal effects are found when the temporal aspects (etiological, prognostic, time) of developing an outcome are accounted for methodologically and statistically.

    6. One clinical trial that shows valid evidence of a causal effect and meets all of the aforementioned criteria is STILL NOT ENOUGH! The results of the most methodologically sound randomized controlled trials or true experiments need to be aggregated in systematic reviews, syntheses, and synopses of syntheses. Pooled effects account for more variance in the general population and strengthen the "causal" understanding of causal effects.  
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    Applying clinical evidence and journal clubs

    Journal clubs should focus strictly on RCTs and meta-analyses

    Baseline competencies are needed before applying clinical evidence

    I participate in a lot of journal clubs at my institution. As the resident "stats person," I get called by residents before they present at journal club to help them discern the statistical methods of papers. I am also asked to attend journal clubs to assist in putting statistical findings into relevant clinical contexts.

    However, a pedagogical disservice is given to learners every time they are asked, "Would this evidence change your clinical practice?" This is a rhetorical question...they must NEVER let one piece of evidence change their clinical practice! This is especially true if the journal club topic that week focuses on observational or quasi-experimental designs!

    The famous text by Straus et al.* stipulates that the individual trial or observational study is the LEAST FAVORABLE type of evidence to be sought out in applied clinical medicine. Systematic reviews, synopses of syntheses, and summaries are the most tangible and relevant pieces of clinical evidence when it comes to real-life patient populations.

    A better use of a graduate level practitioner's time would be to seek out the highest levels of evidence in journal club, all the time. Observational studies are much more feasible for busy residents and fellows to conduct for academic requirements. But when it comes to teaching residents how to apply clinical evidence to their practice in the journal club environment, the highest levels of evidence should be used by faculty to correctly model reality-based clinical practice.    
    *Straus SE, Glasziou P, Richardson WS, Haynes RB.  (2011).  Evidence-based medicine:  How to practice and teach it.  Edinburgh: Churchill LIvingston.  
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    Retrospective cohort designs are useful to many researchers

    Retrospective cohort designs are very feasible

    The "go-to" research design for busy clinicians

    In my experience working as a biostatistician at a graduate school of medicine, I have learned that there are three precious commodities for busy clinicians and researchers: Time, competency, and accessibility to data.

    Systematic reviews constitute the most prodigious contribution that scientific-practitioners can make to a given body of clinical knowledge. When conducted in a rigorous and objective fashion, the pooled treatment effects yielded from this design are considered the highest level of applied clinical evidence that exists. It is much more of an academic/empirical task versus applied experimental and observational designs. Yet, the time and experience needed to conduct a systematic review often impede these pursuits by researchers. (However, they are greatly needed and should be undertaken if at all possible!  I'm going to start my first one soon.) 

    True experiments such as randomized controlled trials are not feasible for most researchers due to lack of funding, logistical support, and available resources. Also, researchers should first show observational evidence of a treatment effect before conducting a randomized controlled trial.  

    Prospective cohort studies can generate important measures of incidence and relative risk, as well as longitudinal data. However, this type of design means you are moving forward in time and are dependent upon enough observations being generated from you methodology to have adequate statistical power. The logistics and time associated with this design also tend to hinder its application in busy clinical environments.

    The next highest level of evidence is the retrospective cohort design and it is easily applied in a busy clinical environment. This is a retrospective design so the data already exists. One defines a cohort with inclusion and exclusion criteria. Then, members of the cohort are separated into independent groups according to some sort of exposure or non-exposure to a treatment, intervention, or risk. They are then followed up to a certain point in time to see if they did or did not have the outcome. There are obvious selection and observation biases associated with this design but it yields important measures of relative risk and many years of data can be mined for longitudinal or large-scale cohort analyses. Survival analyses are perfect for this type of design when establishing the 1-year, 3-year, or 5-year survival or "time-to-event" rates of an outcome.  They are also relatively inexpensive to conduct and time-friendly. This research design is much more preferable to case-control designs.