GATE Presentation 180213

GATE: Graphic Approach To
Epidemiology
Rod
Jackson
2013
1 picture, 2 formulas & 3 acronyms

1
The GATE frame:

Graphic Appraisal Tool for Epidemiological
studies a framework for appraising studies
Graphic Architectural Tool for
Epidemiological studies a framework for
designing studies
Presentation outline
1.a framework for study design
2.a framework for study analysis
3.a framework for study error
4. a framework for practicing EBP
1 picture, 2 formulas & 3 acronyms
1. GATE: design of epidemiological studies:

the picture & 1st acronym: PECOT
every epidemiological study can be hung on the

4
GATE frame
GATE Frame picture
a cohort of British doctors

smoking status measured (observed)
smokers
lung cancer
events
counted
yes
no
non-smokers
follow for
10 years
longitudinal (cohort or followobservational studies:

allocated to groups by
up ) study
5
1st acronym: PECOT

P
British doctors
Population/Participan
smoking status measured
Exposure
smokers
Outcomes
Lung cancer
yes
no
Comparison
non-smokers
O
T
Time
10 years
GATE Frame picture & 1st

acronym
cohort of British doctors
randomly allocated to aspirin or placebo

aspirin
heart
attacks
counted
yes
no
E C placebo
O
follow for 5
years
randomised controlled
RCT: allocated to Etrial
& C by randomisation
7

acronym
Middle-aged Americans
Body mass index measured

overweight
Diabetes status yes

measured in all
no
participants
C normal weight
O
T
Cross-sectional (prevalence)
8

acronym
P
overweight
Body mass index measured

obese E E C normal weight
1
2
Diabetes
yes
preno
Cross-sectional
study (multiple

acronym
Body Mass Index (BMI) measured

High BMI
C Low BMI
high
mean (average) Blood glucose

low
Cross-sectional
study (with
10

acronym
P
Middle-aged American women
Receive Mammogram
screening Test
Mammogram positive
yes
Breast cancer
no
Mammogram negative
Diagnostic
11
2. GATE: analysis of epidemiological studies:

the 1st formula: outcomes population
the numbers in every epidemiological study can

12
be hung on the GATE frame
1st formula: Occurrence of outcomes =

number of outcomes number in
population/group
British doctors
P Participant Population
Exposed Group EG CGComparison Group

smokers
Outcomes
Lung cancer
non-smokers
yes
no
b
T
Time
10 years
13
1st formula: occurrence = outcomes

population
P
British doctors
Population
Exposed GroupEG CGComparison Group

smokers
Outcomes
Lung cancer
non-smokers
yes
no
b
T
Time
10 years
Exposed Group Occurrence (EGO) = aEG

= number of outcomes (a) number in exposed
14
population (EG)
1st formula: occurrence = outcomes

population
P
British doctors
Population
Exposed Group EG CG
Comparison Group
smokers
non-smokers
yes
Lung cancer
no
b Outcomes
T
Time
10 years
Comparison Group Occurrence (CGO) =

bCG
15
= number of outcomes (b) number in comparison
goal of all epidemiological studies is to

measure (& compare) the occurrence of
outcomes in (different) populations (EGO
compared with CGO)
British doctors

smokers EG CG non-smokers
EGO:
Occurrence
(risk) of cancer
in smokers
yes
no
10 years
Lung cancer
CGO:
Occurrence of
cancer in nonsmokers
16

compared with CGO)
British doctors
Randomly allocated to aspirin or placebo

aspirin
yes
EGO:
Occurrence of
MI if taking
no
EG CG placebo
a
5 years
Heart attack (MI)
CGO:
Occurrence of
MI if not taking
17
aspirin

compared with CGO)
Body Mass Index (BMI) measured

High BMI
EGO:
high
Average blood
glucose in EG low
EG CG Low BMI
CGO:
Average blood
glucose in CG
18
EGO = sum of all glucose levels in EG

compared with CGO)
P

receive Mammogram
screening Test
mammogram positive EG CG mammogram negative
yes
EGO:
Occurrence of
cancer if
no
b
T
Breast cancer
CGO:
Occurrence of
cancer if
19
comparing EGO & CGO

Risk Ratio or Relative Risk (RR) =
EGO CGO
Risk Difference (RD) = EGO CGO
Number Needed to Treat/expose
(NNT) = 1 RD
its all about EGO and CGO

Measures of occurrence include: risk; rate;
likelihood; probability; average; incidence;
3. GATE: identifying where errors occur

in epi studies: the 2nd acronym:
RAMBOMAN
Recruitment
Allocation
Maintenance
Blind
Objective
Measurements
ANalyses
GATE frame with RAMBOMAN can be used to
21
identify risk of error in most/all epidemiological
Study setting
RAMBOMAN
Eligible population
recruitment process
P
P
were Recruited participants

relevant to the study
objectives?
who are the findings applicable
to?
22
RAMBOMAN:
how well were participants

Allocated to exposure & comparison groups?
was
Allocation to
EG & CG
RCT: Allocated bysuccessful?
Cohort: Allocated by
randomisation (e.g to
drugs)
measurement (e.g.
smoking)
EG & EG CG
CG
similar
?
E&C
EG CG measure
s
accurate
?
O
23
RAMBOMAN
how well were Participants

Maintained in the groups
they were allocated to (i.e. to
EG & CG) throughout the
EG CG
study?
completeness of
follow-up
compliance
contamination
co-interventions
24
EG
RAMBOMAN
Were outcomes
measured
blind to whether
CG
participant was in EG or
CG ?
O
T
25
RAMBOMAN
EG
CG
Were outcomes
measured
Objectively?
O
T
26
RAMBOMAN
Were the Analyses done
appropriately?
EG CG
Adjustment for
confounding
O
T
27
RAMBOMAN
Were the Analyses done

appropriately?
EGA
CGA
EGC CGC
Intention to treat?
T
28
the 2nd formula:

random error = 95% confidence
interval
EGO 95% CI
CGO 95% CI
There is about a 95% chance that the true value of EGO

& CGO (in the underlying population) lies somewhere in
29
the 95% CI (assuming no non-random error)
the 3rd acronym: FAITH

Critically appraising a
systematic review
Find were all potentially relevant studies

found?
Appraise were studies appraised for
validity?
Include were only appropriate studies
included in the final analyses?
Total-up were studies pooled appropriately?
Heterogeneity were studies too
heterogeneous (i.e. too different) to pool?
4. GATE : a framework for the 4 steps of

EBP
the steps of EBP:

1.ask
2.access
3. appraise
4. apply
[5. audit your
practice]
EBP Step 1: ASK - turn your

question into a focused 5-part
PECOT question
P
2. Exposure
4. Outcomesyes
no
1. Participants
3. Comparison
O
T
5. Time
33
EBP Step 2: ACCESS the

evidence use PECOT to help
choose search terms
1.
2.
3.
4.
5.
Participants
Exposure
Comparison
Outcome
Time frame
34
EBP Step 3: APPRAISE the

evidence with the picture,
acronyms & formulas
P
Recruitment
Allocation
E
C
Maintenance
E
O
T
blind
objective
Measurements
ANalyses
T
Occurrence = outcomes population
Random error = 95% Confidence 35
EBP Step 4: APPLY the evidence by

AMALGAMATING the relevant information
& making an evidence-based decision:
the X-factor
X-factor: making evidence-based decision
person
family
community
practitioner
epidemiolo
gical
economic
evidence
values &
system legal
preferenc
feature
political
es patients
s
clinical
ph
circumsta
ps
ys
yc
so nces
ic
h
ci
al
Practitioner e
ol
og
ic
al
al
h
ea
lth
Xpertise: putting it all together - the art

of practice
Clinical expertise in the era of evidence-based medicine and patient choice. EBM 2002;736-8 (March/April)
6-page GATE CATs (word docs)
39
1-page GATE Calculators (excel

files)
40
1-page GATE-lites (writeable pdf

files)
all forms on Cecil EBM s
41
extra slides

acronym
P
smokers
C non-smokers

cases
yes
O
Lung cancer
controls T
no
Case-control
study
Observational
study: allocated by
44

acronym
P
Measured with gold standard for breast

cancer
Breast cancer positive
positive
Mammogram
negative
C Breast cancer negative
Diagnostic test
45
The goal of all epidemiological studies is

to measure (& compare) the occurrence
of outcomes in (different) populations
(EGO compared with CGO)
P
iddle-aged American women

Measured with gold standard
for breast cancer
Breast cancer EG CG No breast cancer
b
positive a
EGO:
O
T
Likelihood of
negative
+ve
Mammogram if
Mammogram
CGO:
Likelihood of
+ve
Mammogram
if
46
1st formula (with time):

occurrence = (outcomes population)
Time
P
Population
British doctors
Exposed Group EG CGComparison Group

smokers
Outcomes
Lung cancer
non-smokers
yes
no
b
T
Time
10 years
= (a EG) during time T (a measure of cumulative incide

EGO = (a EG) T (a measure of incidence
rate)
47
1st formula (with time):

occurrence = (outcomes population)
Time
P

Receive Mammogram
screening Test
Mammogram positive EG CG Mammogram negative
yes
CGO:
EGO:
no
Occurrence of
Occurrence of
cancer if
cancer if
Breast cancer
48
mammogram
mammogram
EGO+ve
= (a EG) at time T (a measure of -ve
prevalence)

GATE Presentation 180213

Uploaded by

Copyright:

Available Formats

GATE Presentation 180213

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

GATE Presentation 180213

Uploaded by

Copyright:

Available Formats

GATE: Graphic Approach To

1 picture, 2 formulas & 3 acronyms

The GATE frame:

1 picture, 2 formulas & 3 acronyms

1. GATE: design of epidemiological studies:

every epidemiological study can be hung on the

GATE Frame picture

a cohort of British doctors

longitudinal (cohort or followobservational studies:

1st acronym: PECOT

smoking status measured

GATE Frame picture & 1st

cohort of British doctors

randomly allocated to aspirin or placebo

GATE Frame picture & 1st

Body mass index measured

Diabetes status yes

GATE Frame picture & 1st

Body mass index measured

GATE Frame picture & 1st

Body Mass Index (BMI) measured

mean (average) Blood glucose

GATE Frame picture & 1st

Middle-aged American women

2. GATE: analysis of epidemiological studies:

the numbers in every epidemiological study can

1st formula: Occurrence of outcomes =

smoking status measured

Exposed Group EG CGComparison Group

1st formula: occurrence = outcomes

smoking status measured

Exposed GroupEG CGComparison Group

Exposed Group Occurrence (EGO) = aEG

1st formula: occurrence = outcomes

smoking status measured

Comparison Group Occurrence (CGO) =

goal of all epidemiological studies is to

smoking status measured

goal of all epidemiological studies is to

Randomly allocated to aspirin or placebo

Heart attack (MI)

goal of all epidemiological studies is to

Body Mass Index (BMI) measured

EGO = sum of all glucose levels in EG

goal of all epidemiological studies is to

Middle-aged American women

comparing EGO & CGO

its all about EGO and CGO

3. GATE: identifying where errors occur

were Recruited participants

how well were participants

how well were Participants

Were the Analyses done

the 2nd formula:

There is about a 95% chance that the true value of EGO

the 3rd acronym: FAITH

Find were all potentially relevant studies

4. GATE : a framework for the 4 steps of

the steps of EBP: