Evidence informed standardised prescription: home care for mild COVID

A vast majority of those with COVID have mild to moderate symptoms- and can appropriately be managed at home. In most cases people seek care from registered medical practitioners . But many clinicians and consultants are prescribing a cocktail of drugs which are known to have little or no value in improvement of patients. On the other hand it adds unnecessarily to costs, causes anxiety and makes diagnosis of progressive symptoms difficult ( progression of disease, complication or drug reactions) . To help clinicians tide over and have a tool which is backed by evidence, the evidence-informed standardised prescription has been developed for modern medicine doctors treating mild or moderate COVID cases at home (in-person or telemedicine).

Access is free but restricted to only modern medicine doctors (anywhere in the world) and organisations on a peer-to-peer basis and is available here . Apart from the prescription it provides an inventory of external resources to enable better clinical decision making. The standardised prescription is licensed under CC BY-NC-SA 4.0 license . This means it is free to use, adapt and mix provided the original source is cited/attributed appropriately, the use is for non-commercial use and further derivates are also licensed similarly.

Access, can be requested through an email to : work [at the rate of] soumyadeepbhaumik [dot] in

For individual modern medicine doctors please send either of the following:

  1. link to institutional webpage which demonstrated your medical degree
  2. information on medical council registration

Organizations working in providing modern medicine might write a mail to the same address providing link to their website and mention the specific potential use of the prescription.

The standardised evidence-informed telemedicine prescription has already been used by more than 30 doctors in India and a more stable Version 2.0 is now available. The passcode changes when a new version is available and requests can be made in a similar fashion as above. Link to access remains same.

Requests from practitioners of other forms of medicine will not be responded to.

Photo by Karolina Grabowska on Pexels.com

Poor quality of Indian clinical practice guidelines : academic elitism, capacity gaps and poor governance key factors

Guideline development has changed internationally with greater stress on the use of rigorous, transparent and evidence-based methods. Guideline development in India has come under increased scrutiny with a growing interest in the use of evidence for guideline development. The National Health Policy 2017 lays stress on the use of evidence in clinical practice guidelines. Quality guidelines are also a prerequisite for Clinical Establishment Act to be implemented too.
Last week we published a study in the Journal of Evidence Based Medicine which explored the issue of guideline quality in India.  (Link)
In the study , we first searched for   all guidelines for four diseases with highest overall burden in India (ischemic heart disease, lower respiratory infections, chronic obstructive pulmonary diseases, tuberculosis) and appraised their quality using an internationally validated tool called AGREE II(WHO also uses it ensuring quality in the guidelines they make). This tool evaluates the guideline quality in six domains and overall domain.
In general we found was that overall Indian guidelines were rated very poorly in 4 of the 6 domains – stakeholder involvement , editorial independence(conflict of interest and funding management), methodological riguor of development, and applicability (pertains to the likely barriers and facilitators to implementation, strategies to improve uptake, and resource implications of applying the guideline) .
We then set out to interview people who developed this guidelines to understand why this was happening and found :
that the key reasons were ;
  • Guideline development was seen as an academic activity and hence restricted to elite academic institutions . The academic elitism meant doctors from non-elite institutions,other healthcare professionals were excluded and there was poor consideration of actual implementation issues
  • There was inadequate capacity on methods for guideline development and no governance structure in place for the purpose.
  • There were mixed views on involving patients (which is standard internationally since they are the ultimate stakeholders) but in general it was negative.
  • People did not understand what conflict of interest meant and declaring it was seen as a taboo

In terms of policy implications the study implies that a lot of concerted efforts are needed by issuing agencies and the government to ensure development of guidelines in transparent, evidence-based and a systematic manner with high quality in India.

Read the full study here .

Too much medical research may be unnecessary, unethical, unscientific, and wasteful, warns new international research network

Researchers, research funders, regulators, sponsors and publishers of research fail to use earlier research when preparing to start, fund or publish the results of new studies. To embark on research without systematically reviewing evidence of what is already known, particularly when the research involves people or animals, is unethical, unscientific, and wasteful.

To address this problem a group of Norwegian and Danish researchers have initiated an international network, the ‘Evidence-Based Research Network’ (EBRNetwork). The EBRNetwork brings together initial partners from Australia, Canada, Denmark, the Netherlands, Norway, the UK, and USA was established in Bergen, Norway in December 2014. It also has members from low and middle income nations like India, South Africa and Brazil.

At the ‘Bergen meeting’ partners agreed the aim of the EBRNetwork is to reduce waste in research by promoting:

No new studies without prior systematic review of existing evidence

Efficient production, updating and dissemination of systematic reviews

Logo of the new Evidence Based Research Network

My take : In real terms this signifies a tactical shift of the way medical research is conducted and funded globally and bring in more objectivity into funding decisions . The current system of research funding is flawed and decisions are often not on the scientific need of the research to be conducted but on peer-perceptions. It will also prevent policy makers to be mis-guided by scientist who are prone to hype their own agenda for causes of career progression.

Note : The information provided here is adapted from the press release by network together with some personal opinions.  Dr. Soumyadeep Bhaumik is one of the members of the network.

Developing evidence based health policy in resource limited settings—lessons from Nepal

Few would argue against the benefits of evidence informed public health and health policies. However, efforts to inform health policy in resource limited settings face particularly daunting challenges—often specific to the political complexity and resource limitations experienced uniquely in low and middle income countries (LMICs).

The Nepal Health Research Council (NHRC), a Government of Nepal body, has a long held mandate to support informed decision making by health policymakers in Nepal—an exciting but daunting role to operationalise. Informing health policy assumes that there is a base of information to communicate: in Nepal, this often isn’t available.

Read the full article by Dr Sangeeta R, Dr. Soumyadeep B and Dr. Krishna A at the British Medical Journal Blogs (Open Access)

Mapping the growth of The Cochrane Collaboration in India

The Cochrane Collaboration held its annual Colloquium for the first time in South Asia at Hyderabad , India in September 2014. Dr. Soumyadeep B presented a poster to analyse the growth of The Cochrane Collaboration in India. As a vehement supporter of open data the poster is also made available here. The same will also be archived at the 2014 Colloquium Official website. Click on link below or the Image for downloading a pdf of it.

Mapping the growth of The Cochrane Collaboration in India

Regional distribution of Cochrane Contributors in India (Click o Image for Full poster)
Regional distribution of Cochrane Contributors in India (Click on Image for Full poster)

Notes from the GRADE and SoF #CochraneMethods Workshop at #CochraneHYD

Interpreting results of Cochrane reviews and Summary of Findings Tables: GRADE and SoF Workshop Magnitude of effect and confidence on effect are important parameters in quality of evidence

The Cochrane Colloquium 2014 is keeping up with its trend of providing high quality training for doing systematic reviews. The workshop today focused on the very useful issue of interpreting reviews and summary of findings. The event was done by the McMaster University , Canada faculty.

Here are some useful notes from the workshop .

Important parameters assessed in GRADE are
risk of bias
publication bias
dose response ,
size of effect ,

IMG_0086 IMG_0089

The conclusion about the effect of studies should provide the following information.
1.results of section
2.no of studeies
3.magnitude of effect
4.converting it to numbers which stakeholders understand (example : how many fractures were prevented after intervention : use confidence interval to report )
5. GRADE quality of evidence and brief on rational behind it.

New online version of grade software : GDT  www.guidelinedevelopment.org

When using scales and reporting in meta-analysis figure or GRADE table it is always important to communicate direction of scale and what is it about.

Remember to adjust for the image scale in forest plot .

Reviewers often forgot the red, green and yellow dots they have created in the risk of bias during interpretation of results .

Funnel plot cannot be created when less than 10 studies
Consider search strategy comprehensiveness, foreign language missing . smaller studies , grey literature search if funnel plot appears skewed.

Also Look at funding of study and competing interests when looking at publication bias .

Look at the characteristics of study carefully when doing GRADE

Do not use terms like ” not statistically significant” .
It is Important to calculate the optimal information size when using GRADE for imprecision. quality

Imprecision is done on basis of following for dichotomous outcomes : 1. sample size and number of events 2, confidence intervals
Imprecision is done on basis of following for Continuos outcomes : at least 400 people providing outcome measures : if not GRADE for imprecision.

Rule of thumb is if CI includes 0.75 to 1.25 indicates null effect and appreciable benefit or harm

IMG_0092 IMG_0093

Distinction between serious and very serious is important : but the balance is to be done by the reviewers: the thinking behind the judgement should be reflected in the footnotes. Let people know the thinking behind the grade done

small sample size but large effect. : could be indicative of the obeservation being just due to chance. Therefore do not depend on confidence interval but on the number of events.

Their are multiple ways of choosing a baseline risk for GRADE process. It can be the average or the extremes or even baseline risk from observational study. However this has to be justified.

All presentations in the colloquium are  available at http://cebgrade.mcmaster.ca/hyderabad/.

The Cochrane Colloquium comes to India

Chowmahalla Palace,Hyderabad
Picture from Chowmahalla Palace,Hyderabad, royal seat of the Asaf Jahi dynasty where the Nizams entertained their official guests and royal visitors.

Cochrane, the global leader in evidence-informed health is for the first time in its more than 20 year history (the first Cochrane Centre opened in Oxford,UK in October 1992 ) is for the first time holding its annual colloquium in India, or for that matter in South Asia.

The 22nd Cochrane Colloquium takes place in Hyderabad, India from 21-26 September, 2014 with the theme ‘Evidence-informed public health: opportunities and challenges’. The event is landmark especially when seen in the background of the impending evidence based medicine as well as universal health coverage in South Asia.The event will see Professor Gordon Guyatt delivering the Annual Cochrane Lecture and plenaries conducted and chaired by global leaders on EBM,public health and policies with the following themes :
1. East meets West: Evidence-Informed Public Health; Concepts, Context, Opportunities, Challenges,
2.Public Health: the context, the vision, the opportunities
3.Capacity Development: Challenges and Innovations
4.Cochrane Reviews: Assuring Quality and Relevance
5.Advocating for Evidence: Improving Health Decision-Making through Advocacy, Partnerships and Better Communication

Five Special themed session which will highlight important issues on the following theme are also scnheduled and their are inumerable workshops held.There are about 88 oral presentations and more than hundred posters.

Keep looking at this page for daily on the spot  updates on the event.
Link: https://colloquium.cochrane.org/