1 00:00:04,604 --> 00:00:07,941 PRESENT NOT ONLY OF THE OBSERVATIONAL COMPARATIVE 2 00:00:08,007 --> 00:00:12,078 EFFECTIVENESS RESEARCH WORKING GROUP, BUT ALSO I'VE REALIZED 3 00:00:12,145 --> 00:00:16,015 THAT THERE'S HEAPS OF CROSSOVER BETWEEN DIFFERENT WORKING 4 00:00:16,082 --> 00:00:20,120 GROUPS, SO THE DATA SCIENCE AND HARMONIZATION AND OTHERS AS 5 00:00:20,186 --> 00:00:20,520 WELL. 6 00:00:21,621 --> 00:00:25,258 SO THE CLINICAL TRIALS GROUP, THERE'S A LOT OF CROSSOVER, THE 7 00:00:25,325 --> 00:00:26,860 IMAGING GROUP AND SO FORTH. 8 00:00:26,926 --> 00:00:30,330 SO THE CONVERSATION THAT WE HAVE TODAY I THINK WILL BE RELEVANT 9 00:00:30,397 --> 00:00:31,398 FOR LOTS OF THOSE. 10 00:00:31,998 --> 00:00:38,705 SO FIRSTLY, I THINK THAT IT'S JUST MOVING TO THE NEXT SLIDE. 11 00:00:39,038 --> 00:00:42,509 THE, THE PURPOSE OF WHAT WE'RE TRYING TO DO TODAY IN THIS ONE 12 00:00:42,575 --> 00:00:45,812 HOUR SESSION IS WE'VE BEEN CHARGED BY DAVID MENON TO COME 13 00:00:45,879 --> 00:00:49,382 UP WITH A A SINGLE SLIDE AT THE END OF THE CONVERSATION WHICH 14 00:00:49,449 --> 00:00:52,685 WOULD BE WHAT WOULD IMPROVE TBI OUTCOMES, WHAT WOULD BE A 15 00:00:52,752 --> 00:00:55,722 FUNDABLE PROPOSITION IN THIS FIELD OF CLINICAL DATA, 16 00:00:55,789 --> 00:00:59,092 OBSERVATIONAL, COMPARATIVE AND EFFECTIVENESS RESEARCH THAT 17 00:00:59,159 --> 00:01:02,796 WOULD IDEA THAT WE COULD AND AND NOT JUST THUNDERBALL, SOMETHING 18 00:01:02,862 --> 00:01:06,466 THAT WOULD CHANGE THE GAME, WHAT WOULD BE IMPORTANT FOR PEOPLE, 19 00:01:06,533 --> 00:01:08,101 WHAT WOULD IMPROVE OUTCOMES. 20 00:01:08,802 --> 00:01:11,704 SO IN ORDER TO DO THAT IN THE FIELD WE NEED TO GET TO THE 21 00:01:11,771 --> 00:01:15,008 POINT WHERE CLINICIANS KNOW WHEN TO TRUST THIS KIND OF RESEARCH 22 00:01:15,074 --> 00:01:18,178 IN TRAUMATIC BRAIN INJURY AND HELP CLINICIANS INTERPRET THESE 23 00:01:18,244 --> 00:01:19,078 KIND OF STUDIES. 24 00:01:19,412 --> 00:01:22,449 AND SO YOU HEARD THIS MORNING ABOUT THE WHITE PAPER THAT'S 25 00:01:22,515 --> 00:01:25,718 BEEN DISCUSSED AND WE'LL TALK ABOUT THAT A LITTLE BIT MORE IN 26 00:01:25,785 --> 00:01:26,286 A MOMENT. 27 00:01:26,519 --> 00:01:28,822 WE ALSO WANT TO BE ABLE TO INCREASE THE NUMBER OF OUTPUTS 28 00:01:28,888 --> 00:01:31,357 THAT CHANGE CLINICAL PRACTICE BECAUSE THERE'S NO POINT REALLY 29 00:01:31,424 --> 00:01:33,860 DOING THESE STUDIES UNLESS THEY ARE GOING TO CHANGE CLINICAL 30 00:01:33,927 --> 00:01:35,462 PRACTICE IF WE FIND SOMETHING USEFUL. 31 00:01:35,962 --> 00:01:39,499 SO PERHAPS REPLICATING THAT FLUID BALANCE PAPER THAT THAT 32 00:01:39,566 --> 00:01:43,303 MATTHEW TOLD US ABOUT IN, IN OTHER AREAS AS WELL AND SO THAT 33 00:01:43,369 --> 00:01:45,772 IT FLOWS THROUGH INTO THE GUIDELINES. 34 00:01:46,439 --> 00:01:51,511 SO THIS DIAGRAM, OH, I SEEM TO HAVE LOST MY DIAGRAM. 35 00:01:52,645 --> 00:01:53,713 I HAVE LOST MY DIAGRAM. 36 00:01:54,314 --> 00:01:59,252 THERE WAS A DIAGRAM WHERE WE SORT OF TALKED A LITTLE BIT 37 00:01:59,319 --> 00:02:04,791 WHICH SHOWED THAT IN A BIT OF A SCHEMATIC FORM AND BUT SORT OF 38 00:02:04,858 --> 00:02:06,159 TO TO SHOW HOW. 39 00:02:06,759 --> 00:02:09,162 BUT THE REASON FOR HAVING OBSERVATIONAL COMPARATIVE 40 00:02:09,229 --> 00:02:12,165 EFFECTIVENESS REALLY THIS KIND OF DATA COLLECTION IN TRAUMATIC 41 00:02:12,232 --> 00:02:15,068 BRAIN INJURIES IS PARTICULARLY IMPORTANT BECAUSE IT'S SUCH A 42 00:02:15,134 --> 00:02:16,169 VARIABLE DISEASE STATE. 43 00:02:16,236 --> 00:02:19,138 IT'S VERY DIFFICULT TO ENROLL PEOPLE IN RANDOMIZED CONTROL 44 00:02:19,205 --> 00:02:20,974 TRIALS WHEN EVERYBODY IS DIFFERENT. 45 00:02:21,040 --> 00:02:23,877 YOU KNOW, THIS IDEA OF AN END OF ONE FOR EACH INDIVIDUAL PERSON 46 00:02:23,943 --> 00:02:24,644 WITH AN INJURY. 47 00:02:25,311 --> 00:02:28,882 SO WE WE, YOU KNOW, EVERYONE IN THIS ROOM, WE'RE PREACHING TO 48 00:02:28,948 --> 00:02:32,519 THE CHOIR THAT WE BELIEVE THIS KIND OF DATA CAN BE IMPORTANT, 49 00:02:32,585 --> 00:02:36,089 BUT WE NEED TO TAKE THE NEXT STEPS TO SEE HOW IT CAN BE USED 50 00:02:36,155 --> 00:02:36,923 MORE BROADLY. 51 00:02:37,991 --> 00:02:41,060 SO TODAY I JUST WANT TO HAVE A BIT OF AN OPEN CONVERSATION. 52 00:02:41,127 --> 00:02:43,963 WE'VE GOT A RANGE OF PEOPLE WHO ARE GOING TO HELP TO LEAD THE 53 00:02:44,030 --> 00:02:46,733 DISCUSSION AND I'M GOING TO THROW TO TO HESTER IN A LITTLE 54 00:02:46,799 --> 00:02:49,669 WHILE TO TALK A LITTLE BIT MORE ABOUT THE WHITE PAPER AND WHAT 55 00:02:49,736 --> 00:02:51,504 MIGHT BE IN IT, WHAT WE SHOULD COVER. 56 00:02:51,905 --> 00:02:54,641 BUT BEFORE WE DO THAT WE MIGHT JUST HAVE A A BIT OF A 57 00:02:54,707 --> 00:02:57,710 CONVERSATION ABOUT SOME OF THE BASIC PRINCIPLES OF OF WHAT 58 00:02:57,777 --> 00:02:58,745 WE'RE TRYING TO DO. 59 00:02:59,045 --> 00:03:01,915 FIRSTLY I'D LIKE I HAD A CONVERSATION YESTERDAY WITH 60 00:03:01,981 --> 00:03:04,984 JENNIFER ALBRECHT ABOUT THE THE WORDING OF COMPARATIVE 61 00:03:05,051 --> 00:03:06,319 EFFECTIVENESS RESEARCH. 62 00:03:06,686 --> 00:03:08,154 THE TITLE IS IT A GOOD ONE. 63 00:03:08,688 --> 00:03:10,890 THE PEOPLE KNOW WHAT WE MEAN WHEN WE TALK ABOUT THAT. 64 00:03:11,324 --> 00:03:14,527 I CERTAINLY DIDN'T KNOW WHAT IT MEANT UNTIL I CAME TO KNOW ABOUT 65 00:03:14,594 --> 00:03:14,961 CENTRE. 66 00:03:15,261 --> 00:03:18,498 SO JENNIFER, DID YOU WANT TO SORT OF GET THE BALL ROLLING ON 67 00:03:18,565 --> 00:03:21,901 THAT ONE AND THEN WE CAN JUST OPEN UP THE CONVERSATION ON THAT 68 00:03:21,968 --> 00:03:22,969 FOR A FEW MINUTES. 69 00:03:23,369 --> 00:03:25,038 SO ARE WE TALKING ABOUT THE RIGHT THING? 70 00:03:26,573 --> 00:03:26,973 YEAH, SURE. 71 00:03:27,040 --> 00:03:27,774 GOOD NUMBER HERE. 72 00:03:28,808 --> 00:03:29,342 OK, GREAT. 73 00:03:29,676 --> 00:03:32,045 SO, SO MAYBE TAKE THE, YEAH, TAKE THE MIC OUT AND WHAT 74 00:03:32,111 --> 00:03:33,846 HAPPENED AS A ROVING TURN THE OTHER WAY. 75 00:03:33,913 --> 00:03:33,980 YEAH. 76 00:03:34,047 --> 00:03:35,515 SO THAT YOU'RE NOT LOOKING AT MY BACK. 77 00:03:35,782 --> 00:03:36,115 OK. 78 00:03:36,182 --> 00:03:39,852 SO FIRST OFF, MY BACKGROUND IS AN EPIDEMIOLOGIST, SO. 79 00:03:39,919 --> 00:03:41,888 SO I, I AM A METHODOLOGIST. 80 00:03:43,356 --> 00:03:47,894 TO ME COMPARATIVE EFFECTIVENESS RESEARCH IMPLIES THE DIRECT 81 00:03:47,961 --> 00:03:50,196 COMPARISON OF TWO TREATMENTS. 82 00:03:50,530 --> 00:03:53,967 I DON'T TEND TO THINK OF IT SO MUCH AS A A TREATMENT VERSUS NO 83 00:03:54,033 --> 00:03:54,601 TREATMENT. 84 00:03:55,301 --> 00:04:00,006 I I BELIEVE THAT WHAT THIS GROUP WOULD LIKE TO DO IS IS ACTUALLY 85 00:04:00,073 --> 00:04:03,710 ESTIMATE CAUSAL EFFECTS USING OBSERVATIONAL DATA. 86 00:04:04,043 --> 00:04:06,646 AND I'LL JUST PUT IT OUT THERE FOR FOR CONSIDERATION AND 87 00:04:06,713 --> 00:04:09,349 DISCUSSION THAT THERE ALREADY IS A VERY WELL ESTABLISHED 88 00:04:09,415 --> 00:04:12,485 FRAMEWORK FOR ESTIMATING CAUSAL EFFECTS FROM OBSERVATIONAL DATA. 89 00:04:15,088 --> 00:04:16,222 DOES ANYONE WANT TO COMMENT ON THAT? 90 00:04:16,289 --> 00:04:18,825 DO WE LIKE THE TERM COMPARATIVE EFFECTIVENESS RESEARCH? 91 00:04:18,891 --> 00:04:20,560 WHO WANTS TO SPEAK AS A CHAMPION OF IT? 92 00:04:21,327 --> 00:04:23,696 MAYBE I'LL WALK AROUND WITH THE WITH THE MIC AND THAT MIGHT 93 00:04:23,763 --> 00:04:24,631 FACIL THE DISCUSSION. 94 00:04:24,831 --> 00:04:28,534 MAYBE TO END ON THAT, I THINK ANOTHER POINT FOR DISCUSSION IS 95 00:04:28,601 --> 00:04:31,037 WHETHER WE WANT THE WHITE PAPER, DO WE? 96 00:04:31,270 --> 00:04:34,240 DO WE NEED IT AND DO WE THINK IT ADDS TO THE FIELD? 97 00:04:34,741 --> 00:04:41,881 SO YES, I COMPLETELY AGREE WITH THAT. 98 00:04:41,948 --> 00:04:44,484 I THINK WE HAVE IN MEDICINE BEEN VERY ADHERENT TO A GOLD 99 00:04:44,550 --> 00:04:47,420 STANDARD, AND I'M NOT SUGGESTING THE GOLD STANDARD ISN'T A GOLD 100 00:04:47,487 --> 00:04:50,356 STANDARD, WHICH IS A RANDOMIZED CONTROLLED TRIAL, BUT IT SIMPLY 101 00:04:50,423 --> 00:04:53,292 DOES NOT WORK FOR A WHOLE LOT OF REASONS THAT I'M SURE EVERYONE 102 00:04:53,359 --> 00:04:54,627 IS COMPLETELY FAMILIAR WITH. 103 00:04:55,228 --> 00:04:58,031 SO WE HAVE TWO OPTIONS, EITHER WE CARRY ON DOING INEFFECTIVE 104 00:04:58,097 --> 00:05:00,800 RANDOMIZED CONTROLLED TRIALS OR WE ACTUALLY TRY AND FIND A 105 00:05:00,867 --> 00:05:02,001 DIFFERENT GOLD STANDARD. 106 00:05:02,068 --> 00:05:04,570 AND I WOULD ALSO SUBMIT THAT THE GOLD STANDARD ISN'T ACTUALLY 107 00:05:04,637 --> 00:05:05,338 COMPLETELY GOLDEN. 108 00:05:05,405 --> 00:05:07,106 THERE ARE PROBLEMS WITH RANDOMIZED CONTROLLED TRIALS 109 00:05:07,173 --> 00:05:07,306 TOO. 110 00:05:07,807 --> 00:05:10,710 AND AND OF THAT CAUSAL EFFECT MODELING, YOU KNOW, THERE'S A 111 00:05:10,777 --> 00:05:13,713 WHOLE SPECTRUM FROM PROPENSITY SCORE MATCHING, FAIRLY SIMPLE 112 00:05:13,780 --> 00:05:16,649 STUFF AT ONE END ALL THE WAY THROUGH TO THE ULTIMATE GOAL, 113 00:05:16,716 --> 00:05:19,686 WHICH I THINK WOULD BE SORT OF INDEPENDENT TREATMENT EFFECTS, 114 00:05:19,752 --> 00:05:22,922 INDIVIDUALIZED TREATMENT EFFECTS TYPE MODELS, WHICH WOULD ENABLE 115 00:05:22,989 --> 00:05:25,725 US TO TAKE THINGS FROM THE TRIAL ALL THE WAY DOWN TO THE 116 00:05:25,792 --> 00:05:28,695 INDIVIDUAL PATIENT AND MAKE PREDICTIONS AT PATIENT LEVEL AS 117 00:05:28,761 --> 00:05:30,096 WELL IF WE HAVE ENOUGH DATA. 118 00:05:30,163 --> 00:05:31,531 SO I DO COMPLETELY SUPPORT THAT. 119 00:05:31,597 --> 00:05:35,835 I THINK IT'S A REALLY GOOD IDEA MAYBE TO KIND OF EXPLAIN AND 120 00:05:35,902 --> 00:05:36,869 BUILD ON THAT. 121 00:05:37,103 --> 00:05:39,138 WE HAD A FIGURE AND IT IT FELT OUT. 122 00:05:39,205 --> 00:05:42,975 BUT TO TO TEASE OUT A LITTLE BIT THE DISCUSSION IS WE HAVE THE 123 00:05:43,042 --> 00:05:46,879 BTF GUIDELINES WHICH PERSONALLY I THINK THEY'RE NON INSTRUCTIVE 124 00:05:46,946 --> 00:05:50,316 FOR CLINICAL PRACTICE BECAUSE IT'S THE HIGHEST LEVEL OF 125 00:05:50,383 --> 00:05:50,850 EVIDENCE. 126 00:05:50,917 --> 00:05:52,018 WE DON'T HAVE ANY EVIDENCE. 127 00:05:52,085 --> 00:05:54,821 SO THERE'S NO NO ADVICE FOR CLINICAL PRACTICE. 128 00:05:55,321 --> 00:05:59,792 THEN AT THE BOTTOM OF AUTUMN WE HAVE THE CONSENSUS GUIDELINES 129 00:05:59,859 --> 00:06:03,563 WHICH MAY HELP HARMONISE TREATMENTS AMONG DIFFERENT 130 00:06:03,629 --> 00:06:08,167 SETTINGS, BUT WE DON'T KNOW IF IT IMPROVES OUTCOME AND THEN IN 131 00:06:08,234 --> 00:06:11,170 BETWEEN MAYBE THAT'S FOR FOR DISCUSSION. 132 00:06:11,237 --> 00:06:15,074 NOW WE HAVE OBSERVATIONAL STUDIES WITH DIFFERENT LEVEL OF 133 00:06:15,141 --> 00:06:19,178 POSSIBILITY TO TO TO DO CAUSAL INFERENCE AND THAT DEPENDS ON 134 00:06:19,245 --> 00:06:21,814 WHICH STATISTICAL METHODS YOU YOU USE. 135 00:06:21,881 --> 00:06:26,018 SO ONE OF THE DISCUSSION MIGHT BE IS IN ORDER TO INFORM 136 00:06:26,085 --> 00:06:30,723 CLINICAL PRACTICE GUIDELINES, SHOULD WE DRAFT THIS WHITE PAPER 137 00:06:30,790 --> 00:06:34,861 TO TRY AND BE BRIDGE THE GAP BETWEEN CONSENSUS PAPERS, 138 00:06:34,927 --> 00:06:39,198 EVIDENCE BASED GUIDELINES WHICH ARE ESSENTIALLY EMPTY AND 139 00:06:39,265 --> 00:06:43,469 ANOTHER LAYER OF EVIDENCE WITH A CERTAIN LEVEL OF CAUSAL 140 00:06:43,536 --> 00:06:47,306 INFERENCE POSSIBILITY TO REALLY INFORM GUIDELINES. 141 00:06:47,373 --> 00:06:51,377 AND I THINK AS LONG AS WE HAVE THIS DICHOTOMY OF CONSENSUS AND 142 00:06:51,444 --> 00:06:55,348 BTF GUIDELINES AND NOTHING IN BETWEEN THAT'S THAT FEELS LIKE 143 00:06:55,414 --> 00:06:58,718 WE'RE MISSING SOMETHING REGARDING CLINICAL PRACTICE 144 00:06:58,785 --> 00:06:59,185 ADVICE. 145 00:06:59,252 --> 00:07:02,388 SO I I THINK THAT'S THAT MIGHT BE THE DISCUSSION, ONE OF THE 146 00:07:02,455 --> 00:07:03,623 POINTS FOR DISCUSSION. 147 00:07:04,123 --> 00:07:04,223 YEAH. 148 00:07:04,423 --> 00:07:04,590 YEAH. 149 00:07:07,126 --> 00:07:10,129 THEN I, YEAH, IT'S A LITTLE BIT STRANGE HOW TO TALK. 150 00:07:10,196 --> 00:07:14,267 I TALK LIKE THIS TO EVERYBODY BECAUSE AND I ALSO LOOK AT YOU 151 00:07:14,333 --> 00:07:15,501 BECAUSE TREATMENT. 152 00:07:15,568 --> 00:07:19,772 WHAT IS THEN FOR THE OBSERVATION OF STUDIES TO EVALUATE 153 00:07:19,839 --> 00:07:24,143 TREATMENT, BECAUSE GUIDELINES IS ALSO ABOUT POLICY ABOUT 154 00:07:24,210 --> 00:07:28,981 ADMISSION OBSERVATION, SO IS FOR FOR THE SER IS ALSO TREATMENT 155 00:07:29,048 --> 00:07:33,586 ADMISSION POLICY FOR EXAMPLE, BECAUSE IF YOU ADMIT PATIENTS 156 00:07:33,653 --> 00:07:38,090 FOR A SHORT TIME, YOU GIVE THEM INFORMATION, YOU GIVE THEM 157 00:07:38,157 --> 00:07:39,392 PSYCHOEDUCATION. 158 00:07:39,725 --> 00:07:43,930 SO I JUST WANTED TO DISCUSS HOW BROAD IS THE CONCEPT OF 159 00:07:43,996 --> 00:07:48,367 TREATMENT WITHIN THE SER APPROACH BECAUSE OTHERWISE I SAW 160 00:07:48,434 --> 00:07:52,705 SOME EXAMPLES WHICH ARE ONLY GIVEN AT THE NEUROCARE UNIT 161 00:07:52,772 --> 00:07:56,909 ALREADY ICU AND I THINK IT'S BROADER THAN THAT RUNS MY 162 00:07:56,976 --> 00:07:57,510 HEALTH. 163 00:08:01,047 --> 00:08:06,385 I THINK IT'S ANY INTERVENTION THAT YOU WOULD APPLY TO IMPROVE 164 00:08:06,452 --> 00:08:07,153 OUTCOME. 165 00:08:08,521 --> 00:08:11,824 AND SO I LIKE THE DISCUSSION AND ONE THING, AND I THINK LENNY 166 00:08:11,891 --> 00:08:14,026 BROUGHT IT UP AS WELL AS A QUESTION. 167 00:08:14,093 --> 00:08:17,830 SO I THINK THERE'S SOME AGREEMENT THAT WE WANT TO FILL 168 00:08:17,897 --> 00:08:21,934 THIS GAP BETWEEN THE GOLD STANDARD AND THEN THE LOWER ENDS 169 00:08:22,001 --> 00:08:24,737 OF EVIDENCE, WHICH IS EXPERT OPINION. 170 00:08:24,804 --> 00:08:27,640 BUT YOU START BY ASKING, IS COMPARATIVE EFFECTIVENESS 171 00:08:27,707 --> 00:08:30,443 RESEARCH THEN SORT OF THE RIGHT TERM STILL TO USE? 172 00:08:41,754 --> 00:08:45,791 SUZANNE MISHIGL, I'M A NEURO INTENSIVIST WHO'S VERY KEEN ON 173 00:08:45,858 --> 00:08:49,395 FINALLY SEEING DATA FROM COMPARATIVE EFFECTIVENESS. 174 00:08:49,829 --> 00:08:52,932 I THINK TRIALS ARE TOO EXPENSIVE, TAKE TOO LONG, 175 00:08:52,999 --> 00:08:56,769 REQUIRE FUNDING, AND I MEAN IT'S TOO LONG UNTIL WE HAVE AN 176 00:08:56,836 --> 00:08:57,270 ANSWER. 177 00:08:58,170 --> 00:09:01,908 I THINK WE'RE DOING A LOT IN ICU AND IT MAY NOT BE ICU AND MAYBE 178 00:09:01,974 --> 00:09:04,911 YOU KNOW WHATEVER INTERVENTION THAT WE THINK WORKS 179 00:09:04,977 --> 00:09:08,314 PHYSIOLOGICALLY MAKES SENSE, BUT WE HAVE NO DATA ON THAT. 180 00:09:08,381 --> 00:09:12,418 I THINK WITH CENTER AND TRACK TBI COMBINED LOOKING AT YOU GUYS 181 00:09:12,485 --> 00:09:16,355 RIGHT, THE RIGHT DATA, DOING VERY RIGOROUS ANALYSIS, I THINK 182 00:09:16,422 --> 00:09:19,292 THAT ACTUALLY WILL DRIVE THE FIELD FORWARD. 183 00:09:19,525 --> 00:09:23,062 I WILL TELL YOU, MY COLLEAGUES AND I, WE'RE VERY KEEN TO SEE 184 00:09:23,129 --> 00:09:26,499 COMPARATIVE EFFECTIVENESS RESEARCH AND I MEAN NIH IS ALSO 185 00:09:26,565 --> 00:09:29,402 RECOGNIZING THAT AND HAS OUR EYES OUT FOR THAT. 186 00:09:39,245 --> 00:09:43,082 I THINK IT'S KNOWN UNDER THAT I THINK IT HAS AI MEAN. 187 00:09:43,149 --> 00:09:44,317 WHAT ELSE WOULD YOU CALL IT? 188 00:09:44,383 --> 00:09:47,086 I MEAN, I DON'T CARE WHAT YOU CALL IT AS LONG AS IT'S 189 00:09:47,153 --> 00:09:47,520 RIGOROUS. 190 00:09:47,586 --> 00:09:51,857 I THINK A WHITE PAPER HAS A ROLE TO EXPLAIN IN SIMPLE TERMS TO 191 00:09:51,924 --> 00:09:54,927 CLINICIANS THE ADVANTAGES AND DISADVANTAGES. 192 00:09:54,994 --> 00:09:58,597 EARLIER I SAW A SLIDE WITH GREEN PROS AND THE RED CONS OF WHAT 193 00:09:58,664 --> 00:10:01,133 COMPARATIVE FACTORS RESEARCH CAN GIVE US. 194 00:10:01,400 --> 00:10:04,603 IF WE CAN OUTLINE THAT TO MAKE CLINICIANS WHO DON'T KNOW 195 00:10:04,670 --> 00:10:08,174 STATISTICS UNDERSTAND WHAT THE ADVANTAGES OF SUCH A STUDY ARE 196 00:10:08,240 --> 00:10:11,344 OVER A CLINICAL TRIAL, I MEAN, IT'S REAL WORLD DATA. 197 00:10:11,410 --> 00:10:12,812 I THINK THAT'S THE BIGGEST ADVANTAGE. 198 00:10:14,347 --> 00:10:14,447 YEAH. 199 00:10:14,513 --> 00:10:19,085 SO SO TO SUMMARIZE YOUR OPINION AND I THINK MANY OF US WOULD 200 00:10:19,151 --> 00:10:23,489 AGREE THAT THERE'S A ROOM FOR A WHITE PAPER TO TO KIND OF 201 00:10:23,556 --> 00:10:27,827 POSITION WHAT COMPARATIVE EFFECTIVENESS CAN BRING TO THE 202 00:10:27,893 --> 00:10:32,531 TABLE AS DOES ANYONE HAVE AN OPPOSING OPINION ON THAT AND WHY 203 00:10:32,598 --> 00:10:34,367 OR SUPPORTS IT AND WHY. 204 00:10:36,769 --> 00:10:40,039 SO I I THINK IT'S A GOOD IDEA BUT MY MY THOUGHT IS I JUST WANT 205 00:10:40,106 --> 00:10:42,908 TO MAKE SURE THAT PEOPLE ARE AWARE THAT IT IT DOESN'T 206 00:10:42,975 --> 00:10:45,978 NECESSARILY HAVE TO ONLY BE A A WHITE PAPER IT COULD BE A 207 00:10:46,045 --> 00:10:46,746 METHODS PAPER. 208 00:10:46,812 --> 00:10:49,982 SO I'M ONE OF THE I'M THE ASSOCIATE EDITOR FOR METHODS AND 209 00:10:50,049 --> 00:10:53,319 STATISTICS AT NEUROLOGY AND WE HAVE METHODS AND IN NEUROLOGY 210 00:10:53,386 --> 00:10:56,722 PAPERS AND IT'S A SUBSECTION SO IT DOESN'T HAVE TO BE A WHITE 211 00:10:56,789 --> 00:10:57,123 PAPER. 212 00:11:02,028 --> 00:11:06,098 WE AGREE AND WE WE WE HAD A VERY ROUGH DRAFT THAT HAD BOTH METHOD 213 00:11:06,165 --> 00:11:06,932 SECTIONS AND. 214 00:11:06,999 --> 00:11:10,903 BUT IN THE END THE QUESTION IS THIS PRIMARILY FOR CLINICIANS OR 215 00:11:10,970 --> 00:11:14,473 FOR METHODOLOGIST OR BOTH OR SHOULD YOU HAVE A CLINICIANS 216 00:11:14,540 --> 00:11:18,177 PAPER AND A METHODS PAPER WHICH CAN REFERENCE TO EACH OTHER 217 00:11:18,244 --> 00:11:19,545 WHICH CAN ALSO BE DO. 218 00:11:24,050 --> 00:11:29,155 YEAH, YOU MEAN THAT'S THAT'S I MEAN I'M ALWAYS CONFUSED ABOUT 219 00:11:29,221 --> 00:11:34,260 THIS TERM WHITE PAPER, BUT YOU MEAN THAT YOU CAN ALSO RECORD 220 00:11:34,326 --> 00:11:36,595 THE METHODS PAPER AND MORE. 221 00:11:36,862 --> 00:11:39,565 YEAH, EXPLAIN THE METHODS BUT ALSO HOW THEY SHOULD BE 222 00:11:39,632 --> 00:11:40,266 INTERRUPTED. 223 00:11:40,332 --> 00:11:43,169 AND YEAH AND TO COME BACK ON THE COMPARATIVE FACTORS. 224 00:11:43,235 --> 00:11:46,472 SO I THINK AND JENNIFER WE HAVE BEEN MAILING AND TALKING ABOUT 225 00:11:46,539 --> 00:11:46,806 THAT. 226 00:11:47,206 --> 00:11:50,242 IF YOU LOOK AT THE ORIGINAL DEFINITIONS OF COMPARATIVE 227 00:11:50,309 --> 00:11:53,345 EFFECTIVENESS RESEARCH, IT'S IT SAYS IT HAS TO USE THE 228 00:11:53,412 --> 00:11:56,749 APPROPRIATE METHODS FOR THE QUESTION AT HAND OR SOMETHING. 229 00:11:56,982 --> 00:11:59,885 SO A PRAGMATIC RANDOMIZED CONTROLLED TRIAL WITH BROAD 230 00:11:59,952 --> 00:12:02,988 INCLUSION CRITERIA AND PATIENT OUTCOMES WOULD ALSO BE A 231 00:12:03,055 --> 00:12:05,291 COMPARATIVE EFFECTIVENESS RESEARCH STUDY. 232 00:12:05,357 --> 00:12:06,492 SO THAT IS THE ONLY THING. 233 00:12:06,559 --> 00:12:10,963 BUT I I NOW I THINK WE JUST HAVE TO MAKE CLEAR THAT IN THIS WHITE 234 00:12:11,030 --> 00:12:13,999 PAPER WE TALK ABOUT OBSERVATIONAL STUDIES OR 235 00:12:14,066 --> 00:12:16,035 ESTIMATING TREATMENT EFFECTS. 236 00:12:16,502 --> 00:12:19,939 SO THAT'S THE ONLY I WONDER IF WE SHOULD JUST CATCH IN TERMS OF 237 00:12:20,005 --> 00:12:23,275 REAL WORLD EVIDENCE RATHER THAN TRIALS EVIDENCE AND ACTUALLY 238 00:12:23,342 --> 00:12:25,311 ALLOW IT TO BE QUITE HETEROGENEOUS. 239 00:12:25,511 --> 00:12:28,080 BECAUSE I'D LIKE TO COIN A NEW PHRASE WHICH IS COMPARATIVE 240 00:12:28,147 --> 00:12:29,248 INEFFECTIVENESS STUDIES. 241 00:12:30,149 --> 00:12:32,551 BECAUSE I THINK YOU KNOW IN REALITY THERE'S THERE'S WHAT WE 242 00:12:32,618 --> 00:12:35,054 SHOULD DO WHICH WE OFTEN DON'T KNOW, WHAT WE THINK WE SHOULD 243 00:12:35,121 --> 00:12:37,690 DO, WHAT WE THINK WE DO, WHAT WE THINK WE DID AND WHAT ACTUALLY 244 00:12:37,756 --> 00:12:38,124 HAPPENED. 245 00:12:38,390 --> 00:12:40,259 AND THEY'RE OFTEN THE COMPLETELY DIFFERENT THINGS. 246 00:12:40,326 --> 00:12:42,061 SO WE THINK WE DO CERTAIN THINGS ACTUALLY. 247 00:12:42,828 --> 00:12:45,297 YOU KNOW, WE, I THINK ONE OF THE PROBLEMS ABOUT INTERVENTIONAL 248 00:12:45,364 --> 00:12:47,700 STUDIES IS THAT WE'RE LOOKING FOR INCREMENTALLY TINY LITTLE 249 00:12:47,766 --> 00:12:50,069 BENEFITS WHICH ARE PROBABLY THERE SOMEWHERE, RIGHT, IF YOU 250 00:12:50,136 --> 00:12:52,471 DID ENOUGH STUDY OR WHATEVER, BUT THEY'RE WASHED OUT BY THE 251 00:12:52,538 --> 00:12:54,807 FACT WE SCREW STUFF UP ALL THE TIME WE DO, WE DO, THERE'S 252 00:12:54,874 --> 00:12:56,675 HEALTHCARE, HEALTHCARE HAPPENS ALL THE TIME. 253 00:12:57,009 --> 00:13:00,279 SO ACTUALLY THE REAL WORLD EVIDENCE IS ABSOLUTELY CRUCIAL, 254 00:13:00,346 --> 00:13:03,549 IS ABSOLUTELY CRITICAL AND THAT'S THE KEY BIT I THINK FOR 255 00:13:03,616 --> 00:13:05,084 ME THAT'S A NICE DIMENSION. 256 00:13:05,151 --> 00:13:08,554 SO FOR INSTANCE FLUID PAPER, IT WAS NOT ONLY OR MAYBE NOT 257 00:13:08,621 --> 00:13:12,224 SPECIFICALLY ABOUT THE FLUIDS, BUT IT WAS ALSO ABOUT DO WE DO 258 00:13:12,291 --> 00:13:15,928 WHAT WE THINK WE DO BECAUSE WE ALL WANT EUVOLEMIA, BUT IN THE 259 00:13:15,995 --> 00:13:19,532 END SOME GIVE A LOT OF FLUIDS OTHER VERY MUCH LESS AND WE WE 260 00:13:19,598 --> 00:13:20,499 PURSUE THE SAME. 261 00:13:20,566 --> 00:13:23,369 SO AND STRANGE THINGS HAPPEN IN PRACTICE. 262 00:13:23,435 --> 00:13:27,840 SORRY, THERE WAS A QUESTION I COME BACK TO YOU, APOLOGIES THAT 263 00:13:27,907 --> 00:13:31,377 MAY BE COMING TO THIS OR NOT IN HERE QUITE RIGHT. 264 00:13:31,443 --> 00:13:34,480 BUT YOU KNOW THE COMPARATIVE EFFECTIVENESS RESEARCH, THE 265 00:13:34,547 --> 00:13:37,616 PATIENT CENTERED OUTCOMES RESEARCH INSTITUTE HERE IN THE 266 00:13:37,683 --> 00:13:40,319 US HAS DONE A VERY SPECIFIC DEFINITION OF THAT. 267 00:13:40,653 --> 00:13:43,455 YOU HAVE TO HAVE TWO EVIDENCE BASED APPROACHES, 2 OR MORE THAT 268 00:13:43,522 --> 00:13:45,357 THEN YOU'RE COMPARING AGAINST EACH OTHER. 269 00:13:45,424 --> 00:13:48,160 YOU COULD DO THAT IN A RANDOMIZED CLINICAL TRIAL OR YOU 270 00:13:48,227 --> 00:13:51,130 COULD DO IT WITH ONE OF THE OBSERVATIONAL METHODS THAT THAT 271 00:13:51,197 --> 00:13:52,031 GET AT CAUSALITY. 272 00:13:52,565 --> 00:13:53,799 YOU HAVE A CHOICE. 273 00:13:54,233 --> 00:13:57,169 WELL, I THINK WHAT WE'RE TALKING ABOUT HERE IS THE LARGER 274 00:13:57,236 --> 00:14:00,372 OBSERVATIONAL RESEARCH AND USE YOU KNOW LIKE A TECHNIQUE LIKE 275 00:14:00,439 --> 00:14:03,475 PROPENSITY SCORE ANALYSIS IS NOT COMPARATIVE EFFECTIVENESS. 276 00:14:03,542 --> 00:14:07,846 IT'S A YOU KNOW IT'S A TEMPTING TO GET AT CAUSALITY BUT WITHOUT 277 00:14:07,913 --> 00:14:09,515 A COMPARATIVE EFFECTNESS. 278 00:14:09,582 --> 00:14:12,751 SO I THINK OBSERVATIONAL RESEARCH IS OUR LARGER 279 00:14:12,818 --> 00:14:13,485 CONSTRUCT. 280 00:14:16,922 --> 00:14:17,723 OK, THANK YOU. 281 00:14:19,992 --> 00:14:23,329 AND I THINK THIS ALSO ILLUSTRATES THAT WE, WE MAY HAVE 282 00:14:23,395 --> 00:14:27,099 THIS WHITE PAPER TO CLARIFY WHAT WE'RE TALKING ABOUT BECAUSE 283 00:14:27,166 --> 00:14:30,603 EVERYONE, DEPENDING ON YOUR BACKGROUND, THINKS SOMETHING 284 00:14:30,669 --> 00:14:33,272 ELSE ABOUT IT OR HAS HIS OWN DEFINITIONS. 285 00:14:36,041 --> 00:14:36,242 YEAH. 286 00:14:39,445 --> 00:14:40,012 THANKS SO MUCH. 287 00:14:40,346 --> 00:14:43,349 AND THANK YOU, JOHN, FOR SAYING EXACTLY WHAT I WANTED TO SAY, 288 00:14:43,415 --> 00:14:44,817 BUT DIDN'T SAY CLEARLY ENOUGH. 289 00:14:44,883 --> 00:14:48,621 AND I THINK IT'S POSSIBLE THAT THIS IS JUST AUS EUROPEAN SORT 290 00:14:48,687 --> 00:14:52,224 OF DEFINITION ISSUE WHERE FOR ME COMPARATIVE EFFECTIVENESS 291 00:14:52,291 --> 00:14:55,861 RESEARCH DOES INVOLVE THE COMPARISON OF TWO EVIDENCE BASED 292 00:14:55,928 --> 00:14:56,595 TREATMENTS. 293 00:14:56,829 --> 00:14:59,732 SO, SO WHAT I'VE BEEN SEEING THAT'S BEING CALLED COMPARATIVE 294 00:14:59,798 --> 00:15:02,635 EFFECTIVENESS RESEARCH IN SOME OF THE STUDIES TO ME DOESN'T 295 00:15:02,701 --> 00:15:03,936 QUITE MEET THAT DEFINITION. 296 00:15:04,003 --> 00:15:08,274 HOWEVER, I LOVE REAL WORLD EVIDENCE FOR TBII THINK THAT 297 00:15:08,340 --> 00:15:12,945 THAT ENCOMPASSES ALL OF IT AND IS REALLY AN EXCELLENT TERM. 298 00:15:13,012 --> 00:15:17,216 SO I'M TRYING. 299 00:15:17,283 --> 00:15:20,286 I'M TRYING TO MAKE SURE THAT WE UNDERSTAND THIS, BUT THIS IS THE 300 00:15:20,352 --> 00:15:21,654 GENESIS OF HESTER'S QUESTION. 301 00:15:21,720 --> 00:15:25,324 AND THEN THIS IS THINGS THAT HAVE COME UP REPEATEDLY ABOUT 302 00:15:25,391 --> 00:15:26,959 WHAT IS THE CORRECT TERM. 303 00:15:27,359 --> 00:15:32,965 AND SOMETIMES THESE ARE OPERATIONAL TERMS, OPERATIONALLY 304 00:15:33,032 --> 00:15:37,636 DEFINED TERMS FOR PEOPLE TO STAY IN SCOPE, OK. 305 00:15:37,703 --> 00:15:40,739 SO FOR THE FOR PAKORI, THE PATIENT CENTERED OUTCOMES 306 00:15:40,806 --> 00:15:44,276 RESEARCH INSTITUTE WHICH IS A FEDERAL FUNDING AGENCY IN THE 307 00:15:44,343 --> 00:15:47,913 UNITED STATES, THEY HAVE TO BE VERY, VERY SPECIFIC ABOUT WHAT 308 00:15:47,980 --> 00:15:51,417 FALLS UNDER THEIR SCOPE SO THAT PEOPLE CAN ALSO UNDERSTAND, 309 00:15:51,483 --> 00:15:54,586 PLEASE DON'T SEND YOUR APPLICATION TO US BECAUSE IT'S 310 00:15:54,653 --> 00:15:55,621 NOT IN OUR SCOPE. 311 00:15:56,188 --> 00:16:01,226 AND SO LIKE IS THIS OR EVAL DOES THIS WHEN YOU HEAR THIS, THIS US 312 00:16:01,293 --> 00:16:06,165 BASED DEFINITION OF COMPARATIVE EFFECTIVENESS RESEARCH, DOES IT 313 00:16:06,231 --> 00:16:10,269 CONFLICT WITH YOUR UNDERSTANDING OF WHAT COMPARATIVE 314 00:16:10,336 --> 00:16:12,371 EFFECTIVENESS RESEARCH IS? 315 00:16:15,074 --> 00:16:20,179 AND THEN ARE WE BETTER OFF SAYING ARE WE BETTER OFF JUST 316 00:16:20,245 --> 00:16:25,417 USING THE WORD REAL WORLD EFFECTIVENESS OR SOMETHING ELSE 317 00:16:25,484 --> 00:16:30,756 SO THAT WE'RE JUST SO THAT WE'RE NOT CREATING THE ISSUE OF 318 00:16:30,823 --> 00:16:31,724 CONFUSION. 319 00:16:31,924 --> 00:16:35,361 I I THINK MY, AS AN AUSTRALIAN, SOMEONE WHO'S COMPLETELY OUT OF 320 00:16:35,427 --> 00:16:38,530 BOTH OF THOSE SYSTEMS, MY DEFINITION OR MY UNDERSTANDING 321 00:16:38,597 --> 00:16:41,333 OF THE TERM COMPARATIVE EFFECTIVENESS RESEARCH WAS 322 00:16:41,400 --> 00:16:44,570 ACTUALLY JUST COMPARING WHAT HAPPENS IN HOSPITAL A IN THIS 323 00:16:44,636 --> 00:16:47,606 COUNTRY TO WHAT HAPPENS IN HOSPITAL B IN THAT COUNTRY. 324 00:16:47,673 --> 00:16:48,807 THAT'S WHAT I THOUGHT IT WAS. 325 00:16:56,081 --> 00:16:59,451 SO INDEED, AND I THINK, AND THAT IS PROBABLY THE FAULT OF CENTRE, 326 00:16:59,518 --> 00:17:02,254 TBI AND MAYBE THEN MYSELF BECAUSE THAT'S HOW WE HAVE 327 00:17:02,321 --> 00:17:03,188 INDEED PRESENTED. 328 00:17:03,622 --> 00:17:07,726 BUT IT'S ACTUALLY A SPECIFIC METHOD, INSTRUMENTAL VARIABLE 329 00:17:07,793 --> 00:17:12,331 ANALYSIS RATHER THAN PROPENSITY SCORE MATCHING OR ANOTHER METHOD 330 00:17:12,398 --> 00:17:15,601 TO TRY TO ADJUST FOR CO FOUNDING BASICALLY. 331 00:17:15,667 --> 00:17:18,837 SO IT'S ONE METHOD IN THE COMPARATIVE EFFECTIVENESS REACH 332 00:17:18,904 --> 00:17:22,007 THAT YOU CAN USE FOR COMPARATIVE EFFECTIVENESS RESEARCH. 333 00:17:22,074 --> 00:17:26,178 AND ONE MORE THING TO JENNIFER, I THINK WE KNOW IN EUROPE AS 334 00:17:26,245 --> 00:17:29,948 WELL THESE THE, THE, YEAH, THE TERM AND AND THE FORMAL 335 00:17:30,015 --> 00:17:34,019 DEFINITION AS THE OR AS THE FORMAL, I DON'T KNOW HOW IT WAS 336 00:17:34,086 --> 00:17:38,357 ONCE DEFINED BY THE INSTITUTES OF HEALTH HAS THESE ELEMENTS OF 337 00:17:38,424 --> 00:17:42,161 PATIENTS RELEVANT OUTCOMES COMPARING TO THINGS THAT ARE 338 00:17:42,227 --> 00:17:44,563 ALREADY COMMON PRACTICE ETCETERA. 339 00:17:45,664 --> 00:17:50,002 I THINK THE MAIN PROBLEM IS THE CONFUSION WITH RANDOMIZED OR NOT 340 00:17:50,068 --> 00:17:53,505 RANDOMIZED IN MY MIND AND THEN REAL WORLD EVIDENCE. 341 00:17:53,572 --> 00:17:54,106 YEAH, I DON'T KNOW. 342 00:17:56,108 --> 00:17:58,744 I MEAN, I THINK THERE'S A THERE'S A SORT OF STATISTICAL 343 00:17:58,811 --> 00:18:01,680 COMMON GOLDEN THREAD THAT RUNS THROUGH A LOT OF THESE THINGS, 344 00:18:01,747 --> 00:18:04,750 WHICH IS ESSENTIALLY WHAT A LOT OF THESE THINGS WE'RE TRYING TO 345 00:18:04,817 --> 00:18:07,386 DO IS EXPLOIT HOPEFULLY RANDOM OR AT LEAST PREDICTABLE 346 00:18:07,453 --> 00:18:08,353 VARIATIONS IN CARE. 347 00:18:08,720 --> 00:18:11,690 AND YOU MIGHT EXPLOIT THAT FROM CENTRE TO CENTRE OR YOU MIGHT 348 00:18:11,757 --> 00:18:14,760 EXPLOIT IT JUST FROM BETWEEN PATIENTS OR YOU MIGHT EXPLOIT IT 349 00:18:14,827 --> 00:18:17,429 BETWEEN PRACTITIONERS OR YOU MIGHT EXPLOIT IT BETWEEN 350 00:18:17,496 --> 00:18:19,298 PRACTITIONERS BEFORE AND AFTER LUNCH. 351 00:18:19,364 --> 00:18:20,199 IT DOESN'T MATTER. 352 00:18:20,432 --> 00:18:23,602 AS LONG AS YOU'VE GOT A BIG ENOUGH COHORT THEN YOU CAN KIND 353 00:18:23,669 --> 00:18:26,872 OF FIND A MATCHING TWIN, IF YOU LIKE IN SOME STATISTICAL WAY 354 00:18:26,939 --> 00:18:29,875 THAT THAT LOOKS SIMILAR BUT GOT A DIFFERENT TREATMENT. 355 00:18:30,642 --> 00:18:31,477 THAT'S THE KIND OF THREAD. 356 00:18:31,543 --> 00:18:33,846 I MEAN, YOU KNOW, I'M RATHER SIMPLIFYING ALL OF THESE MODELS 357 00:18:33,912 --> 00:18:34,179 METHODS. 358 00:18:34,246 --> 00:18:38,584 BUT BASICALLY I MEAN I I THINK I KNOW I CAME UP WITH IT. 359 00:18:38,650 --> 00:18:41,286 I THINK REAL WORLD EVIDENCE IS, AND I'M HEARING IT A LOT PEOPLE 360 00:18:41,353 --> 00:18:42,654 ARE USING THIS IN OTHER DOMAINS. 361 00:18:42,721 --> 00:18:45,958 AND IT IS ABOUT, IT'S ALL ABOUT USING THE DATA WE'VE GOT IN THE 362 00:18:46,024 --> 00:18:48,994 REAL WORLD TO FIND OUT WHAT WHAT WORKS AND WHAT DOESN'T. 363 00:18:50,195 --> 00:18:53,332 AND I THINK IT DO YOU, WOULD YOU AGREE THAT IT EXCLUDES 364 00:18:53,398 --> 00:18:55,234 RANDOMIZATION OR INTERVENTIONAL? 365 00:18:55,434 --> 00:18:55,701 YEAH. 366 00:18:55,901 --> 00:19:00,405 CAN I JUST ASK THE ROOM, DO YOU THINK THERE ARE ANY UNINTENDED 367 00:19:00,472 --> 00:19:04,643 CONSEQUENCES FROM CHANGING AND USING THIS KIND OF A TERM? 368 00:19:04,943 --> 00:19:10,682 WE MENTIONED FUNDING BODIES AND BEING ABLE TO USE, YOU KNOW, 369 00:19:10,749 --> 00:19:16,455 LIKE IS THIS GOING TO UPSET FUNDERS OR UPSET INSTITUTES THAT 370 00:19:16,522 --> 00:19:22,261 ARE SUPPOSED TO USE A PARTICULAR TYPE OF RESEARCH AS LONG AS 371 00:19:22,327 --> 00:19:27,866 WE'RE CREATING A TERM, A PHRASE I'VE ALWAYS LIKED A LOT IS 372 00:19:27,933 --> 00:19:30,202 PRACTICE BASED EVIDENCE. 373 00:19:31,236 --> 00:19:34,373 BECAUSE IT, YOU KNOW, IT PLAYS OFF OF EVIDENCE BASED PRACTICE 374 00:19:34,439 --> 00:19:34,973 OBVIOUSLY. 375 00:19:35,307 --> 00:19:38,810 BUT WHEN YOU'RE USING ACTUAL REAL WORLD TREAT, YOU KNOW, 376 00:19:38,877 --> 00:19:42,881 PRACTICE DATA IN SOME WAY, THEN YOU CAN USE IT ANY WAY YOU WANT, 377 00:19:42,948 --> 00:19:43,382 FRANKLY. 378 00:19:43,448 --> 00:19:44,917 YOU CAN DO COMPARATIVE EFFECTIVENESS. 379 00:19:44,983 --> 00:19:49,121 YOU CAN DO PROPENSITY SCORE ANALYSIS OR OTHER OTHER METHODS. 380 00:19:52,291 --> 00:19:52,824 NOT AT THAT. 381 00:19:52,891 --> 00:19:56,895 I'M COMPLETELY AGAINST RETERMING IT, BUT I I DO WANT TO PUT OUT A 382 00:19:56,962 --> 00:19:59,798 WORD OF CAUTION FOR NON STATISTICALLY EDUCATED 383 00:19:59,865 --> 00:20:03,168 CLINICIANS, WHICH IS PROBABLY 90% OF THEM OUT THERE. 384 00:20:03,802 --> 00:20:09,975 THAT CER IS A RESPECTED TERM FOR A SOLID METHODOLOGY EVEN IF THEY 385 00:20:10,042 --> 00:20:11,910 DON'T UNDERSTAND IT. 386 00:20:12,544 --> 00:20:16,348 SO IF WE NOW COME UP WITH A NEW TERM THAT NO ONE'S HEARD BEFORE 387 00:20:16,415 --> 00:20:20,252 AND WHILE WE THINK REFLECTS MORE OF WHAT WE'RE ACTUALLY DOING, I 388 00:20:20,319 --> 00:20:23,722 WORRY THAT IN THEIR HEAD, AS THEY'RE READING THE ABSTRACT 389 00:20:23,789 --> 00:20:27,459 THAT COMES OUT IN THE IN THE JOURNAL, THEY MAY NOT TAKE IT AS 390 00:20:27,526 --> 00:20:31,430 SERIOUSLY OR MAY NOT THINK OF IT AS THIS IS, YOU KNOW, INCREDIBLY 391 00:20:31,496 --> 00:20:35,133 IMPORTANT DATA OR MAY NOT EVEN THINK, OH, MAYBE WE SHOULD PUT 392 00:20:35,200 --> 00:20:36,368 THIS IN GUIDELINES. 393 00:20:36,702 --> 00:20:40,072 AGAIN, IT'S MORE OF THE PERCEPTION OF THE UNEDUCATED 394 00:20:40,138 --> 00:20:43,742 CLINICIAN AND THAT'S WHAT WE'RE TRYING TO CHANGE, RIGHT. 395 00:20:43,809 --> 00:20:46,545 I MEAN LOOKING BACK AT THE FLUID THING, WE'RE TRYING TO GIVE 396 00:20:46,612 --> 00:20:47,512 PATIENTS LESS FLUID. 397 00:20:48,280 --> 00:20:49,414 SO WE'RE TRYING TO CHANGE PRACTICE. 398 00:20:49,481 --> 00:20:50,616 SO IT NEEDS TO BE PRACTICAL. 399 00:20:50,682 --> 00:20:52,351 SO THAT'S JUST A WORD OF CAUTION. 400 00:20:53,685 --> 00:20:57,189 SO LET'S IN THE INTERESTING, I DO AGREE THAT WE, I THINK IT'S A 401 00:20:57,255 --> 00:21:00,359 GOOD DISCUSSION, BUT WE SHOULDN'T TRY TO KIND OF CHANGE 402 00:21:00,425 --> 00:21:01,760 ESTABLISHED TERMINOLOGY. 403 00:21:01,994 --> 00:21:05,230 WE SHOULD CLARIFY WHAT'S THERE AND THEN LET'S SEE HOW TO MAKE 404 00:21:05,297 --> 00:21:06,131 BETTER USE OF IT. 405 00:21:06,198 --> 00:21:06,331 YEAH. 406 00:21:07,199 --> 00:21:08,000 AND I APPRECIATE. 407 00:21:08,200 --> 00:21:11,503 I APPRECIATE THE THE THE CONCERNS ABOUT TIME BUT THE 408 00:21:11,570 --> 00:21:15,707 IRONY HERE IS THAT WE'RE THIS IS LIKE A MAJOR OUTPUT OF THIS WORK 409 00:21:15,774 --> 00:21:19,645 GROUP AND WE DON'T HAVE WE DON'T HAVE CLARITY OR AGREEMENT ON 410 00:21:19,711 --> 00:21:21,346 WHAT TO WHAT TO CALL THIS. 411 00:21:21,713 --> 00:21:24,950 AND THEN WHEN IT COMES TO FUNDING AGENCIES, THE ORIGINAL 412 00:21:25,017 --> 00:21:28,687 TRACK GRANT THAT WE GOT IN 2009 WAS 1 MECHANISM BUT THEN IN 2000 413 00:21:28,754 --> 00:21:31,089 WE NOW THAT CALL THAT THAT TRACK PILOT. 414 00:21:31,590 --> 00:21:35,360 IN 2013 WHEN WE GOT THE MAJOR GRANT THAT WE NOW START TO REFER 415 00:21:35,427 --> 00:21:38,630 TO AS TRACK, IT WAS BY DEFINITION MANDATORY FOR US TO 416 00:21:38,697 --> 00:21:41,066 DO COMPARATIVE EFFECTIVENESS RESEARCH. 417 00:21:41,333 --> 00:21:44,036 AND BY THE DEFINITION THAT THE TWO OF YOU JUST USED NOT ONE 418 00:21:44,102 --> 00:21:46,805 SINGLE THING IN THAT GRANT WAS COMPARATIVE EFFECTIVENESS. 419 00:21:49,041 --> 00:21:54,012 SO THAT'S TRICKY AND AND ARE YOU KNOW SO ARE WE BETTER SERVED 420 00:21:54,079 --> 00:21:58,917 LIKE REACHING AN AGREEMENT ON WHAT IS BEST AND SO WHAT I'VE 421 00:21:58,984 --> 00:22:03,989 HEARD SO FAR IS PRACTICE BASED EVIDENCE REAL WORLD DATA OR TO 422 00:22:04,056 --> 00:22:08,527 STICK WITH COMPARATIVE EFFECTIVENESS RESEARCH OR ARE WE 423 00:22:08,593 --> 00:22:10,062 MISSING SOMETHING? 424 00:22:10,762 --> 00:22:14,099 I THINK I THINK IT WOULD BE BENEFICIAL TO ACTUALLY HAVE AN 425 00:22:14,166 --> 00:22:16,201 AN AGREEMENT ON WHAT TO CALL THIS. 426 00:22:21,473 --> 00:22:24,676 YEAH BUT THAT BUT AGAIN WILL AGAIN A LITTLE BIT OPPOSING LIKE 427 00:22:24,743 --> 00:22:28,146 WITH THE TROPONIN I I THINK IT'S ABOUT THE THE LEVEL OF CAUSALITY 428 00:22:28,213 --> 00:22:30,916 BASED ON OBSERVATIONAL DATA AND THE LEVEL HOW THESE 429 00:22:30,982 --> 00:22:33,318 OBSERVATIONAL ANALYSIS MIGHT INFORM PRACTICE. 430 00:22:33,385 --> 00:22:38,323 I I DON'T ACTUALLY CARE MUCH ON HOW YOU MENTION IT BUT IT'S IT'S 431 00:22:38,390 --> 00:22:42,961 ABOUT WHAT GOAL ARE WE TRYING TO ACCOMPLISH WITH CLARIFYING 432 00:22:43,028 --> 00:22:47,566 METHODOLOGY AND WHAT WHAT CAN WE EXTRACT THE MAXIMUM OUT OF 433 00:22:47,632 --> 00:22:52,637 OBSERVATIONAL DATA OR AND CAN IT BE INSTRUCTED FOR GUIDELINES AND 434 00:22:52,704 --> 00:22:54,406 AND INFORMAL PRACTICE. 435 00:22:54,706 --> 00:22:59,911 SO YEAH HOWEVER YOU YOU MENTION IT THAT'S SOMETHING WE CAN 436 00:22:59,978 --> 00:23:03,081 DISCUSS IN THE IN THE WHITE PAPER. 437 00:23:04,349 --> 00:23:07,719 I WANTED TO MENTION THE THE AVIATION INDUSTRY BECAUSE THEY 438 00:23:07,786 --> 00:23:11,490 HAVE BEEN SUCCESSFUL IN FINDING CORE ROUTES TO PROBLEMS AND THEY 439 00:23:11,556 --> 00:23:15,127 USE A METHOD KNOWN AS CASE BASED REASONING WHICH KIND OF FITS 440 00:23:15,193 --> 00:23:18,430 INTO WHAT YOU'RE TALKING ABOUT ABOUT DIGITAL DEPLOYING. 441 00:23:19,231 --> 00:23:22,501 I DON'T KNOW HOW WELL IT OR HOW CLOSE IT IS TO COMPARATIVE 442 00:23:22,567 --> 00:23:23,869 EFFECTIVENESS RESEARCH. 443 00:23:24,603 --> 00:23:27,372 I THINK WITH CR IT ASSUMES YOU HAVE ENOUGH PATIENTS THAT ARE 444 00:23:27,439 --> 00:23:30,041 SIGNIFICANTLY SIMILAR TO ONE ANOTHER IN ORDER TO MAKE AN 445 00:23:30,108 --> 00:23:32,277 INFORMED SPECIFICALLY STATISTICALLY SIGNIFICANT 446 00:23:32,344 --> 00:23:32,744 DECISION. 447 00:23:34,246 --> 00:23:35,413 SO THAT THAT'S JUST MY THOUGHTS. 448 00:23:37,315 --> 00:23:40,986 CAN I JUST SUGGEST THAT WE MOVE ON BUT PARK THIS AND NOT LEAVE 449 00:23:41,052 --> 00:23:44,389 THE ROOM AT THE END UNTIL, BUT I THINK THE DECISION, THE 450 00:23:44,456 --> 00:23:48,160 DISCUSSION THAT WE CONTINUE TO HAVE WILL HELP TO INFORM THIS. 451 00:23:48,627 --> 00:23:52,330 SO LET'S, I THINK WE'VE ALREADY COVERED IS IT WORTH DOING. 452 00:23:52,397 --> 00:23:54,866 WE'VE BEEN TALKING ABOUT A DEFINITION, SO A LOT OF WHAT 453 00:23:54,933 --> 00:23:56,501 WE'VE TALKED ABOUT WILL WILL HELP. 454 00:23:57,102 --> 00:24:00,939 SO I'D LIKE TO HAND OVER TO HESTER TO TAKE US THROUGH SOME 455 00:24:01,006 --> 00:24:05,310 OF THE THE OUTLINE FOR THE WHITE PAPER AND WHAT SHOULD BE COVERED 456 00:24:05,377 --> 00:24:09,347 AND HOW WE CAN PITCH IT SO THAT IT IS PERCEIVED AS SOMETHING 457 00:24:09,414 --> 00:24:12,450 THAT CAN HELP CHANGE PRACTICE FOR THE BETTER. 458 00:24:20,559 --> 00:24:24,763 SO DO YOU WANNA GIVE THE OVERVIEW FIRST OR PER SLIDE OPEN 459 00:24:24,830 --> 00:24:28,767 THE DISCUSSION WHILE YOU'RE GOING THROUGH THE THE THE 460 00:24:28,834 --> 00:24:31,970 HEADINGS, LET'S SEE WHAT EVERYBODY WANTS. 461 00:24:32,704 --> 00:24:33,772 IT DOESN'T MATTER ACTUALLY. 462 00:24:35,006 --> 00:24:36,341 I THINK WE SHOULD COME FIRST. 463 00:24:38,910 --> 00:24:40,779 NOW LET'S GO TO THE OUTLINE AND THINGS WILL COME UP. 464 00:24:40,846 --> 00:24:44,549 SO PLEASE DON'T RESTRICT YOURSELF TO OPINIONS THAT ARE OR 465 00:24:44,616 --> 00:24:48,186 TO THINGS THAT ARE ONLY THINGS THAT ARE ON THE SLIDES. 466 00:24:48,453 --> 00:24:53,024 SO IT IS NICE THAT WE HAVE THESE DISCUSSIONS BECAUSE IT'S I THINK 467 00:24:53,091 --> 00:24:57,596 IT HIGHLIGHTS THE NEEDS TO WRITE DOWN FOR OURSELVES ALSO WHAT WE 468 00:24:57,662 --> 00:25:00,265 MEAN EXACTLY AND WHAT WE WANT TO DO. 469 00:25:01,967 --> 00:25:06,171 SO WE HAVE MADE SORT OF AN THERE MANY PEOPLE HAVE ALREADY 470 00:25:06,238 --> 00:25:10,642 PROVIDED INPUT ON THE ON THE DRAFT TEXT OF THE WHITE PAPER. 471 00:25:10,842 --> 00:25:15,113 WE TOOK ONE STEP BACK AND MADE MORE OF AN OUTLINE TO ALL AGREE 472 00:25:15,180 --> 00:25:19,317 ON WHAT SHOULD BE COVERED AND THE OUTLINE IS ON THE SLIDE SO 473 00:25:19,384 --> 00:25:20,852 WE CAN GO THROUGH IT. 474 00:25:21,119 --> 00:25:26,625 BUT AS I SAID THIS MORNING IN MY OVER, IN OUR VIEW THE AIM WOULD 475 00:25:26,691 --> 00:25:28,627 BE TO CLARIFY CONCEPTS. 476 00:25:28,693 --> 00:25:34,199 NOW I THINK THIS SHOWS THAT THAT IS USEFUL AND THEN TO PROVIDE 477 00:25:34,266 --> 00:25:39,404 RECOMMENDATIONS ON HOW TO DESIGN COMPARATIVE EFFECTIVENESS 478 00:25:39,471 --> 00:25:41,873 OBSERVATIONAL SPECIFICALLY. 479 00:25:42,173 --> 00:25:46,077 SO I GUESS WE SHOULD WHATEVER WE CALL IT RIGHT FROM THE START, WE 480 00:25:46,144 --> 00:25:49,848 WILL SAY THAT WE WILL NOT TALK ABOUT RANDOMIZED TRIALS BUT ON 481 00:25:49,915 --> 00:25:51,716 OBSERVATIONAL REAL WORLD DATA. 482 00:25:53,084 --> 00:25:56,955 SO HOW DO YOU DESIGN SUCH A STUDY AND THERE HOW YOU ANALYZE 483 00:25:57,022 --> 00:26:01,092 IT AND HOW YOU INTERPRET IT AND WHAT COULD BE THE IMPLICATIONS 484 00:26:01,159 --> 00:26:02,527 FOR CLINICAL PRACTICE. 485 00:26:02,594 --> 00:26:07,699 AND OF COURSE THE LAST TWO THINGS ARE CLOSELY RELATED AND 486 00:26:07,766 --> 00:26:12,938 IN THE METHODOLOGIST VIEW THE THE INTERPRETATION OF COURSE 487 00:26:13,004 --> 00:26:18,543 CLOSELY RELATED TO THE DESIGN AND THE METHODS REMARKS TO THAT. 488 00:26:18,610 --> 00:26:28,653 SO THAT OVERALL CONTENT OR OUTLINE THIS SPEAK UP OF COURSE 489 00:26:28,720 --> 00:26:32,624 IF YOU INTERRUPT, YEAH. 490 00:26:32,691 --> 00:26:36,361 SO, SO THE START WOULD BE THE RATIONALE FOR COMPARATIVE 491 00:26:36,428 --> 00:26:40,699 EFFECTIVENESS RESEARCH AS IT WAS INITIALLY OUTLINED SPECIFICALLY 492 00:26:40,765 --> 00:26:45,003 IN THE US THE FACT THAT MANY THE PRACTICE IS ACTUALLY NOT BASED 493 00:26:45,070 --> 00:26:48,606 ON EVIDENCE BECAUSE THE RANDOMISED TRIALS USUALLY NOT 494 00:26:48,673 --> 00:26:52,544 MEET OR NOT INFORM THE REAL CLINICAL QUESTIONS THAT ARE AT 495 00:26:52,610 --> 00:26:55,747 HAND DUE TO RESTRICTED POPULATIONS, NOT PATIENT 496 00:26:55,814 --> 00:26:57,649 RELEVANT OUTCOMES ETCETERA. 497 00:26:58,350 --> 00:27:02,520 BUT THEN AND THEN MOVE TO TBI THAT IN TBI SPECIFICALLY RCTS 498 00:27:02,587 --> 00:27:06,691 HAS NOT HAVE NOT BROUGHT US WHAT WE WOULD HAVE HOPED FOR. 499 00:27:08,994 --> 00:27:12,430 AND THEN TO MAKE THE POINT THAT WE THEREFORE NOW HAVE THESE 500 00:27:12,497 --> 00:27:15,633 LARGE OBSERVATIONAL DATA SETS THAT WE NOW CAN ANALYZE, 501 00:27:15,700 --> 00:27:17,902 PREFERABLY JOINTLY BUT ALSO SEPARATE. 502 00:27:18,803 --> 00:27:22,774 BUT IT'S IMPORTANT TO AVOID BOTH OVER AND UNDER INTERPRETATION. 503 00:27:22,841 --> 00:27:27,112 SO NOT TO USE TOO SIMPLE METHODS TO DEAL WITH CONFOUNDING AND 504 00:27:27,178 --> 00:27:31,049 THEN DRAW CONCLUSION THAT IS BIAS OR THAT IS NOT TRUE. 505 00:27:32,384 --> 00:27:35,920 SO THEN THE AIM IS NOW FORMULATED LIKE THIS TO MAKE 506 00:27:35,987 --> 00:27:40,325 MAXIMAL USE OF SO TO LINK IT TO THE FACT THAT WE HAVE ALL THESE 507 00:27:40,392 --> 00:27:41,359 EXISTING DATA. 508 00:27:41,726 --> 00:27:44,095 WHEREAS WE ALSO WANT TO SAY SOMETHING I GUESS WHEN YOU NOW 509 00:27:44,162 --> 00:27:45,263 SET UP A PROSPECTIVE STUDY. 510 00:27:45,764 --> 00:27:51,136 BUT THAT THE THE RATIONALE IS ALSO ABOUT USING THE DATA THAT 511 00:27:51,202 --> 00:27:56,775 WE HAVE ALREADY COLLECTED AND ALL THE REAL WORLD DATA THAT ARE 512 00:27:56,841 --> 00:28:00,311 EVERYDAY COLLECTED IN EHR FOR EXAMPLE. 513 00:28:01,679 --> 00:28:05,350 SO WE AIM TO GUIDE CLINICIANS RESEARCH AND FUNDERS ARE QUITE 514 00:28:05,417 --> 00:28:09,287 BROAD WITH DESIGN EXECUTION AND INTERPRETATIONS OF PROFESSIONAL 515 00:28:09,354 --> 00:28:10,288 SEARCH STUDIES. 516 00:28:11,556 --> 00:28:12,223 COMMENTS. 517 00:28:12,957 --> 00:28:13,224 THOUGHTS. 518 00:28:14,025 --> 00:28:14,192 ARIE? 519 00:28:21,966 --> 00:28:22,600 NO, I AGREE. 520 00:28:22,667 --> 00:28:25,804 I'LL DEFINITELY MAKE THE THING ABOUT ELECTRONIC HEALTH RECORDS 521 00:28:25,870 --> 00:28:26,805 ROUTINE EXCESS DATA. 522 00:28:26,871 --> 00:28:30,408 NOW THIS IS FOR THE HIGH INCOME COUNTRY SPECIFIC RATHER THAN 523 00:28:30,475 --> 00:28:34,212 LONDON, SO I APPRECIATE IT NOT, YOU KNOW, GLOBAL, BUT THE SPACE 524 00:28:34,279 --> 00:28:37,615 OF HOSPITALS THAT DON'T HAVE ELECTRONIC HEALTH RECORDS IS 525 00:28:37,682 --> 00:28:39,884 GOING TO BECOME SMALLER AND SMALLER. 526 00:28:40,285 --> 00:28:42,620 CENTRE AND TRACK WERE PHENOMENALLY EXPENSIVE IN TERMS 527 00:28:42,687 --> 00:28:43,788 OF TIME AND ACTUAL MONEY. 528 00:28:44,489 --> 00:28:47,225 ACTUALLY WITH A BIT OF AN EFFORT WE CAN BE COLLECTING THE RIGHT 529 00:28:47,292 --> 00:28:49,494 DATA AS PART OF CLINICAL PRACTICE AND WE SHOULD BE 530 00:28:49,561 --> 00:28:52,163 BECAUSE THE LAST TWO DAYS HAVE SHOWN US THAT THESE ARE DATA 531 00:28:52,230 --> 00:28:54,866 THAT WE SHOULD BE COLLECTING BECAUSE WE THINK IT'S IMPORTANT 532 00:28:54,933 --> 00:28:56,167 TO DEFINE THE TBI PHENOTYPE. 533 00:28:57,202 --> 00:28:59,637 SO I AND SO THAT WILL JUST THINK GROW AND GROW AND GROW AND IT'S 534 00:28:59,704 --> 00:29:00,638 A BIG OPPORTUNITY I THINK. 535 00:29:00,705 --> 00:29:03,942 SO WE SHOULD EXPLICITLY NO I AGREE. 536 00:29:04,008 --> 00:29:07,745 AND THAT WOULD THEN IN THE RECOMMENDATIONS REQUIRE MORE 537 00:29:07,812 --> 00:29:11,749 ATTENTION TO ALSO DEFINITIONS, HOW TO IDENTIFY POPULATIONS 538 00:29:11,816 --> 00:29:12,383 ETCETERA. 539 00:29:12,450 --> 00:29:17,155 SO THAT WOULD BE THAT SORT OF AN EXTRA BUT I I AGREE OTHER 540 00:29:17,222 --> 00:29:20,658 PEOPLE, SPONSORS MAYBE A COUNTER QUESTION. 541 00:29:20,725 --> 00:29:26,364 ARE THERE CLINICIANS HERE OR METHODOLOGIES THAT THAT THINK WE 542 00:29:26,431 --> 00:29:31,035 SHOULD CLARIFY THIS TO TO HELP CLINICAL PRACTICE. 543 00:29:31,369 --> 00:29:36,341 IS THERE A HOW DO YOU SAY BOTH THERE NEED, IS THERE A NEED TO 544 00:29:36,407 --> 00:29:41,312 TO DO THIS EXERCISE TO BE ABLE TO BETTER INTERPRET DIFFERENT 545 00:29:41,379 --> 00:29:45,950 LEVEL OF LEVELS OF OBSERVATIONAL STUDY WITH A COMPARATOR 546 00:29:46,017 --> 00:29:49,420 TREATMENT ONE TREATMENT VERSUS THE OTHER. 547 00:29:51,756 --> 00:29:55,460 I THINK SUSANNA AND ELOQUENTLY SAID THAT THE NEED IS THERE AND 548 00:29:55,527 --> 00:29:59,297 I THINK MANY OF US AGREE, BUT I I MAYBE IT'S GOOD THAT WE DON'T 549 00:29:59,364 --> 00:30:03,067 HEAR MANY COUNTER ARGUMENTS SO MAYBE WE SHOULD LEAVE THAT THAT 550 00:30:03,134 --> 00:30:03,801 THEY'LL GO. 551 00:30:07,872 --> 00:30:08,273 THANK YOU. 552 00:30:08,806 --> 00:30:13,011 WE ARE HERE WITH ALL PEOPLE DOING CLINICAL SCIENCE AND AND 553 00:30:13,077 --> 00:30:15,280 WE ARE NOT THE GENERAL PUBLIC. 554 00:30:16,881 --> 00:30:21,486 SO IF I AGREE WITH THE WHITE PAPER, BUT IT SHOULD ALSO TAKE 555 00:30:21,553 --> 00:30:26,324 INTO ACCOUNT THAT THE ANALYZES YOU USE IN CER COMPARED TO RCT 556 00:30:26,391 --> 00:30:30,662 IS FOR NORMAL CLINICIANS VERY DIFFICULT TO UNDERSTAND. 557 00:30:32,363 --> 00:30:35,833 SO IT TOOK WITH ME ONE YEAR TO UNDERSTAND WHAT YOU AND THOMAS 558 00:30:35,900 --> 00:30:39,370 DID AND I WAS NOT VERY HAPPY IN THE BEGINNING, YOU REMEMBER. 559 00:30:39,904 --> 00:30:43,408 SO I THINK THAT IF YOU WRITE A WHITE PAPER, THE AUDIENCE SHOULD 560 00:30:43,474 --> 00:30:45,510 BE BROADER THAN PEOPLE SITTING HERE. 561 00:30:46,077 --> 00:30:51,349 IT SHOULD BE PROBABLY FOR A VERY BIG AUDIENCE OF PEOPLE WHO ARE 562 00:30:51,416 --> 00:30:54,686 NOT STATISTICAL TRAITS OR A LITTLE BIT. 563 00:30:54,752 --> 00:30:58,256 I THINK THAT'S A VERY IMPORTANT COMMENT BECAUSE WHEN WHEN WE 564 00:30:58,323 --> 00:31:02,093 UNDERSTAND IT AND ADOPT IT, THAT MIGHT NOT HOLD FOR ANYONE WHO'S 565 00:31:02,160 --> 00:31:04,429 NOT INVOLVED IN ANY CLINICAL RESEARCH. 566 00:31:06,764 --> 00:31:10,001 YEAH, SO, SO DEFINITELY THAT THERE MAY BE WIDER SCOPE FOR 567 00:31:10,068 --> 00:31:13,338 COMPARATIVE EFFECTIVENESS AND EXPLAINING IT TO MORE NORMAL 568 00:31:13,404 --> 00:31:14,439 PEOPLE IN A SENSE. 569 00:31:14,706 --> 00:31:20,178 AND ALSO WHAT I WONDERED ABOUT IN THE AIM AS YOU PUT IT, YOU 570 00:31:20,245 --> 00:31:25,750 SAID MAXIMIZE USE CAN CAN BE REPLACED THAT BY TO MAKE DEFINE 571 00:31:25,817 --> 00:31:28,019 SAY MINIMAL REQUIREMENTS. 572 00:31:28,086 --> 00:31:31,289 SO NOT MAXIMIZE BUT MINIMIZE REQUIREMENTS IN LINE WITH WHAT 573 00:31:31,356 --> 00:31:34,559 WE KNOW FROM CAUSAL INFERENCE LIKE POSITIVITY DEFINITION. 574 00:31:34,626 --> 00:31:37,462 YOU NEED TO KNOW WHAT YOU'RE TALKING ABOUT THAT IF YOU SAY 575 00:31:37,528 --> 00:31:40,565 THIS IS A TREATMENT, IT'S NOT VERY LOCALLY DEFINED BY PRACTICE 576 00:31:40,632 --> 00:31:43,635 IN ONE CENTER, BUT IT'S REALLY IT'S A POSITIVE THE ASSUMPTION 577 00:31:43,701 --> 00:31:46,337 IN THE CAUSE OF INFLUENCE RESEARCH, RIGHT THAT YOU CAN 578 00:31:46,404 --> 00:31:49,507 INTERPRET THAT ACROSS SETTINGS AND THE COMPARABILITY ISSUE, THE 579 00:31:49,574 --> 00:31:50,742 CONFOUNDING ACCELERATION. 580 00:31:50,808 --> 00:31:54,512 YOU CAN GO THROUGH ALL THESE REQUIREMENTS THAT WE HAVE IN THE 581 00:31:54,579 --> 00:31:58,416 CAUSE INFLUENCE LITERATURE AND SEE TO WHAT EXTENT IT'S FEASIBLE 582 00:31:58,483 --> 00:31:59,083 TO DO THAT. 583 00:31:59,150 --> 00:32:00,051 THEN FOR TBI. 584 00:32:01,686 --> 00:32:05,657 SO THE WAY TO THEN ILLUSTRATE THE PAPER I GUESS YOU WILL COME 585 00:32:05,723 --> 00:32:09,494 TO THAT IS EITHER GIVE EXAMPLES OR WHERE IT'S FAILED, MOST 586 00:32:09,560 --> 00:32:13,331 PEOPLE CRITICIZE THE FINDINGS SAY YEAH, YOU YOU, YOU CLAIM 587 00:32:13,398 --> 00:32:17,535 THIS IS COMPARATIVE BUT IT'S NOT COMPARABLE AND IT'S JUST BIASED 588 00:32:17,602 --> 00:32:21,339 IN SOME SENSE OR IT IS TO SOME EXTENT SUCCESSFUL AND WELL 589 00:32:21,406 --> 00:32:24,776 EXAMPLES AND ACROSS THIS RANGE MIGHT BE VERY USEFUL. 590 00:32:24,842 --> 00:32:28,346 I WOULD LEARN FROM THAT AT LEAST TO UNDERSTAND WHERE WE ARE IN 591 00:32:28,413 --> 00:32:28,646 TBI. 592 00:32:29,280 --> 00:32:32,684 YEAH, YEAH, THANKS NOW. 593 00:32:32,750 --> 00:32:36,721 SO WE DEFINITELY INDEED HAVE THE EXAMPLES NOW. 594 00:32:36,788 --> 00:32:41,159 SO THAT MAXIMAL USE IS MAYBE IT IS MEANT WHAT I SAID TO TO TO 595 00:32:41,225 --> 00:32:45,697 GET A BIT ANGLE OF OK WE HAVE DATA AND HOW CAN WE ANALYZE THAT 596 00:32:45,763 --> 00:32:49,701 TO GET INFORMATION THAT IS USEFUL FOR CLINICAL PRACTICE 597 00:32:49,767 --> 00:32:53,771 RATHER THAN BECAUSE I THINK IF YOU MANY PEOPLE WOULD SAY 598 00:32:53,838 --> 00:32:58,009 OBSERVATIONAL STUDY SHOULD BE DESIGNED AS A CLINICAL TRIAL 599 00:32:58,076 --> 00:33:02,013 EXCEPT THAT YOU DON'T RANDOMIZE SO SAME WAY OF DEFINING 600 00:33:02,080 --> 00:33:03,514 POPULATIONS ETCETERA. 601 00:33:03,581 --> 00:33:06,851 AND HERE WE BUT YOU'RE RIGHT THAT WE HAVE TO DO IT AND IT 602 00:33:06,918 --> 00:33:09,887 NEEDS TO MEET CERTAIN CRITERIA BUT WE DO A CERTAIN. 603 00:33:10,621 --> 00:33:13,858 SO IT WOULD BE DIFFERENT CONSIDERATION SLIGHTLY I WOULD 604 00:33:13,925 --> 00:33:17,061 SAY TO SETTING ADVISING PEOPLE ON HOW TO SET UP A NEW 605 00:33:17,128 --> 00:33:20,698 PROSPECTIVE STUDY VERSUS HOW TO ANALYZE DATA THAT ARE ALREADY 606 00:33:20,765 --> 00:33:21,065 THERE. 607 00:33:21,132 --> 00:33:25,069 SO THAT IS A BIT THE BACKGROUND, BUT THE TERM MAXIMAL I DON'T 608 00:33:25,136 --> 00:33:25,436 KNOW. 609 00:33:25,503 --> 00:34:10,615 BUT ANYWAY, THE AND THEN IT WOULD BE THE KIND OF WHATSOEVER. 610 00:34:10,681 --> 00:34:11,249 AND THEN TRY TO. 611 00:34:11,315 --> 00:34:12,917 YEAH, FOR ALSO AND WE'LL GO. 612 00:34:12,984 --> 00:34:16,387 THAT'S WHY I ALSO THINK WE HAVE TO DO THIS ALTOGETHER, TO AVOID 613 00:34:16,454 --> 00:34:19,023 US FROM WRITING THINGS THAT NO ONE UNDERSTANDS. 614 00:34:27,398 --> 00:34:33,337 I'M WONDERING IF THERE'S NOT MAYBE TWO PAPERS, ONE HERE THAT 615 00:34:33,404 --> 00:34:39,410 HELPING PERMISSIONS INTERPRET WHAT THEY SEEM TO ALL RECOGNIZE 616 00:34:39,477 --> 00:34:45,216 AS COMPARATIVE EFFECTIVENESS RESEARCH BY PROVIDING THE THE 617 00:34:45,283 --> 00:34:51,222 BASIS FOR HIGH QUALITY PRIOR TO THE BACK OF THIS RESEARCH IN 618 00:34:51,289 --> 00:34:54,358 LIKE DIFFERENT TYPES OF DESIGNS. 619 00:34:54,425 --> 00:34:58,196 FOR EXAMPLE, IF THERE'S A STUDY THAT USES INSTRUMENTAL VARIABLE 620 00:34:58,262 --> 00:35:01,799 ANALYSIS, THEN AS A CLINICIAN YOU SHOULD BE LOOKING TO MAKE 621 00:35:01,866 --> 00:35:05,403 SURE THAT THE ASSUMPTIONS OF THAT ANALYSIS WILL MET AND MAY 622 00:35:05,470 --> 00:35:09,307 BE DISCUSSED IN THE PAPER AND SO INFLUENCING RESEARCH THIS WAY. 623 00:35:09,640 --> 00:35:13,611 WHEREAS PERHAPS ANOTHER PAPER, MAYBE IT'S A SERIES, MAYBE 624 00:35:13,678 --> 00:35:17,582 THERE'S ONE PAPER CALLED CLINICIANS INTERPRET AND AND TO 625 00:35:17,648 --> 00:35:21,619 APPLY AND THEN ANOTHER TO HELP PEOPLE ACTUALLY DESIGN AND 626 00:35:21,686 --> 00:35:22,186 EXECUTE. 627 00:35:22,253 --> 00:35:24,922 BECAUSE GETTING TO THE POINT THAT IT WAS MADE EARLIER, THE 628 00:35:24,989 --> 00:35:27,592 STATISTICAL METHODS INVOLVED ARE ACTUALLY VERY COMPLEX. 629 00:35:28,292 --> 00:35:31,662 SO IT PERHAPS IT'S IT'S IT'S NOT THE CLINICIAN WHO'S GOING TO BE 630 00:35:31,729 --> 00:35:34,665 DOING THESE ANALYSIS AND THEN THAT MAY BE TIERED TOWARD 631 00:35:34,732 --> 00:35:35,533 ANOTHER BOTTOM. 632 00:35:46,944 --> 00:35:50,281 I PREVIOUSLY MENTIONED THIS MORNING THAT I I THINK REALLY 633 00:35:50,348 --> 00:35:53,918 ABOUT THE DISCUSSION BETWEEN THE NATION AND THE AND THE STAFF 634 00:35:53,985 --> 00:35:54,986 STATION WHATEVER. 635 00:35:55,319 --> 00:35:57,922 SO AND THAT BUILDS TRUST. 636 00:35:58,122 --> 00:36:01,792 SO WHEN I WORK WITH HEFTER AND I DON'T UNDERSTAND WHAT'S WHAT'S 637 00:36:01,859 --> 00:36:02,960 GOING ON WITH DATA. 638 00:36:03,027 --> 00:36:07,265 I DISCUSSED LONG ENOUGH TO THAT I'M CONVINCED THAT WHAT SHE SAID 639 00:36:07,331 --> 00:36:11,502 AND ACTUALLY EXPLAINED IT TO ME THAT IT CAN BE THAT I CAN TRUST 640 00:36:11,569 --> 00:36:11,769 IT. 641 00:36:12,436 --> 00:36:17,074 SO I THINK THAT THAT DIALOGUE, IT WOULD BE GOOD TO KIND OF HAVE 642 00:36:17,141 --> 00:36:21,512 IT ON PAPER, THE DIALOGUE AND THE ELEMENT OF THE DIALOGUE TO 643 00:36:21,579 --> 00:36:24,148 HELP CLINICIANS TRUST OR DISTRUST. 644 00:36:27,752 --> 00:36:34,292 CAN I, CAN I JUST ASK THE QUESTION. 645 00:36:34,358 --> 00:36:38,095 SO ONE THING THAT IS DEFINITELY REAL WORLD EVIDENCE AND WE'VE 646 00:36:38,162 --> 00:36:41,699 JUST DONE A SMALL EXAMPLE OF THIS IN TBR IS REALLY, REALLY 647 00:36:41,766 --> 00:36:45,303 TINY IS THE IDEA OF HISTORICAL CASE, HISTORICAL CONTROLS. 648 00:36:45,903 --> 00:36:50,274 SO TO USE OBSERVATIONAL DATA AND THEN YOU SCORE WHATEVER MATCH 649 00:36:50,341 --> 00:36:54,612 THE OBSERVATION RELATED TO SOME INTERVENTION THAT'S SOMEWHERE 650 00:36:54,679 --> 00:36:55,746 BETWEEN THE TWO. 651 00:36:55,813 --> 00:36:57,381 BUT IT'S DEFINITELY REAL WORLD DATA. 652 00:36:57,682 --> 00:37:00,518 EVERY REAL WORLD EVIDENCE FALLS INTO THAT COUNT. 653 00:37:00,851 --> 00:37:02,720 WOULD THAT BE PARTS OF WHAT WE GET? 654 00:37:02,787 --> 00:37:07,425 I DON'T I DON'T HAVE SHARES IN IN THIS METHODOLOGY BUT I JUST 655 00:37:07,491 --> 00:37:12,363 YEAH I THINK SO A LOT ALSO MADE ME THINK SO I THINK THERE'S SORT 656 00:37:12,430 --> 00:37:16,534 OF RISK OF LISTING ALL POTENTIAL NAMES OF DESIGNS LIKE 657 00:37:16,601 --> 00:37:21,072 INTERRUPTED TIME SERIES IVY HISTORICAL CASE IS IS A BIT THE 658 00:37:21,138 --> 00:37:25,776 RISK OF I DON'T KNOW CONFUSING PEOPLE AND SO TO ME BUT I VERY 659 00:37:25,843 --> 00:37:30,247 MUCH LIKE WHAT YOU SAID BEFORE YOU ARE TRYING TO FIND SOME 660 00:37:30,314 --> 00:37:34,652 IDEALLY RANDOM AND IF NOT CONDITIONED ON THE COVARIUS ALL 661 00:37:34,719 --> 00:37:36,420 THAT WE HOPE TO KNOW. 662 00:37:36,487 --> 00:37:40,658 SO I WOULD RATHER NOW I'M THAT MADE ME THINK IN DIRECTION AND 663 00:37:40,725 --> 00:37:44,929 IT ALSO RELATES TO WHAT I WOULD SAID THAT YOU SORT OF SAY OK, 664 00:37:44,996 --> 00:37:49,266 WHAT ARE WE COMPARING AND HOW VALID OR WHAT ASSUMPTIONS DO YOU 665 00:37:49,333 --> 00:37:52,903 THEN NEED TO MAKE TO BELIEVE THAT THAT IS A UNBIASED 666 00:37:52,970 --> 00:37:53,704 COMPARISON. 667 00:37:57,208 --> 00:37:57,408 THANK YOU. 668 00:37:57,475 --> 00:38:00,478 THE REASON I BRING THAT ONE UP SPECIFICALLY IN TBI IS THAT IT 669 00:38:00,544 --> 00:38:03,581 IT DOES POTENTIALLY ADDRESS A NUMBER OF ISSUES WITH TRAUMATIC 670 00:38:03,648 --> 00:38:06,484 BRAIN INJURY TRIALS WHICH IS THEY'RE EXPENSIVE HARD TO GET 671 00:38:06,550 --> 00:38:09,587 THEM AND YOU COULD HAVE ISH YOU KNOW THE NUMBER OF PEOPLE YOU 672 00:38:09,654 --> 00:38:10,955 NEED TO YOU NEED TO RECRUIT. 673 00:38:11,022 --> 00:38:13,557 SO AGAIN I'M NOT VESTED IN IT, BUT I JUST WONDER WHETHER IT'S 674 00:38:13,624 --> 00:38:15,526 IT'S AN AREA THAT WE WANT TO EXPLORE OR NOT. 675 00:38:20,264 --> 00:38:20,598 YEAH. 676 00:38:20,965 --> 00:38:21,298 YEAH. 677 00:38:21,365 --> 00:38:22,166 WE HAVE 10 MINUTES LEFT. 678 00:38:22,233 --> 00:38:24,835 OK WELL, I DON'T THINK. 679 00:38:25,903 --> 00:38:26,437 LET'S SEE. 680 00:38:26,504 --> 00:38:26,737 OH YEAH. 681 00:38:26,804 --> 00:38:30,408 MAYBE WE CAN DISCUSS ABOUT ANOTHER QUESTION. 682 00:38:33,077 --> 00:38:38,416 I ONE THOUGHT I HAD AS I'VE JUST BEEN LISTENING IS PERHAPS SOME 683 00:38:38,482 --> 00:38:42,286 SORT OF FRAMEWORK WOULD BE MOST USEFUL HERE. 684 00:38:42,586 --> 00:38:45,990 AND I, YOU KNOW, I COME AT IT FROM SORT OF AN EPIDEMIOLOGY 685 00:38:46,057 --> 00:38:46,757 PERSPECTIVE. 686 00:38:47,024 --> 00:38:50,861 A LOT OF TIMES PEOPLE THINK ABOUT THE QUALITY OF EVIDENCE, 687 00:38:50,928 --> 00:38:51,328 RIGHT? 688 00:38:51,729 --> 00:38:55,366 AND HERE YOU'RE TRYING TO HELP CLINICIANS UNDERSTAND THE 689 00:38:55,433 --> 00:38:58,903 QUALITY OF COMPARATIVE EFFECTIVENESS RESEARCH STUDY. 690 00:38:59,870 --> 00:39:03,507 SO PERHAPS MAYBE PART OF THE WHITE PAPER, IT COULD BE VERY 691 00:39:03,574 --> 00:39:07,411 SOMETHING VERY SIMPLE BUT LIKE A VISUAL SORT OF IF THIS, THEN 692 00:39:07,478 --> 00:39:09,914 THAT OR SOMETHING LIKE THAT FRAMEWORK. 693 00:39:10,281 --> 00:39:12,917 AND YOU KNOW, PEOPLE LOVE ACRONYMS AND THINGS LIKE THAT, 694 00:39:12,983 --> 00:39:13,984 BUT REALLY USING THAT. 695 00:39:14,051 --> 00:39:17,121 SO SOMETHING THAT'S EASY TO THINK THROUGH, EASY TO SAY THIS 696 00:39:17,188 --> 00:39:19,223 MEETS THIS CRITERIA AND THIS DOES NOT. 697 00:39:19,490 --> 00:39:21,559 I FOUND THAT VERY HELPFUL IN MY WORK. 698 00:39:21,625 --> 00:39:23,928 SO YEAH, VERY NICE SUGGESTION. 699 00:39:23,994 --> 00:39:24,428 THANKS. 700 00:39:24,628 --> 00:39:25,096 I LIKE IT. 701 00:39:25,162 --> 00:39:31,135 ANOTHER QUESTION I I, I DON'T KNOW ABOUT ANYBODY ELSE, BUT I'M 702 00:39:31,202 --> 00:39:34,839 GETTING REALLY STUCK ON THE TERM NOW. 703 00:39:35,706 --> 00:39:37,675 WHAT ARE WE COMPARING THE EFFECT OF? 704 00:39:39,043 --> 00:39:39,710 GOOD QUESTION. 705 00:39:40,277 --> 00:39:40,411 YEAH. 706 00:39:40,911 --> 00:39:45,316 I MEAN TO ME ARI'S LAST SUGGESTION WAS THE FIRST TIME 707 00:39:45,382 --> 00:39:50,387 WE'VE ACTUALLY TALKED ABOUT COMPARING EFFECTIVENESS RESEARCH 708 00:39:50,454 --> 00:39:54,859 AT LEAST BY THE YOU KNOW, TYPICAL AMERICAN DEFINITION 709 00:39:54,925 --> 00:39:59,730 COMPARING AN INTERVENTION TO PEOPLE WHO WEREN'T TOLD TO DO 710 00:39:59,797 --> 00:40:04,635 ANYTHING IN PARTICULAR DOES CENTRE TBI HAVE DATA ON FOLLOW 711 00:40:04,702 --> 00:40:09,507 UP INTERVENTIONS THAT THAT PEOPLE VOLUNTARILY SUBMITTED TO 712 00:40:09,573 --> 00:40:14,311 NOW SO CENTRE TBI WAS PURELY OBSERVATIONAL, SO NO ONE WAS 713 00:40:14,378 --> 00:40:16,881 TOLD TO DO ANYTHING BASICALLY. 714 00:40:17,181 --> 00:40:21,285 SO THAT'S THAT'S LEADS TO VARIABILITY BOTH BETWEEN PAGE IN 715 00:40:21,352 --> 00:40:25,322 TREATMENT I MEAN AND TREATMENTS DEFINES I THINK IN THE. 716 00:40:25,956 --> 00:40:29,827 BROAD SENSE AND JENNIFER CORRECT ME IF I'M WRONG, BUT IN MY VIEW 717 00:40:29,894 --> 00:40:33,197 IT CAN BE LIKE YOU SAID ADMISSION OR NOT ADMISSION, BUT 718 00:40:33,264 --> 00:40:36,834 WE WILL NOT THE IN CONTEXT WE ARE TALKING ABOUT WE WILL NOT 719 00:40:36,901 --> 00:40:40,604 TELL PEOPLE TO ADMIT A SPECIFIC GROUP OF PATIENTS OR AND ALSO 720 00:40:40,671 --> 00:40:42,540 NOT RANDOMIZED PATIENTS BETWEEN. 721 00:40:42,606 --> 00:40:46,076 BUT IN REALITY SOME PATIENTS WILL BE ADMITTED AND SOME WILL 722 00:40:46,143 --> 00:40:46,477 BE NOT. 723 00:40:46,544 --> 00:40:48,846 SOME PATIENTS WILL BE OPERATED ON SOME WILL NOT. 724 00:40:48,913 --> 00:40:52,750 SO THE THE THE AND THAT IS THAT IS WHAT WE CONSIDER THE 725 00:40:52,817 --> 00:40:57,188 TREATMENT GROUPS LIKE YOU KNOW AND AND BUT YEAH THAT THEY COULD 726 00:40:57,254 --> 00:41:01,392 BE DISTINGUISHED ON EVERYTHING THAT WE WANT TO ESTIMATE THE 727 00:41:01,458 --> 00:41:05,696 EFFECT OF THE THE PREMISE OF SANTA TBI IF I SAY CORRECTLY WAS 728 00:41:05,763 --> 00:41:09,600 THE LEVERAGING NICE WORD LEVERAGING THE THE VARIABILITY 729 00:41:09,667 --> 00:41:14,038 IN TREATMENTS TO IDENTIFY BEST PRACTICES AND THE VARIABILITY IS 730 00:41:14,104 --> 00:41:18,075 IN PART CAUSED BY RANDOM VARIABILITY BECAUSE WHEN YOU ARE 731 00:41:18,142 --> 00:41:22,313 TREATED IN HOSPITAL A, THERE WILL BE ANOTHER HISTORY ANOTHER 732 00:41:22,379 --> 00:41:26,851 CUSTOM AMONG CLINICIANS THEN IN ANOTHER CENTRE AND THAT'S RANDOM 733 00:41:26,917 --> 00:41:31,322 VARIATION AND THAT IS ON TOP OF VARIATION BASED ON CONFINING BY 734 00:41:31,388 --> 00:41:34,725 INDICATION SO BASED ON PATIENT CHARACTERISTICS. 735 00:41:35,226 --> 00:41:36,894 AND THAT'S I THINK WHAT IT'S ABOUT. 736 00:41:36,961 --> 00:41:39,830 IF I IT'S NOT RANDOM VARIATION YOU HAVE TO DO ALL KIND OF 737 00:41:39,897 --> 00:41:42,299 TRICKS TO I BELIEVE THAT IT'S RANDOM VARIATION. 738 00:41:42,366 --> 00:41:43,367 BUT ANYWAY IT DOESN'T MATTER. 739 00:41:45,903 --> 00:41:49,940 I'M NOW REALLY HESITANT TO SAY WHAT I WAS GOING TO SAY AS A AS 740 00:41:50,007 --> 00:41:51,175 A VERY NAIVE POINT. 741 00:41:51,242 --> 00:41:55,412 I'M SORT OF THINKING IS WHAT WE'RE TRYING TO FIND A CAUSAL 742 00:41:55,479 --> 00:41:57,381 EFFECT IS SOMETHING CAUSAL. 743 00:41:57,715 --> 00:41:57,948 YEAH. 744 00:41:58,682 --> 00:42:03,621 SO HOW DO WE PUT THAT INTO A TERMINOLOGY THAT MAYBE DOESN'T 745 00:42:03,687 --> 00:42:08,726 GET US CAUGHT UP IN EVERYBODY'S PRECONCEPTION OF COMPARATIVE 746 00:42:08,792 --> 00:42:10,728 EFFECTIVENESS RESEARCH. 747 00:42:11,061 --> 00:42:16,267 AND AND I I TAKE THE POINT WELL MADE ABOUT IT, THAT IT'S THAT 748 00:42:16,333 --> 00:42:18,269 THE TERM IS WELL KNOWN. 749 00:42:18,502 --> 00:42:22,806 I'M WONDERING HOW WELL THE TERM IS WELL KNOWN BEYOND THE PEOPLE 750 00:42:22,873 --> 00:42:27,044 IN THIS ROOM AND THE PEOPLE WHO LIKE IT DOES A SHOW OF HANDS. 751 00:42:27,111 --> 00:42:30,948 DOES ANYONE ELSE THINK IT'S WELL KNOWN WHEN I TALK ABOUT IT, NO 752 00:42:31,015 --> 00:42:33,450 ONE KNOWS ABOUT IT IN BUT I DON'T KNOW. 753 00:42:34,151 --> 00:42:38,289 I THINK IN THE US IT'S EXTREMELY WELL KNOWN, BUT PLEASE CORRECT 754 00:42:38,355 --> 00:42:40,624 ME IF I'M WRONG, DAVID AND OTHERS. 755 00:42:40,991 --> 00:42:43,894 I GET THE SENSE THAT THE WHITE PAPER WOULD HAVE BEEN WELL TIMED 756 00:42:43,961 --> 00:42:46,163 BEFORE SENT TO TBI BECAUSE OF THIS DISCUSSION. 757 00:42:46,397 --> 00:42:50,701 JUST A COMMENT, I THINK I REALLY LIKE THE IDEA OF A FRAMEWORK AND 758 00:42:50,768 --> 00:42:54,705 I THINK THERE'S A CONCEPTUAL FRAMEWORK WHICH COULD BE QUITE 759 00:42:54,772 --> 00:42:59,009 PEDAGOGICAL AS WELL AND ACTUALLY EXPLAINING THESE THINGS BECAUSE 760 00:42:59,076 --> 00:43:00,077 IN FACT, RIGHT. 761 00:43:01,211 --> 00:43:04,548 SO, YEAH, SO IN A A INDIVIDUALIZED TREATMENT EFFECTS 762 00:43:04,615 --> 00:43:07,851 MODEL IS A VERY, VERY COMPLICATED MACHINE LEARNING 763 00:43:07,918 --> 00:43:11,789 MODEL AND THAT'S REALLY HARD THING TO GET ACROSS TO PEOPLE. 764 00:43:12,022 --> 00:43:12,289 OK. 765 00:43:12,556 --> 00:43:15,326 BUT AT THE VERY OTHER END OF THE SPECTRUM IS BRADFORD HILL CAN 766 00:43:15,392 --> 00:43:17,795 WRITE CRITERIA SAYING ACTUALLY IF THE STRENGTH OF THE 767 00:43:17,861 --> 00:43:20,664 ASSOCIATION WITH THIS RESPONSE AND THE TIMING IS RIGHT, THEN IT 768 00:43:20,731 --> 00:43:23,600 MAY WELL, IT'S MORE LIKELY TO BE CAUSAL THAN ASSOCIATIVE, RIGHT. 769 00:43:23,667 --> 00:43:26,570 THAT'S MOST PEOPLE GET THAT THE NEXT THING WHICH IS PROPENSITY 770 00:43:26,637 --> 00:43:28,505 SCORE IS A LITTLE BIT MORE COMPLICATED. 771 00:43:28,572 --> 00:43:30,674 SO ACTUALLY JUST FIND, LET'S FIND TWO GROUPS OF PATIENTS THAT 772 00:43:30,741 --> 00:43:32,910 ROUGHLY SPEAKING LOOK THE SAME BUT GOT DIFFERENT TREATMENTS. 773 00:43:33,143 --> 00:43:34,411 THAT'S QUITE EASY TO EXPLAIN. 774 00:43:34,945 --> 00:43:37,014 INVERSE PROBABILITY WEIGHTING IS A LITTLE BIT MORE DIFFICULT. 775 00:43:37,081 --> 00:43:40,517 BUT AGAIN, YOU'RE SORT OF TRYING TO GET ALONG TO THAT KIND OF 776 00:43:40,584 --> 00:43:43,120 LINE, YOU KNOW, STRUCTURAL EQUATION MODELING. 777 00:43:43,187 --> 00:43:45,189 OK, BUT WE CAN DRAW SOME DIAGRAMS OF THAT AND SAY, WELL 778 00:43:45,255 --> 00:43:47,458 ACTUALLY WHAT ABOUT IF IF THIS EFFECT IS DIFFERENT THAN THIS, 779 00:43:47,524 --> 00:43:49,460 THEN MAYBE THERE'S A DIFFERENT AND THEN EVENTUALLY GET 780 00:43:49,526 --> 00:43:50,327 SOMETHING REALLY COMMON. 781 00:43:50,394 --> 00:43:53,464 SO THERE IS A GRADUATION OF OF INTELLECTUAL COMPLEXITY AS 782 00:43:53,530 --> 00:43:56,900 OPPOSED TO THESE MODELS AND A FRAMEWORK MIGHT BE A REALLY GOOD 783 00:43:56,967 --> 00:43:57,267 THING. 784 00:43:58,268 --> 00:43:59,737 I DON'T THINK WE HAVE TO WRITE A PAPER. 785 00:43:59,803 --> 00:44:03,240 WE HIRE YOU TO MAKE A 15 MINUTE VIDEO AND EVERYBODY WILL. 786 00:44:04,008 --> 00:44:05,642 I SEE 22 MODELS. 787 00:44:05,709 --> 00:44:08,912 THE ID MODEL WHEN YOU'RE A PHYSICIST AND AN INTENSIVIST AND 788 00:44:08,979 --> 00:44:09,913 VERY SMART ON IT. 789 00:44:10,314 --> 00:44:16,253 AND MY MODEL LIKE TALKING A LOT TO KNOWLEDGE STATISTICIANS. 790 00:44:16,987 --> 00:44:19,123 SO SOMEWHERE IN BETWEEN, THERE MUST BE A GREY AREA. 791 00:44:25,763 --> 00:44:26,296 YEAH, GO AHEAD. 792 00:44:26,363 --> 00:44:26,930 YEAH, SO SURE. 793 00:44:26,997 --> 00:44:31,101 SO I THINK WE HAVE A LOT, WE HAVE HEARD A LOT OF USEFUL 794 00:44:31,168 --> 00:44:31,602 THINGS. 795 00:44:31,668 --> 00:44:34,738 SO I SUGGEST WE JUST BECAUSE WE, SINCE WE DON'T HAVE SO MUCH 796 00:44:34,805 --> 00:44:37,775 TIME, WE JUST LEAVE THE SLIDES AND PLEASE BRING UP EVERYONE 797 00:44:37,841 --> 00:44:39,810 THING THAT YOU STILL WANTED TO SHARE. 798 00:44:40,411 --> 00:44:40,577 YEAH. 799 00:44:40,644 --> 00:44:43,881 SO THE ONLY THING THAT'S WORRYING ME, AND I'M, I'M A 800 00:44:43,947 --> 00:44:47,718 REHABILITATION PERSON, SO I'M SORT OF RIGHT AT THE OTHER END 801 00:44:47,785 --> 00:44:51,688 OF THE SPECTRUM IS JUST ALL OF THE FACTORS WE WOULD HAVE TO BE 802 00:44:51,755 --> 00:44:55,492 TAKING ACCOUNT AND THINKING ALL THE TIME OF THE FACTORS THAT 803 00:44:55,559 --> 00:44:57,194 INFLUENCE DECISION MAKING. 804 00:44:57,561 --> 00:45:02,132 SO FOR EXAMPLE, PEOPLE WHO GET MORE REHABILITATION SEEM TO DO 805 00:45:02,199 --> 00:45:06,837 WORSE AND THAT'S BECAUSE THEY NEED MORE REHABILITATION BECAUSE 806 00:45:06,904 --> 00:45:11,308 THEY'VE GOT BIGGER DEFICITS AND I'M SURE ALL THOSE SORTS OF 807 00:45:11,375 --> 00:45:15,646 DECISIONS ARE MADE IN THE INTENSIVE CARE SETTING AS WELL. 808 00:45:15,712 --> 00:45:20,250 SO IT ALL, IT KIND OF SCARES ME BECAUSE ALL THE TIME THIS TYPE 809 00:45:20,317 --> 00:45:24,855 OF RESEARCH ENDS UP FINDING OUT THAT THE TREATMENT DIDN'T WORK 810 00:45:24,922 --> 00:45:29,259 FOR FOR EXACTLY THOSE REASONS BECAUSE THE PEOPLE WHO NEEDED 811 00:45:29,326 --> 00:45:32,229 THE TREATMENT WERE WORSE TO START WITH. 812 00:45:33,330 --> 00:45:37,000 SO THAT'S JUST SOMETHING YOU HAVE TO REALLY THINK THROUGH AND 813 00:45:37,067 --> 00:45:38,168 TAKE INTO ACCOUNT. 814 00:45:38,502 --> 00:45:40,838 YEAH, IN DOING THIS, NO, I AGREE. 815 00:45:40,904 --> 00:45:44,775 SO WE HAVE ALL THESE METHODS TO TRY TO AVOID THIS, BUT THEY ALL 816 00:45:44,842 --> 00:45:46,677 HAVE THEIR LIMITATIONS AS WELL. 817 00:45:46,743 --> 00:45:50,013 SO I, I, I CALL THIS OVER TO AVOID OVER AND UNDER 818 00:45:50,080 --> 00:45:51,014 INTERPRETATION. 819 00:45:51,081 --> 00:45:54,251 I THINK ON BOTH ENDS OF THE SPECTRUM THERE IS ROOM FOR 820 00:45:54,318 --> 00:45:57,588 IMPROVEMENT STUDIES THAT WE THINK ARE ALL WELL DONE AND 821 00:45:57,654 --> 00:46:00,190 DESERVE FOR CAUSAL INTERPRETATION THAT THEY 822 00:46:00,257 --> 00:46:01,325 ACTUALLY GET THAT. 823 00:46:01,525 --> 00:46:04,428 BUT THEN ON THE OTHER END OF THE SPECTRUM, THERE ARE MANY STUDIES 824 00:46:04,495 --> 00:46:07,097 WHERE WE WILL PROBABLY ALL THINK THAT THEY DO NOT DESERVE A 825 00:46:07,164 --> 00:46:08,098 CAUSAL INTERPRETATION. 826 00:46:08,165 --> 00:46:11,201 BUT THEN IN THE CONCLUSION IT SAID PATIENTS DO BETTER WHEN 827 00:46:11,268 --> 00:46:14,605 THEY RECEIVE LESS REHABILITATION AND THAT'S WHAT WE ALSO WANT TO 828 00:46:14,671 --> 00:46:14,938 AVOID. 829 00:46:15,005 --> 00:46:20,144 SO YEAH, MAKING PEOPLE CLEAR ON BOTH THE RISKS AND MAYBE THE THE 830 00:46:20,210 --> 00:46:25,015 FACT THAT THEY ONLY CONSIDER AN RCT A GOLD STANDARD, I THINK 831 00:46:25,082 --> 00:46:30,120 THERE'S BOTH SHOULD BE ADDRESSED AT THE START OF THE CENTER TV. 832 00:46:30,187 --> 00:46:38,061 I HAVE MADE NOTHING WORRIED FOR WHAT WHICH IS DISABLED TO SHOW. 833 00:46:38,128 --> 00:46:41,098 SO TO MY UNDERSTANDING YOU ARE MR. 834 00:46:41,165 --> 00:46:45,202 HAPPY MOST OF THE ANALYZED DPI. 835 00:46:46,003 --> 00:46:51,275 SO MY QUESTION IS, HAVE YOU FOUND ANY EVIDENCE THAT SOME 836 00:46:51,341 --> 00:46:54,511 PRACTICES ARE BETTER THAN OTHERS? 837 00:46:54,912 --> 00:46:55,045 YEAH. 838 00:46:55,879 --> 00:46:56,046 YEAH. 839 00:46:56,113 --> 00:46:58,081 WERE YOU IN ANTWERP LAST YEAR? 840 00:46:58,148 --> 00:47:01,251 THERE I HAD TO GIVE A TALK ON THE HIGHLIGHTS OF COMPARATIVE 841 00:47:01,318 --> 00:47:02,953 FACTORY SHARES FROM CENTER TBI. 842 00:47:03,921 --> 00:47:08,392 SO I THINK THERE ARE ACTUALLY 2 EXAMPLES SO FAR FROM CENTER TBI. 843 00:47:08,625 --> 00:47:12,629 IT'S THE PAPER THAT WE WROTE WITH MACHO AND WITH THOMAS. 844 00:47:13,330 --> 00:47:16,266 AND I KNOW SOMEWHAT MORE EXAMPLES REALLY MADE IT TO HIGH 845 00:47:16,333 --> 00:47:17,134 IMPACT JOURNALS. 846 00:47:17,201 --> 00:47:23,006 AND WHERE I DARE TO CLAIM THAT'S WHAT WE FIND IS THE YEAH OR TRUE 847 00:47:23,073 --> 00:47:24,608 OR CAUSAL EFFECT. 848 00:47:25,642 --> 00:47:28,679 BUT THERE ARE ALSO MANY OTHERS WHERE WE TRIED AND WE MISSED 849 00:47:28,745 --> 00:47:31,915 EITHER AN INTERMEDIATE ENDPOINT OR WE WERE NOT CONFIDENT THAT 850 00:47:31,982 --> 00:47:34,318 THE GROUP GROUPS WERE COMPARABLE IN THE END. 851 00:47:35,185 --> 00:47:36,486 SO YEAH, IT'S TRICKY. 852 00:47:37,054 --> 00:47:39,523 BUT YEAH, LIKE I SAID, WE HAVE THESE RULE DATA. 853 00:47:39,957 --> 00:47:40,624 THERE'S YEAH. 854 00:47:40,691 --> 00:47:42,292 WHAT'S THE OTHER WAY TO MOVE FORWARD? 855 00:47:43,093 --> 00:47:45,395 I DON'T KNOW WHAT THAT SHOULD BE. 856 00:47:46,363 --> 00:47:51,168 IT'S IT'S WORTH REFLECTING THAT RANDOMIZED CONTROL TRIALS DON'T 857 00:47:51,235 --> 00:47:52,436 PROVE CAUSALITY. 858 00:47:52,869 --> 00:47:56,106 OK, THEY'RE QUITE GOOD EVIDENCE FOR CAUSALITY, BUT THE REASON WE 859 00:47:56,173 --> 00:47:59,309 DO A RANDOMIZATION IS TO TRY AND MAKE SURE THAT ALL THE FACTORS 860 00:47:59,376 --> 00:48:02,045 THAT WE THINK MIGHT BE CONFOUNDERS OR INFLUENCE STUFF 861 00:48:02,112 --> 00:48:04,781 ARE EQUALLY DISTRIBUTED IN THE TWO DIFFERENT GROUPS. 862 00:48:05,449 --> 00:48:07,851 AND YOU CAN THEN POST TOP CHECK THAT AND SAY, WELL LOOK, THE 863 00:48:07,918 --> 00:48:10,120 AGES WERE THE SAME IN THE TWO DIFFERENT GROUPS, AND THE 864 00:48:10,187 --> 00:48:12,089 ADMISSION WHATEVER WAS THE SAME AND WHATEVER. 865 00:48:12,623 --> 00:48:15,225 BUT YOU DON'T CHECK FOR THE THINGS YOU HAVEN'T THOUGHT OF, 866 00:48:15,292 --> 00:48:18,161 SO YOU CANNOT BE 100% SURE THAT THERE WASN'T A MASSIVE IMBALANCE 867 00:48:18,228 --> 00:48:21,031 OR SOMETHING YOU HAVEN'T THOUGHT OF LOOKING FOR BETWEEN THE TWO 868 00:48:21,098 --> 00:48:23,333 GROUPS, AND THEREFORE YOU HAVEN'T PROVEN ANYTHING. 869 00:48:23,400 --> 00:48:26,036 NOW IT'S PROBABLY VERY UNLIKELY IF YOU'VE DONE THINGS WELL, BUT 870 00:48:26,103 --> 00:48:27,971 IT'S NOTHING IS ACTUALLY A PROOF OF ANYTHING. 871 00:48:28,038 --> 00:48:29,239 THERE'S ALWAYS VARIABILITIES. 872 00:48:29,306 --> 00:48:33,677 IT'S IT'S STATS, LINDA. 873 00:48:33,744 --> 00:48:34,745 YEAH, YOU CAN WRAP UP. 874 00:48:37,581 --> 00:48:45,656 SO ACTUALLY WE DO HAVE ABOUT 10 MINUTES LEFT TO TO THINK ABOUT 875 00:48:45,722 --> 00:48:49,326 WHAT WE'VE ALL TALKED ABOUT. 876 00:48:50,027 --> 00:48:54,631 I'M GOING TO FLICK THROUGH ALL OF THESE, BUT TO TAKE US BACK TO 877 00:48:54,698 --> 00:48:58,969 THAT ORIGINAL QUESTION THAT WE STARTED WITH, WHICH WAS WHAT 878 00:48:59,036 --> 00:49:03,273 WOULD BE WHAT WOULD WE PUT FORWARD WITH THE WEALTH OF DATA 879 00:49:03,340 --> 00:49:07,778 THAT WE HAVE AND THE WEALTH OF DATA THAT WE COULD COLLECT AND 880 00:49:07,844 --> 00:49:12,349 WHAT WOULD THAT LOOK LIKE AND WHEN WE ALSO NEED TO REVISIT THE 881 00:49:12,416 --> 00:49:15,652 TERM NOW THAT WE'VE HAD THAT CONVERSATION. 882 00:49:15,719 --> 00:49:17,888 SO BECAUSE WE HADN'T, WE HADN'T RESOLVED THAT ONE. 883 00:49:18,522 --> 00:49:23,627 SO DOES ANYONE HAVE ANY COMMENTS THEY'D LIKE TO MAKE? 884 00:49:23,694 --> 00:49:27,331 WE'VE, YOU KNOW, PULLING THIS TOGETHER WITH, YOU KNOW, WE'VE 885 00:49:27,397 --> 00:49:31,001 LANDED ON THE FACT THAT A WHITE PAPER WOULD BE GOOD, THAT A 886 00:49:31,068 --> 00:49:34,971 FRAMEWORK AND THAT THERE'S A LOT OF EVIDENCE OR THERE'S A LOT OF 887 00:49:35,038 --> 00:49:38,809 DATA OUT THERE AND IT COULD BE PASSED INTO THE DIFFERENT KINDS 888 00:49:38,875 --> 00:49:41,878 OF LAYERS OF EVIDENCE AND WE COULD GET OUTCOMES. 889 00:49:42,346 --> 00:49:48,719 SO IF WE'RE GOING TO ASK FOR POTS OF MONEY IN THIS PLAY IN 890 00:49:48,785 --> 00:49:55,158 THIS FIELD, WHAT WOULD WE ASK FOR OR WHAT WOULD WE DO WITH 891 00:49:55,225 --> 00:50:00,464 THAT MONEY OR WHAT WOULD WE DO WITH THAT MONEY? 892 00:50:01,331 --> 00:50:04,368 SO IF WE WERE, IF WE WERE GOING TO DO SOMETHING IN THIS FIELD 893 00:50:04,434 --> 00:50:07,437 THAT COST MONEY, WHAT WOULD BET THAT DO AND HOW WOULD IT HELP 894 00:50:07,504 --> 00:50:07,971 PATIENTS? 895 00:50:08,171 --> 00:50:08,572 YOU KNOW WHAT? 896 00:50:08,638 --> 00:50:12,275 WHAT WHAT COULD WE DO THAT WOULD HAVE THE MOST BANG FOR THAT 897 00:50:12,342 --> 00:50:12,642 BUCK. 898 00:50:15,746 --> 00:50:24,588 SO MY ALL OF THESE TECHNIQUES REQUIRED TO HAVE REALLY LARGE 899 00:50:24,654 --> 00:50:28,492 THAT'S THE BEST TRADE OFF. 900 00:50:28,558 --> 00:50:32,596 SO YOU CAN FIND AN EQUIPPED TWIN WITH ALL THE OTHER THINGS THAT 901 00:50:32,662 --> 00:50:36,533 EXACTLY AS YOU SAY THAT THAT THAT HAD THE SAME ARE IDENTICAL 902 00:50:36,600 --> 00:50:40,370 IN EVERY WAY EXCEPT FOR THE THING THAT RANDOMLY THEY DID OR 903 00:50:40,437 --> 00:50:41,171 DIDN'T GET. 904 00:50:43,206 --> 00:50:45,942 SO FOR ME, IT'S ABOUT GETTING REALLY BIG SETS OF DATA. 905 00:50:46,009 --> 00:50:48,512 AND I AND I, AGAIN, THE APOLOGIES HAVE BEEN SORT OF 906 00:50:48,578 --> 00:50:49,279 BORING ABOUT IT. 907 00:50:49,346 --> 00:50:51,581 I THINK ONE OF THE REALLY IMPORTANT THINGS IS THAT WE 908 00:50:51,648 --> 00:50:54,317 STANDARDIZE WHAT WE'RE TRYING TO COLLECT SO THAT WE CAN EXTRACT 909 00:50:54,384 --> 00:50:56,253 THINGS OUT OF BIG ELECTRONIC HEALTH RECORDS. 910 00:50:56,319 --> 00:51:00,090 AND IN ORDER TO DO THAT, SOMEBODY NEEDS TO DO THE REALLY, 911 00:51:00,157 --> 00:51:03,927 REALLY BORING, REALLY TEDIOUS BUT UNBELIEVABLY INCREDIBLY 912 00:51:03,994 --> 00:51:07,664 IMPORTANT TASK OF MAPPING ALL THE THINGS WE THINK OF IN 913 00:51:07,731 --> 00:51:11,768 TRAUMATIC BRAIN INJURY TO SOME KIND OF COMMON DATA MODEL LIKE 914 00:51:11,835 --> 00:51:13,970 LIKE O MOP OR OR WHATEVER IT IS. 915 00:51:14,404 --> 00:51:15,238 SO I WAS JUST LOOKING HERE. 916 00:51:15,305 --> 00:51:16,573 SO YOU KNOW, TRAUMATIC BRAIN INJURY. 917 00:51:16,640 --> 00:51:25,549 IT CAN BE 127295002 IN SNOW MED OR 124209 IN CIL OR 127-295-0202 918 00:51:25,615 --> 00:51:28,318 IN NEBRASKA LEXICON. 919 00:51:28,385 --> 00:51:32,055 AND AS QUITE A LOT OF THESE OR ICD 10 S 06, I KNOW THAT ONE OFF 920 00:51:32,122 --> 00:51:32,622 MY HEART. 921 00:51:33,824 --> 00:51:37,327 YOU NEED TO DECIDE WHICH ONE I'M GOING TO DO AND THAT'S BEEN DONE 922 00:51:37,394 --> 00:51:40,464 BY PEOPLE ALREADY AND AND REALISTIC THAT WITH MY NON TBI, 923 00:51:40,530 --> 00:51:41,932 NON HOSPITALS CCIO HAT ON. 924 00:51:42,265 --> 00:51:45,869 I AM NEVER GOING TO MAP MY ELECTRONIC HEALTHCARE RECORD TO 925 00:51:45,936 --> 00:51:47,504 NINDS COMMON DATA ELEMENT. 926 00:51:47,571 --> 00:51:48,438 SORRY IT'S NOT GOING TO HAPPEN. 927 00:51:48,505 --> 00:51:49,172 IT'S TOO NICHE. 928 00:51:49,239 --> 00:51:50,307 I'M NEVER GOING TO DO THAT. 929 00:51:50,607 --> 00:51:53,143 BUT WHAT I AM GOING TO DO IS MAP IT TO O MOB. 930 00:51:53,477 --> 00:51:56,279 BECAUSE O MOB HAS BEEN USED BEFORE FOR DOING COMPARATIVE 931 00:51:56,346 --> 00:51:59,449 DRUG TRIALS AND THAT ALLOWS MY ELECTRONIC HEALTH RECORDS TO BE 932 00:51:59,516 --> 00:52:02,385 COMPARED WITH YOUR ELECTRONIC HEALTH RECORD COMPARED TO BE 933 00:52:02,452 --> 00:52:05,655 SENT TO TBI EVERYTHING SUDDENLY FOR FREE I CAN I CAN REPEAT SENT 934 00:52:05,722 --> 00:52:06,490 TO TBI FOR YOU. 935 00:52:07,190 --> 00:52:08,492 SO I WOULD I WOULD DO THAT. 936 00:52:12,762 --> 00:52:17,067 SO THERE IS TO SAY WHAT ALL THAT IS THERE ALREADY AN OMOP MODEL 937 00:52:17,133 --> 00:52:17,601 FOR TBI. 938 00:52:17,667 --> 00:52:20,303 WELL OMOP AND THERE ARE OTHER OTHER COMMON DATA MODEL BUT I 939 00:52:20,370 --> 00:52:21,671 THINK OMOP'S A VERY GOOD ONE. 940 00:52:22,205 --> 00:52:25,675 SO WHAT OMOP WILL DO IS SAY WHAT THOSE ONES I'VE JUST TOLD YOU 941 00:52:25,742 --> 00:52:28,211 THE CONCEPTS ARE NON STANDARD, NON STANDARD. 942 00:52:28,278 --> 00:52:32,082 THE ONE THAT IT SAYS IS STANDARD IS 127295 THE ONE I SET UP FIRST 943 00:52:32,148 --> 00:52:33,717 WHICH IS THE SNOW MADE ONE. 944 00:52:33,917 --> 00:52:35,151 SO THAT'S THE ONE YOU CHOOSE. 945 00:52:35,752 --> 00:52:38,622 NOW IF ANYBODY ELSE IN THEIR ELECTRONIC HEALTH RECORD HAS 946 00:52:38,688 --> 00:52:41,892 USED CIL, NEBRASKA, PPI DOESN'T MATTER BECAUSE IT ALSO SAYS THAT 947 00:52:41,958 --> 00:52:43,493 IT LINKS TO THE SNOW MADE ONE. 948 00:52:44,060 --> 00:52:46,763 SUDDENLY YOU GET COMPLETE INTEROPERABILITY OF ALL DATA 949 00:52:46,830 --> 00:52:47,063 SETS. 950 00:52:47,397 --> 00:52:50,901 BUT SOMEONE HAS TO GO THROUGH THE REALLY TEDIOUS TASKS SAYING 951 00:52:50,967 --> 00:52:54,471 THESE ARE THE THINGS THAT WE THINK ARE IMPORTANT ON THE BASIS 952 00:52:54,538 --> 00:52:57,807 OF THE LAST TWO DAYS FOR DEFINING THE SENSITIVITY THE THE 953 00:52:57,874 --> 00:53:01,411 TBI PHENOTYPE AND THERE MAY BE THINGS THAT AREN'T IN SNOW MED, 954 00:53:01,478 --> 00:53:04,814 RIGHT, LIKE FOR EXAMPLE POST TRAUMATIC AMNESIA ASSESSMENT. 955 00:53:04,881 --> 00:53:07,517 IF THAT'S NOT WE NEED TO GET IT ADDED TO SNOW MADE AND ACTUALLY 956 00:53:07,584 --> 00:53:08,585 THAT'S QUITE EASY TO DO. 957 00:53:10,887 --> 00:53:16,092 SO THOSE ARE VERY IMPORTANT AND DEEP IN THE WEEDS POINTS ONE OF 958 00:53:16,159 --> 00:53:20,730 THE OUTPUTS OF TODAY AND TOMORROW IS INTENDED FOR US TO 959 00:53:20,797 --> 00:53:25,101 UNDERSTAND PRIORITIES FOR COMMUNICATION WITH FUNDING 960 00:53:25,168 --> 00:53:29,472 AGENCIES TO PROPEL THIS EFFORT INTO ITS NEXT PHASE. 961 00:53:30,440 --> 00:53:34,144 AND AS WE'VE DISCOVERED AND YOU KNOW HESTER ALMOST MORE THAN 962 00:53:34,210 --> 00:53:38,181 ANYONE IN THIS ROOM EXCEPT MAYBE ABOUT HAVE DISCOVERED THAT WE'VE 963 00:53:38,248 --> 00:53:41,952 BEEN CHALLENGED OVER THE LAST FIVE YEARS TO CONVINCE FUNDING 964 00:53:42,018 --> 00:53:44,220 AGENCIES TO SUPPORT THIS VERY WORK. 965 00:53:44,888 --> 00:53:48,858 AND THE TRICK IS WHAT LINDY'S GETTING AT, WHICH IS WHAT'S THE 966 00:53:48,925 --> 00:53:50,360 DELIVERABLE AT THE END? 967 00:53:50,427 --> 00:53:54,965 BECAUSE IF THE DELIVERABLE AT THE END IS GOING TO CHANGE 968 00:53:55,031 --> 00:54:00,036 CLINICAL PRACTICE, THEN WE CAN JUSTIFY THE RESOURCES NECESSARY 969 00:54:00,103 --> 00:54:03,807 TO GO AS DEEP INTO THE WEEDS AS AS NECESSARY. 970 00:54:04,074 --> 00:54:09,179 SO I THINK AN IMPORTANT THING AND THE THE WISDOM OF THE CROWD 971 00:54:09,245 --> 00:54:13,116 IS HOW DO WE IDENTIFY THE PRIORITIES INSIDE OF 972 00:54:13,183 --> 00:54:18,355 OBSERVATIONAL DATA THAT WOULD MOST IMPACT CLINICAL PRACTICE SO 973 00:54:18,421 --> 00:54:23,426 THAT WE COMPEL THE NECESSARY RESOURCES TO DRIVE THE EFFORT. 974 00:54:25,862 --> 00:54:29,466 SO AGAIN, I MEAN, I DO HAVE A BIAS HERE, OF COURSE, BUT SO I 975 00:54:29,532 --> 00:54:32,902 THINK WHAT, WHAT A MAPPING ALLOWS YOU TO DO IS 2 THINGS. 976 00:54:33,637 --> 00:54:36,906 THE FIRST THING IS THAT THAT GROUP'S OUTPUT ALLOWS US NOT TO 977 00:54:36,973 --> 00:54:39,509 HAVE TO REINVENT THE WHEEL EVERY SINGLE TIME. 978 00:54:39,743 --> 00:54:42,379 SO THE MOMENT IF I WANT TO HARMONIZE CENTRE AND TRACK, I'LL 979 00:54:42,445 --> 00:54:44,014 HAVE TO HARMONIZE CENTRE AND TRACK. 980 00:54:44,080 --> 00:54:47,317 AND THEN WHEN YOU COME ALONG WITH TRACK X OR SOME NEW STUDY, 981 00:54:47,384 --> 00:54:50,553 I'LL HAVE TO DO IT ALL OVER AGAIN AND HARMONIZE IT AGAIN. 982 00:54:50,920 --> 00:54:54,524 WHEREAS ACTUALLY, IF EVERYBODY AGREES ON THE SAME SET OF DATA 983 00:54:54,591 --> 00:54:57,861 HARMONISED TO AN AGREED INTERNATIONAL STANDARD, THEN YOU 984 00:54:57,927 --> 00:54:59,162 DON'T HAVE TO DO THAT. 985 00:54:59,229 --> 00:55:00,096 YOU JUST NEED TO COLLECT IT. 986 00:55:00,163 --> 00:55:02,032 AND IF YOU COLLECTED IT IN A DIFFERENT STANDARD, THERE'S A 987 00:55:02,098 --> 00:55:03,400 MAPPING BACK TO THE INTERNATIONAL ONE. 988 00:55:03,633 --> 00:55:04,701 SO THAT'S THE FIRST THING THAT ALLOWS YOU. 989 00:55:04,768 --> 00:55:07,137 IT SAVES A HUGE AMOUNT OF TIME AND OPENS UP ALL OF THE 990 00:55:07,203 --> 00:55:09,639 ROUTINELY COLLECTED DATA, AT LEAST AS FAR AS ELECTRONIC 991 00:55:09,706 --> 00:55:11,007 HEALTH RECORDS ARE CONCERNED. 992 00:55:11,408 --> 00:55:14,477 THE CAVEAT OF HIGH INCOME COUNTRY NOTWITHSTANDING. 993 00:55:15,278 --> 00:55:18,248 THE OTHER THING IT DOES IS IT ACTUALLY ALLOWS US TO DEFINE AS 994 00:55:18,314 --> 00:55:21,351 A GROUP WHAT IS IT THAT THE DATA ELEMENTS THAT WE THINK WE ARE 995 00:55:21,418 --> 00:55:21,918 IMPORTANT. 996 00:55:22,318 --> 00:55:26,289 SO FOR EXAMPLE, I MISSED A TRICK IN 2014 WHEN I BUILT THE EHR FOR 997 00:55:26,356 --> 00:55:26,790 MY ICU. 998 00:55:27,023 --> 00:55:30,827 SO WE DIDN'T, I DIDN'T CODIFY GLASGOW OUTCOME SCORES IN AN IN 999 00:55:30,894 --> 00:55:34,831 A CODED WAY, I DIDN'T CODIFY THE SOME OF THE IMPACT VARIABLES. 1000 00:55:35,031 --> 00:55:38,101 I WILL CHANGE THAT NOW AND I WILL CODE THEM IN ACCORDING TO 1001 00:55:38,168 --> 00:55:41,271 OMAR SO THAT I'VE GOT THEM IN THE FUTURE AND OTHERS MAY WANT 1002 00:55:41,337 --> 00:55:41,838 TO GO AWAY. 1003 00:55:41,905 --> 00:55:44,207 SO DO YOU KNOW WHAT THESE ARE THINGS THAT WE'RE NOT ACTUALLY 1004 00:55:44,274 --> 00:55:45,608 CAPTURING IN A IN A STRUCTURED WAY. 1005 00:55:45,675 --> 00:55:48,378 WE SHOULD BE DOING IT AS PART OF CLINICAL CARE BECAUSE IT'S PART 1006 00:55:48,445 --> 00:55:50,680 OF THE ATVI PHENOTYPE AND THEREFORE RELEVANT TO US. 1007 00:55:51,181 --> 00:55:53,917 BUT THAT FINAL LIST OF THINGS ALLOWS PEOPLE TO DO IT IN THE 1008 00:55:53,983 --> 00:55:56,252 APPROPRIATE WAY AND NOT COLLECT THE WRONG THING. 1009 00:55:57,620 --> 00:56:01,758 SO CAN I JUST CARRY ON FROM DAVID'S POINT, I I THINK THAT'S 1010 00:56:01,825 --> 00:56:05,128 REALLY, REALLY VALID AND WOULD ENABLE THE WORK. 1011 00:56:05,195 --> 00:56:09,699 BUT WHAT IF THERE WAS ONE THING THAT WE WANTED TO BE ABLE TO 1012 00:56:09,766 --> 00:56:14,504 TEST WITH THE OBSERVATIONAL DATA THAT WE HAVE THAT YOU THINK WE 1013 00:56:14,571 --> 00:56:19,375 WOULD BE ABLE TO THEN MODIFY TO IMPROVE OUTCOMES IF WE KNEW THAT 1014 00:56:19,442 --> 00:56:21,544 SUCH COULD IMPROVE OUTCOMES? 1015 00:56:22,145 --> 00:56:24,047 IS THERE SOMETHING THAT, YOU KNOW WHAT? 1016 00:56:24,114 --> 00:56:25,115 WHAT WOULD WE TEST? 1017 00:56:27,383 --> 00:56:29,452 SO YOU'RE ASKING FOR A SPECIFIC INTERVENTION? 1018 00:56:29,519 --> 00:56:29,719 YEAH. 1019 00:56:29,786 --> 00:56:32,388 BECAUSE IF I'M GOING TO PUT A SLIDE TOGETHER, I'VE GOT A LIST 1020 00:56:32,455 --> 00:56:34,724 OF ALL THESE GREAT POINTS EVERYONE'S MADE OF HOW WE'D 1021 00:56:34,791 --> 00:56:36,259 HARMONIZE THE DATA AND ALL THAT. 1022 00:56:36,326 --> 00:56:40,029 BUT THE LAST BULLET WHO WANT TO SAY, AND WE'D USE THIS TO PROVE, 1023 00:56:40,096 --> 00:56:43,233 TO ADDRESS THIS SPECIFIC RESEARCH QUESTION, CLINICALLY 1024 00:56:43,299 --> 00:56:43,867 RELEVANT. 1025 00:56:43,933 --> 00:56:44,200 YEAH. 1026 00:56:46,102 --> 00:56:49,672 BUT DO WE NOW HAVE TO PICK, I TOTALLY AGREE WITH WITH DAVID 1027 00:56:49,739 --> 00:56:53,510 THAT THERE SHOULD BE KIND OF A DELIVERABLE TO KEEP THAT WE MUST 1028 00:56:53,576 --> 00:56:55,512 HAVE A REASON TO TO PURSUE THIS. 1029 00:56:55,879 --> 00:57:02,118 BUT JUST TO TRY TO END ALSO THE DISCUSSION, SHOULDN'T WE TRY TO 1030 00:57:02,185 --> 00:57:07,924 THINK ABOUT HAVING IN THE WHITE PAPER THE INFORMATION THAT 1031 00:57:07,991 --> 00:57:08,691 DRIVES? 1032 00:57:08,758 --> 00:57:10,627 I I THINK WE DEFINITELY DO THAT. 1033 00:57:10,693 --> 00:57:13,730 BUT THE FUNDERS ARE NOT GOING TO SAY WE'RE GOING TO GIVE YOU POTS 1034 00:57:13,797 --> 00:57:15,665 OF MONEY TO WRITE A WHITE PAPER, SORRY. 1035 00:57:16,032 --> 00:57:21,237 SO YEAH, I THINK SO WE DEFINITELY DO THAT BUT AS WELL 1036 00:57:21,304 --> 00:57:26,276 AS WHAT WHAT CLINICAL THING WOULD WE TEST, I THINK. 1037 00:57:26,342 --> 00:57:28,211 BUT THEN I THINK THAT'S NOT THE DISCUSSION. 1038 00:57:28,278 --> 00:57:30,413 I'M NOT SURE TIME ALLOWS. 1039 00:57:30,480 --> 00:57:37,921 IF I COULD GIVE YOU A SENSE OF TBI DATA SET OR TRACK TBI DATA 1040 00:57:37,987 --> 00:57:41,391 SET, THAT'S 20,000 PATIENTS. 1041 00:57:42,125 --> 00:57:43,593 WHAT FEDERATION ANALYSIS WOULD YOU DO? 1042 00:57:48,131 --> 00:57:52,235 YEAH, WHAT WOULD BE INTERESTED IN FOR EXAMPLE, GUIDELINES IS 1043 00:57:52,302 --> 00:57:56,139 ABOUT, I THINK ALSO IT'S NOT ONLY ABOUT ICU ADMISSION OR 1044 00:57:56,206 --> 00:57:59,509 ABOUT NEUROSURGICAL INTERVENTIONS, BUT IT'S ALSO 1045 00:57:59,576 --> 00:58:03,346 ABOUT DISCHARGED FROM THE EMERGENCY DEPARTMENT OR NOT. 1046 00:58:04,280 --> 00:58:08,251 SO AND WE DON'T KNOW A LOT OF THOSE PEOPLE WHO ARE DISCHARGED 1047 00:58:08,318 --> 00:58:10,286 FROM THE EMERGENCY DEPARTMENT. 1048 00:58:10,486 --> 00:58:14,958 THERE'S A LOT OF DISCUSSION WITHIN GUIDELINES HOW TO LOOK AT 1049 00:58:15,024 --> 00:58:19,762 THESE PEOPLE'S GET ACT SCAN THEN DISCHARGE THEM OR EVEN IF THEY 1050 00:58:19,829 --> 00:58:22,298 HAVE ACT CAN JUST DISCHARGE THEM. 1051 00:58:22,365 --> 00:58:28,071 WHATEVER THE CT CAN SCAN DOES IS WHAT YOU SEE IN THE CT SCAN. 1052 00:58:28,371 --> 00:58:32,275 SO I WOULD LIKE TO KNOW WHAT'S THE POLICY OVERALL, FOR EXAMPLE 1053 00:58:32,342 --> 00:58:36,279 IN THOSE WITH MILD TBI ADMITTED TO THE EMERGENCY DEPARTMENT WHO 1054 00:58:36,346 --> 00:58:39,949 IS DISCHARGED OR NOT, WHAT'S THE POLICY IN CT, YES OR NO, 1055 00:58:40,016 --> 00:58:41,317 ABNORMALITY YES OR NO? 1056 00:58:41,384 --> 00:58:42,385 AND WHAT'S THE OUTCOME? 1057 00:58:42,719 --> 00:58:46,222 I THINK THAT WOULD BE COULD BE A QUESTION TO BE ANSWERED FROM THE 1058 00:58:46,289 --> 00:58:46,556 DATA. 1059 00:58:47,724 --> 00:58:48,324 THANKS VERY MUCH. 1060 00:58:48,391 --> 00:58:50,526 ANYONE ELSE, LET'S GET A FEW IDEAS. 1061 00:58:50,593 --> 00:58:55,431 SO I'M NOT A CLINICIAN. 1062 00:58:56,766 --> 00:59:00,603 HOWEVER, I'VE WORKED WITH MANY AND THEY ALWAYS SEEM TO HAVE 1063 00:59:00,670 --> 00:59:04,140 THIS SAME QUESTION REGARDING OLDER ADULTS AND WHETHER 1064 00:59:04,207 --> 00:59:07,210 NEUROSURGICAL INTERVENTION AMONG OLDER ADULTS. 1065 00:59:07,277 --> 00:59:08,845 I MEAN, THIS IS JUST PUTTING THIS OUT THERE. 1066 00:59:08,912 --> 00:59:12,582 I'M SURE THERE'S TONS OF CLINICIANS OUT HERE, BUT WHETHER 1067 00:59:12,649 --> 00:59:16,653 NEUROSURGICAL INTERVENTION IN OLDER ADULTS WAS BENEFICIAL, BUT 1068 00:59:16,719 --> 00:59:19,355 UNRELATEDLY SOMETHING THAT WAS FUNDABLE. 1069 00:59:19,923 --> 00:59:23,359 I WAS GOING TO SAY YOU KNOW METHODS SOMETIMES SOMETIMES CAN 1070 00:59:23,426 --> 00:59:26,896 BE FUNDABLE AND I KNOW THAT RIGHT NOW FOR EXAMPLE, THERE ARE 1071 00:59:26,963 --> 00:59:30,533 CALLS AND AGING RESEARCH TO FUND METHODS THAT ARE SPECIFIC TO 1072 00:59:30,600 --> 00:59:33,736 THAT KIND OF RESEARCH, SO SPECIFIC TO THAT POPULATION. 1073 00:59:33,803 --> 00:59:37,707 SO IS THERE ANY WAY TO FUND METHODS SPECIFIC TO THESE TBI 1074 00:59:37,774 --> 00:59:41,344 DATA SETS THAT WOULD THAT WOULD INFORM THE RESEARCH? 1075 00:59:41,411 --> 00:59:47,717 SHANA, FIRST WEEK, SHANA, YOU WE'RE LOOKING FOR TO HAVE THE 1076 00:59:47,784 --> 00:59:54,724 RESULTS FROM GENDER AND YOU HAVE SPECIFIC EXAMPLES FROM YOUR THAT 1077 00:59:54,791 --> 00:59:56,793 YOU DON'T KNOW YET. 1078 01:00:00,263 --> 01:00:05,535 WELL, I PERSONALLY HOPE YOU KNOW I'M PARTICULARLY INTERESTED IN 1079 01:00:05,601 --> 01:00:10,707 THE BIAS BY CLINICIANS THAT GOES INTO THE WITHDRAWAL BY STATE 1080 01:00:10,773 --> 01:00:13,843 THERAPIES ESPECIALLY FOR THREE DAYS. 1081 01:00:14,811 --> 01:00:18,081 SO AS WE ALL KNOW, IN SOME GUYS. 1082 01:00:19,315 --> 01:00:23,252 FOR HOW PEOPLE LIVE FOR, LET'S SAY, 12 MONTHS, SOME OF THEM 1083 01:00:23,319 --> 01:00:24,921 MAJOR SURPRISINGLY WELL. 1084 01:00:26,155 --> 01:00:31,728 AND SO, YOU KNOW, YOU MIGHT WANT TO CALL THIS POSITIVE DEVIANCE 1085 01:00:31,794 --> 01:00:32,562 RESEARCH. 1086 01:00:32,628 --> 01:00:35,798 SO WHY DO THOSE PEOPLE DO WELL AND IS IT REALLY THE TREATMENTS 1087 01:00:35,865 --> 01:00:38,735 THEY'RE RECEIVING AND THE AGGRESSIVENESS OF THE CENTER OR 1088 01:00:38,801 --> 01:00:39,669 THE NEUROSURGEON? 1089 01:00:40,069 --> 01:00:43,339 I'M VERY, YOU KNOW, BASED ON WHAT I SEE IN EVERYDAY PRACTICE, 1090 01:00:43,406 --> 01:00:46,042 THERE'S A HUGE AMOUNT OF HEURISTICS THAT GOES INTO 1091 01:00:46,109 --> 01:00:48,044 DECISION MAKING AND JUST DECIDING. 1092 01:00:48,111 --> 01:00:50,513 I'M NOT GOING TO OFFER SURGERY TO AN OLD PATIENT, 'CAUSE I KNOW 1093 01:00:50,580 --> 01:00:51,881 THEY'RE GOING TO DO WELL, POORLY. 1094 01:00:52,281 --> 01:00:53,783 WELL, HOW DO WE KNOW THAT, RIGHT? 1095 01:00:53,850 --> 01:00:55,985 I MEAN, WE'VE HAD THAT CONVERSATION MANY TIMES. 1096 01:00:56,486 --> 01:01:00,356 WHAT I DON'T KNOW IS WHETHER OBSERVATIONAL DATA IS SUFFICIENT 1097 01:01:00,423 --> 01:01:01,257 TO STUDY THAT. 1098 01:01:01,324 --> 01:01:04,560 THAT I I DOUBT THAT TO BE HONEST, BUT WOULD LOVE YOUR 1099 01:01:04,627 --> 01:01:04,927 INPUT. 1100 01:01:04,994 --> 01:01:09,365 I THINK THAT'S THE BIGGEST PROBLEM IN OUR WORLD IS I'M 1101 01:01:09,432 --> 01:01:14,404 OBVIOUSLY BIASED, BUT I WOULD ALSO LOOK AT VARIABLES THAT MANY 1102 01:01:14,470 --> 01:01:18,975 PATIENTS ARE EXPOSED TO INCENTIVE TBI, LET'S SAY GLUCOSE 1103 01:01:19,042 --> 01:01:23,312 AND IT'S MANAGEMENT TEMPERATURE AND IT'S MANAGEMENT. 1104 01:01:24,747 --> 01:01:29,685 SO AS TO KIND OF COPY PASTE WHAT WE DID WITH THE FLUIDS TO SEE IF 1105 01:01:29,752 --> 01:01:34,290 CLINICS WHERE THEY HAVE OTHER THRESHOLDS MIGHT FARE WORSE OR 1106 01:01:34,357 --> 01:01:36,325 THE PATIENTS VERSUS BETTER. 1107 01:01:36,392 --> 01:01:38,528 SO THAT WOULD BE MY FIRST. 1108 01:01:40,063 --> 01:01:40,129 YEAH. 1109 01:01:40,196 --> 01:01:43,299 YEAH, I I'M, I THINK THEY BOTH ARE FASCINATING AND I THINK THE 1110 01:01:43,366 --> 01:01:46,002 THE HEALTHCARE UTILIZATION OR OUTCOMES OF YOU KNOW OR 1111 01:01:46,069 --> 01:01:47,437 EFFECTIVE NIHILISMS REALLY. 1112 01:01:47,637 --> 01:01:50,239 AND I THINK IT IS ACTUALLY SOMETHING THAT YOU CAN GET A 1113 01:01:50,306 --> 01:01:53,076 HANDLE ON USING OBSERVATIONAL DATA BECAUSE YOU WILL FIND 2 1114 01:01:53,142 --> 01:01:56,212 PATIENTS WHO ARE, IF THE DATA IS SUFFICIENTLY GOOD DESCRIPTION OF 1115 01:01:56,279 --> 01:01:58,948 THE PHENOTYPE OTHERWISE IDENTICAL, RIGHT IN TERMS OF NOT 1116 01:01:59,015 --> 01:02:01,484 ONLY THEIR PHENOTYPE BUT EVERYTHING THAT HAPPENED TO 1117 01:02:01,551 --> 01:02:01,784 THEM. 1118 01:02:02,285 --> 01:02:03,486 YOU'D BE A LOT OF DATA FOR THAT. 1119 01:02:04,187 --> 01:02:06,255 BUT YET ONE DOES IS WITHDRAWAL, THE OTHER ONE ISN'T. 1120 01:02:06,322 --> 01:02:10,126 AND YOU CAN START TO GET A HANDLE ON THAT WITH ON SHIBAYA'S 1121 01:02:10,193 --> 01:02:14,097 ORIGINAL PAPER THAT I DID, THE METHODOLOGY THAT SHIBAYA THEN 1122 01:02:14,163 --> 01:02:18,167 EXTENDED, HE'S LOOKING AT ALL OF DATA WITHIN MIMIC, WHICH IS A 1123 01:02:18,234 --> 01:02:20,236 BIG ICU, AMERICAN ICU DATA SET. 1124 01:02:20,570 --> 01:02:23,739 WE JUST DID SOME MORTALITY PREDICTION AND ACTUALLY ONE OF 1125 01:02:23,806 --> 01:02:27,343 THE THINGS THAT JUST DROPPED OUT OF THE OF THE MACHINE LEARNING 1126 01:02:27,410 --> 01:02:30,880 MODEL, PERHAPS NOT SURPRISINGLY WITHOUT IT WAS THE REFERRAL TO 1127 01:02:30,947 --> 01:02:34,584 THE PRIEST ACTUALLY BECAUSE IT'S CODED RIGHT IS A STRONG NEGATIVE 1128 01:02:34,650 --> 01:02:35,985 PROGNOSTIC SIGNIFICANCE. 1129 01:02:36,352 --> 01:02:39,222 THOSE THAT THAT THAT DATA ABOUT WHAT PEOPLE ARE DOING AND WHAT 1130 01:02:39,288 --> 01:02:40,223 IS ACTUALLY IN THERE. 1131 01:02:40,289 --> 01:02:42,825 IN SOME WAYS SOMETHING A BIT SNEAKY ABOUT HOW YOU HOW YOU GET 1132 01:02:42,892 --> 01:02:45,294 AT IT, BUT I THINK YOU PROBABLY CAN GET A HANDLE ON THAT. 1133 01:02:45,361 --> 01:02:50,333 THOSE SORTS OF QUESTIONS YOU MENTIONED THE WORD IDENTICAL, 1134 01:02:50,399 --> 01:02:55,238 ARE THEY THEY HAVE TO BE IDENTICAL ACROSS ALL DIMENSIONS 1135 01:02:55,304 --> 01:02:56,172 OR DO MORE? 1136 01:02:56,239 --> 01:02:57,874 DO SOME DIMENSIONS MATTER MORE? 1137 01:02:58,508 --> 01:03:00,476 AND I THINK THAT NEEDS TO BE ADDRESSED BEFORE YOU CAN GET 1138 01:03:00,543 --> 01:03:00,743 THERE. 1139 01:03:03,246 --> 01:03:05,781 IT WILL NEVER BE ENTIRELY UNETHICAL, I THINK WE AGREE ON 1140 01:03:05,848 --> 01:03:06,082 THAT. 1141 01:03:11,754 --> 01:03:16,559 SO JUST BEING A MEMBER OF THE PSYCHOSOCIAL ENVIRONMENTAL 1142 01:03:16,626 --> 01:03:21,564 MODIFIERS GROUP, WE HAD A REAL LACK OF DATA TO SUPPORT OUR 1143 01:03:21,631 --> 01:03:26,702 MODIFIERS, AND I DON'T KNOW HOW MUCH, HOW COMPREHENSIVELY. 1144 01:03:26,769 --> 01:03:32,208 SO FOR EXAMPLE, ABOUT CULTURE OR LANGUAGE OR SO IF, AND IT SEEMS 1145 01:03:32,275 --> 01:03:36,946 LIKE THIS IS SOMETHING WE COULD GATHER, YOU CAN LOOK AT 1146 01:03:37,013 --> 01:03:42,485 COMPARATIVE INFLUENCE OF FACTORS ON OUTCOME WITHOUT IT BEING TOO 1147 01:03:42,552 --> 01:03:43,486 CONFOUNDED. 1148 01:03:43,986 --> 01:03:49,725 SO YEAH, THAT WOULD BE SOMETHING TO PICK SOME KEY ENVIRONMENTAL 1149 01:03:49,792 --> 01:03:51,160 SOCIAL FACTORS. 1150 01:03:51,627 --> 01:03:54,797 IF YOU HAVE THE DATA, I DON'T KNOW IF YOU COLLECT THE DATA. 1151 01:03:55,164 --> 01:03:57,967 SO THAT'S WHAT I'D LIKE. 1152 01:04:04,907 --> 01:04:08,344 YES, I DON'T WANT TO REPEAT MY FLASH PRESENTATION, BUT I OF 1153 01:04:08,411 --> 01:04:11,948 COURSE HEAVILY INVESTED IN THE SURGICAL QUESTIONS BUT FOR THE 1154 01:04:12,014 --> 01:04:15,384 FUTURE MATH ANALYSIS BETWEEN THE THREE LARGE STUDIES NOW. 1155 01:04:15,885 --> 01:04:19,989 BUT THE OTHER THING IT OFFERS IS THAT IT IS ONE OF THE RARE 1156 01:04:20,056 --> 01:04:24,193 OCCASIONS AND WE CAN COMPARE A SURGICAL INTERVENTION WITHIN 1157 01:04:24,260 --> 01:04:24,961 CENTER TBI. 1158 01:04:25,027 --> 01:04:29,232 IT WAS ACTUALLY ALSO STUDIED IN A RANDOMIZED SESSION WHICH 1159 01:04:29,298 --> 01:04:33,936 RESCUE ACH OF COURSE AND WE DID THAT CRANIOTOMY FIRST CRANECTOMY 1160 01:04:34,003 --> 01:04:38,241 PARALLEL TO RESCUE HDH AND IT SHOWED THE EXACT SAME EFFECT 1161 01:04:38,307 --> 01:04:42,278 ESTIMATES EVEN THE CONFIDENCE IS OVER VERY COMPARABLE. 1162 01:04:42,845 --> 01:04:47,516 OF COURSE RESCUE HH IS WAY MORE VALID, BUT IT SHOWS THE STRONG 1163 01:04:47,583 --> 01:04:51,554 MARKETING POTENTIAL OF OBSERVATIONAL EVIDENCE BECAUSE 1164 01:04:51,621 --> 01:04:55,925 YOU CAN SEE WELL IF WE JUST ADHERE TO ALL THE ASSUMPTIONS 1165 01:04:55,992 --> 01:05:00,429 FOR THE FOR THE OBSERVATIONAL EVIDENCE OF THE IVNS, YOU CAN 1166 01:05:00,496 --> 01:05:03,733 ALMOST ACQUIRE THE SAME LEVEL OF VALIDITY. 1167 01:05:04,033 --> 01:05:07,436 AND OF COURSE BOTTOM LINES, YOU CAN NEVER PROVE CAUSAL INFERENCE 1168 01:05:07,503 --> 01:05:09,372 OF COURSE, BUT THAT'S NOT RELEVANT. 1169 01:05:09,438 --> 01:05:12,441 YOU HAVE TO SHOW WHICH ASSUMPTIONS ARE ACTUALLY MET OR 1170 01:05:12,508 --> 01:05:15,611 NOT, AND THAT'S WHAT THE DISCUSSION SHOULD BE I THINK. 1171 01:05:16,112 --> 01:05:19,148 AND A SURGERY MAKES A STRONG CASE, BUT I'M VERY HEAVILY 1172 01:05:19,215 --> 01:05:22,318 CONFOUNDED BEING A NURSE SURGEON, BUT I REALLY LIKE THAT 1173 01:05:22,385 --> 01:05:24,553 EXAMPLE WITH ALSO IN THAT WHITE PAPER. 1174 01:05:25,187 --> 01:05:28,991 AND THAT'S THE OTHER THING IS BECAUSE YOU'VE BEEN MAKING 1175 01:05:29,058 --> 01:05:31,927 GUIDELINES TO ALSO DEFINE KNOWLEDGE GAPS. 1176 01:05:32,261 --> 01:05:35,765 AND THOSE KNOWLEDGE GAPS IS ALWAYS RELATED TO WHAT DO WE 1177 01:05:35,831 --> 01:05:39,635 KNOW ABOUT WHAT WE DO AND IT GIVES THAT ENOUGH INFORMATION TO 1178 01:05:39,702 --> 01:05:40,803 DISCHARGE PATIENTS. 1179 01:05:40,870 --> 01:05:44,473 OR IS IT JUST AN IDEA THAT YOU REALLY WANT TO KNOW WHAT ACT 1180 01:05:44,540 --> 01:05:48,344 SCAN LET'S SHOWS TO US MAYBE WE CAN DISCHARGE EVERYBODY WITH A 1181 01:05:48,411 --> 01:05:52,181 MILD, I'M NOT SUPPOSED TO SAY THAT, BUT MAYBE WE CAN DISCHARGE 1182 01:05:52,248 --> 01:05:53,783 EVERYBODY WITH A MILD TBI. 1183 01:05:53,849 --> 01:05:54,450 IT DOESN'T MATTER. 1184 01:05:54,517 --> 01:05:56,385 THEY COME BACK WHEN THEY HAVE COMPLAINTS. 1185 01:05:56,452 --> 01:06:00,323 SO THE KNOWLEDGE GAPS GIVE YOU SOME IDEAS OF HOW YOU COULD 1186 01:06:00,389 --> 01:06:03,959 CHANGE THE GUIDELINES AND COMPETITIVE EFFECTIVENESS. 1187 01:06:04,527 --> 01:06:08,497 RESEARCH IS ABOUT GUIDELINES, SO YOU THAT'S HOW YOU CAN LOOK AT 1188 01:06:08,564 --> 01:06:08,731 IT. 1189 01:06:08,798 --> 01:06:11,567 IN THE END, I KNOW NOTHING ABOUT BUSH. 1190 01:06:12,068 --> 01:06:13,736 I'LL BE REALLY EDUCATED. 1191 01:06:13,803 --> 01:06:18,207 I WORK ON SEARING, BUT NOW I KNOW THAT ACTUALLY YOU'RE 1192 01:06:18,274 --> 01:06:23,579 INTERESTED IN THAT AND IT'S PART OF, IT'S A REALLY IMPORTANT PART 1193 01:06:23,646 --> 01:06:28,484 OF THE MILD MILDER END, TO USE THE OLD TERMINOLOGY SCORING, 1194 01:06:28,551 --> 01:06:31,387 THAT WE SHOULD BE COLLECTING THAT. 1195 01:06:31,721 --> 01:06:34,223 OK, SO I NEED TO GO BACK AND CLEARLY THERE'S TWO THINGS. 1196 01:06:34,290 --> 01:06:36,759 ONE, I NEED TO CONVINCE ALL THE OTHER PEOPLE AROUND ME TO 1197 01:06:36,826 --> 01:06:38,027 ACTUALLY COLLECT THAT DATA. 1198 01:06:38,260 --> 01:06:41,364 WELL, THAT'S THE JOB OF THE NOMENCLATURE THE LAST TWO DAYS. 1199 01:06:41,564 --> 01:06:45,768 BUT WHAT WE NEED TO KNOW IS I NEED TO TELL YOU THAT IN OMAR 1200 01:06:45,835 --> 01:06:49,805 THAT'S CONCEPT 717323005 WESTMEAD POST TRAUMATIC AMNESIA 1201 01:06:49,872 --> 01:06:53,743 SCALE SCORE RESERVABLE ENTRY VALID SNOW MADE, RIGHT. 1202 01:06:53,809 --> 01:06:56,946 SO THAT YOU CAN GO AND START COLLECTING IT ACCORDING TO THAT 1203 01:06:57,012 --> 01:07:00,282 SO THAT I CAN JUST ASK FOR THAT WHEN IN YOUR ELECTRONIC HEALTH 1204 01:07:00,349 --> 01:07:00,916 RECORD MUCH. 1205 01:07:00,983 --> 01:07:02,585 SO THIS IS FASCINATING. 1206 01:07:02,785 --> 01:07:03,119 WE NEED. 1207 01:07:04,987 --> 01:07:07,022 I THINK WE'RE REALLY WE MUST WRAP UP. 1208 01:07:07,089 --> 01:07:07,423 YEAH. 1209 01:07:08,090 --> 01:07:12,294 SO THANK YOU ALL INCREDIBLY MUCH FOR YOUR INPUT. 1210 01:07:12,361 --> 01:07:15,631 WE WILL BE HAVING A WORKING GROUP MEETING AT 2:00 TOMORROW 1211 01:07:15,698 --> 01:07:19,001 FOR THE PEOPLE WHO WANT TO BE INVOLVED IN WRITING THE PAPER 1212 01:07:19,068 --> 01:07:20,770 AND WANT TO BE A NAMED AUTHOR. 1213 01:07:21,203 --> 01:07:24,240 SO IF YOU WANT TO BE CONTRIBUTING TO THE MORE FINE 1214 01:07:24,306 --> 01:07:27,343 DETAIL ABOUT THE STATISTICAL METHODS AND ABOUT THE 1215 01:07:27,410 --> 01:07:31,213 HARMONISATION OF DATA AND ALL OF THE THE SORT OF THINGS THAT WE 1216 01:07:31,280 --> 01:07:35,184 UNFORTUNATELY HAD TO GLOSS OVER BECAUSE THERE WASN'T TIME TODAY, 1217 01:07:35,251 --> 01:07:37,186 PLEASE BE HERE AT 2:00 TOMORROW. 1218 01:07:38,287 --> 01:07:42,691 AND BEFORE WE CLOSE, CAN I JUST HAVE A SHOW OF HANDS ON THE 1219 01:07:42,758 --> 01:07:46,429 TITLE ON THE COMPARATIVE EFFECTIVENESS RESEARCH? 1220 01:07:47,029 --> 01:07:51,066 WHO WANTS TO KEEP COMPARATIVE EFFECTIVENESS RESEARCH HAS A 1221 01:07:51,133 --> 01:07:51,467 NAME. 1222 01:07:53,369 --> 01:07:55,504 I I'LL TALK TELL WE'LL TALK ABOUT ALTERNATIVES. 1223 01:07:55,571 --> 01:07:58,507 BUT WHO DESPERATELY WANTS TO KEEP COMPARATIVE EFFECTIVENESS 1224 01:07:58,574 --> 01:07:59,041 RESEARCH? 1225 01:08:00,309 --> 01:08:05,581 WELL, ALL RIGHT. 1226 01:08:05,848 --> 01:08:12,588 WHO WANTS TO CALL IT REAL WORLD EVIDENCE FOR TBI GOT ABOUT FOUR 1227 01:08:12,655 --> 01:08:14,990 OF THEM I DON'T THINK. 1228 01:08:15,391 --> 01:08:18,894 WELL, I I HAVEN'T SAID MUCH I NORMALLY DO BUT YOU YOU HAVE TO 1229 01:08:18,961 --> 01:08:22,398 GO IN TERMS OF OTHER PEOPLE UNDERSTAND AND WE GET IT IN THIS 1230 01:08:22,465 --> 01:08:22,865 ROOM. 1231 01:08:22,932 --> 01:08:26,669 BUT WHEN YOU GO TO YOUR GRAPH, I MEAN ONCE IT WOULD BE LIKE 1232 01:08:26,735 --> 01:08:28,170 CHANGING THE WORD RCT. 1233 01:08:28,237 --> 01:08:29,772 IT'S SO EMBEDDED IN CULTURE. 1234 01:08:30,573 --> 01:08:33,042 I WOULD BE VERY CAUTIOUS ABOUT LIVING AWAY. 1235 01:08:33,108 --> 01:08:36,145 I THINK IT'S A WELL KNOWN ONE AND AND I REALLY HAVE TO DO WHAT 1236 01:08:36,212 --> 01:08:37,246 MY PERSPECTIVE TO DO. 1237 01:08:37,480 --> 01:08:38,380 BUT IT IS THE REAL TERM. 1238 01:08:38,447 --> 01:08:42,985 IT'S NOT REAL THING YOU LIKE BUT IT IS ANY OTHER WHAT IS 1239 01:08:43,052 --> 01:08:46,255 COMPARATIVE EFFECT REAL WORLD EVIDENCE. 1240 01:08:46,322 --> 01:08:51,927 OK AND WHAT ABOUT PRACTICE BASED IT IT THE PEOPLE OUTSIDE THIS 1241 01:08:51,994 --> 01:08:55,998 ROOM WILL, WILL UNDERSTAND WHAT IT IS STILL. 1242 01:08:56,065 --> 01:08:59,969 I MEAN IT WILL UNDERSTAND WHAT COMPARED TO EFFECTIVENESS AND 1243 01:09:00,035 --> 01:09:03,806 YOU KNOW IT'S THERE AND IT'S IT'S A RECOGNIZED METHODOLOGY 1244 01:09:03,873 --> 01:09:07,443 WE'VE ALREADY PROVED GREAT SUCCESS CENTRE TRACK AND YOU 1245 01:09:07,510 --> 01:09:11,614 KNOW I'D BE VERY KEEN TO KEEP IT ALL RIGHT JUST BEARING THAT IN 1246 01:09:11,680 --> 01:09:15,518 MIND TOTALLY TOTALLY HEAR THAT ANY HANDS FOR PRACTICE BASED 1247 01:09:15,584 --> 01:09:16,151 EVIDENCE. 1248 01:09:17,586 --> 01:09:24,093 SORRY THAT ONE GOT VERY LITTLE AND SOME WORDING THAT HAS CAUSAL 1249 01:09:24,159 --> 01:09:25,394 EFFECT IN IT. 1250 01:09:25,461 --> 01:09:27,496 NO, SURE. 1251 01:09:27,563 --> 01:09:32,234 NOBODY IS FOR CARE BECAUSE IT'S ABOUT CARE. 1252 01:09:32,501 --> 01:09:36,372 IT'S NOT ONLY ABOUT. 1253 01:09:40,643 --> 01:09:44,346 SO I THINK THE MOST HANDS WERE FOR COMPARATIVE EFFECTIVENESS 1254 01:09:44,413 --> 01:09:45,047 RESEARCH. 1255 01:09:45,114 --> 01:09:47,516 SO ARE WE COMFORTABLE LEAVING THE ROOM WITH TAKING IT LIKE 1256 01:09:47,583 --> 01:09:47,783 THAT? 1257 01:09:48,651 --> 01:09:48,851 YEAH. 1258 01:09:49,351 --> 01:09:49,652 COOL. 1259 01:09:50,085 --> 01:09:54,890 THANK YOU VERY MUCH AND THANK YOU VERY MUCH FOR PEOPLE ONLINE. 1260 01:09:54,957 MUCH APPRECIATED.