Evidence Based Practice Dr Jaspreet Singh Vij Ph. D. (Physiotherapy); MPT Associate Professor University College of Physiotherapy BFUHS

What is - Evidence? Anything that provides material or information on which a conclusion or proof may be based; used to arrive at the truth, used to prove or disprove the point at issue. (Webster)

What is Evidence Based Practice? A process whereby research evidence, clinical knowledge and reasoning are used to make decisions about interventions that are effective for a specific client(s)

“Evidence based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” “Evidence based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” BMJ 1996; 312: BMJ 1996; 312: 71-2.

It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

EBP is both a process and a product… requiring that the evidence which is produced – is also applied to practice. EBP is both a process and a product… requiring that the evidence which is produced – is also applied to practice. (D. Rutledge, 2002) (D. Rutledge, 2002)

The Evolution of Evidence-Based Practice

Formal introduction in It started in medicine as evidence- based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology, education, library and information science and other fields.medicineevidence- based medicinedentistrynursing psychologyeducation

Research vs. EBP Research= systematic process of gathering and synthesizing empirical data to generate knowledge about a given topic Research= systematic process of gathering and synthesizing empirical data to generate knowledge about a given topic EBP is not about conducting research it is about USING RESEARCH

Tactics for efficiently tracking down the best evidence Carry out instant information searching as soon as we need to know something

InternetResourcesforSEARCHING

TRIP (Turning Research Into Practice) TRIP (Turning Research Into Practice) TRIP (Turning Research Into Practice)

Mental Health Resources Mental Health Resources Mental Health Resources

SUM Search SUM Search bin/SUMSearch.exe SUM Search

Cochrane Library Cochrane Library Cochrane Library

Drug Reference Site Drug Reference Site Drug Reference Site

NASWNASW - NASW

Urban Institute Urban Institute Urban Institute

The essence of evidence based practice All evidence is sought and examined systematically All evidence is sought and examined systematically Evidence is wherever possible quantified Evidence is wherever possible quantified Evidence is considered in All decisions in healthcare Evidence is considered in All decisions in healthcare Evidence doesn’t make decisions: human beings do Evidence doesn’t make decisions: human beings do

Formulate a focussed question Patient / Problem / Population Intervention Comparison Outcome

Scenario Tom, a smoker of 20 years goes to his GP to ask for help with stopping smoking. He’s tried various methods in the past but nothing has worked so far, so asks the GP whether acupuncture might be a good option.

Our PICO P = Smoking I = Acupuncture C = N/A O = Stopping smoking Is acupuncture an effective way of stopping smoking?

Quick search: Demonstration TRIP PubMed Clinical Queries

Hands-on Formulate a focussed question – Use your own question – Record the search terms you’re using Run a quick search on TRIP Run a quick search on PubMed Clinical Queries

Run a full search strategy: Why bother? Too few results Too many results Irrelevant results Submitting a funding proposal Writing a guideline Conducting a systematic review

Developing a search strategy Take your PICO and think about: – synonyms – using and/or – phrases – truncation

Combine terms with OR smoking tobacco Smoking OR tobacco – either term can be present

Combine terms with AND Smoking AND acupuncture – both terms must be present acupuncture smoking

Phrases and truncation Take a common word stem and look for spelling variations e.g. ◦ psycho* - will retrieve papers psychosis, psychoses, psychotic…but also psychology, psychological… Phrase searching ◦ Use double quote marks if you want words to appear next to each other e.g. “psychotic episode”

Develop a search strategy Using OR then AND to broaden then focus the search PIO smoker* or smoking or tobacco acupuncture or acupressure cessation or stop* or quit* and

Perform a search on PubMed

Searching tips: PubMed Subject searching - use MeSH – Subject headings added to articles on Medline – Search the MeSH Database Finding similar articles – use the ‘Related articles’ link

Search the Cochrane Library International Cochrane Collaboration >90 countries effects of interventions Includes: Full-text Systematic Reviews Abstracts to further SRs and RCTs Available at:

Resources Cochrane Library PubMed TRIP Other sources – CEBM web-site – EBM tools

Help Finding the Evidence tutorials: – eencasts eencasts PubMed – Short online tutorials – Quick guides to PubMed – basics, MeSH search and MyNCBI

Evolving Interest in Evidence-Based Practice 2011 – Medline search > 38,000

How many randomized trials are published each year

Need to become Critical Consumers of Information Just because it is published doesn’t make it right. And, just because a study was done and written up does not mean that the evidence behind that study is strong or reliable. (Hyde, et. al 2003)

Has EBP changed the world? Old world: Source of knowledge is expert opinion Old world: Source of knowledge is expert opinion New world: Source of knowledge is systematic review of evidence New world: Source of knowledge is systematic review of evidence

Has EBP changed the world? Old world: Research is marginal to practice Old world: Research is marginal to practice New world: Research and practice go together New world: Research and practice go together

Has EBP changed the world? Old world: Main information sources are experts, selected journals, and books Old world: Main information sources are experts, selected journals, and books New world: Essential to have immediate (electronic) access to systematically collected evidence New world: Essential to have immediate (electronic) access to systematically collected evidence

Has EBP changed the world? Old world: Clinical performance is not systematically audited Old world: Clinical performance is not systematically audited New world: Clinical performance is regularly reviewed and managed New world: Clinical performance is regularly reviewed and managed

Has EBP changed the world? Old world: Organisational model is hierarchical Old world: Organisational model is hierarchical New world: Organisational model is much more democratic, based on ability to use evidence New world: Organisational model is much more democratic, based on ability to use evidence

Has EBP changed the world? Old world: Doctor patient relationship is essentially master/pupil Old world: Doctor patient relationship is essentially master/pupil New world: Patient partnership is the norm New world: Patient partnership is the norm

Has EBP changed the world? Old world: Patients do not have easy access to the knowledge base of doctors Old world: Patients do not have easy access to the knowledge base of doctors New world: Patients have as much access to the evidence base of medicine as doctors New world: Patients have as much access to the evidence base of medicine as doctors

Has EBP changed the world? Old world: The doctor is smartest Old world: The doctor is smartest New world: Often the patient is smarter New world: Often the patient is smarter

Problems with information sources Too slow Too slow Don’t deliver information tailored to individual patients Don’t deliver information tailored to individual patients Guidelines must give guidance even when the evidence is incomplete--very tricky, culturally bound, may ignore the patients’ wishes Guidelines must give guidance even when the evidence is incomplete--very tricky, culturally bound, may ignore the patients’ wishes

What skills will you need to keep up to date with the best evidence? To find the evidence more efficiently To find the evidence more efficiently To appraise the quality of the evidence more effectively To appraise the quality of the evidence more effectively To use good quality evidence more systematically To use good quality evidence more systematically

Conclusions EBP has swept the world in less than 10 years EBP has swept the world in less than 10 years The appearance of EBP does mark a radical break from the old world The appearance of EBP does mark a radical break from the old world It is a new world in which the traditional authority and skills of doctors are questioned It is a new world in which the traditional authority and skills of doctors are questioned There are many ways in which it might/will develop There are many ways in which it might/will develop

Conclusions Information on its own doesn’t change practice Information on its own doesn’t change practice We must learn more about how we move from evidence to change, but we know it’s hard We must learn more about how we move from evidence to change, but we know it’s hard

Finally “When a steamroller comes through you are either part of the roller or part of the road.” “When a steamroller comes through you are either part of the roller or part of the road.” Stuart Brand Stuart Brand

ANY QUESTIONS?