Evidence Based Practice 1 Understanding EBP and Developing Your Question

What is EBP? Early protagonists were focused on the development of evidence based medicine: Sackett et.al.,(1996) defined evidence based medicine as the ‘conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’.

EBP This definition provides 3 specific pointers to EBP: – Conscientious explicit and judicious The use of EBP is deliberate and overt however there is some judgement required. – Use of current best available evidence Not last years evidence or what I was taught as a student – what is currently known. The onus is on every clinician to keep up to date – Care of individual patients Evidence must be applied to and appropriate for the individual patient

4 pillars of EBP 1.Clinician experience and expertise (this is what you bring each day) 2.Need current evidence (we will spend some time on how to locate and synthesise this) 3.Must understand the needs and preferences of the individual patient (requires a comprehensive assessment and discussion with the patient including consideration of specific cultural, religious or other requirements. Any client choices must be informed) 4.Context or environment of practice (Is the proposed management plan reasonable in the circumstances? Are the required resources available?)

Clinician experience and expertise This is what you bring to your clinical setting each day. This is individual and specific to yourself. YOU must decide if you have the skill and experience or expertise to provide the best available care for each individual patient. There may be times when you decide that a referral or second opinion are in the patients best interests. THIS IS A CORE ELEMENT OF PROVIDING EBP that requires sound and accurate clinical judgement.

Current Evidence Do I have knowledge of the current evidence for management of the specific issues/ problems of this individual? How can I be sure? How can I find current best evidence? – the efficacy and safety of an intervention or treatment, or – explore the accuracy and precision of assessment or diagnostic tests, or – the power of clinical signs and symptoms for prediction of client or patient outcomes. How do I make sense of the evidence I find? THIS IS ALSO A CORE ELEMENT OF EBP

Patient needs and preferences Why has the individual come to you? What are they seeking? Do they have strong (or even mild) preferences about how they would like this to occur? Do their preferences change how you would approach their problem? Are there trade-offs involved? Have you explained each option (and possible outcomes/complications) so that the client is able to make an informed decision? THIS IS A FURTHER CORE ELEMENT OF EBP

Context or environment Is there any environmental barrier to the provision of appropriate management? Are the resources available? Can the selected management be delivered? Are there any relevant legislation/ registration/ scope of practice/ practice guidelines /community expectations to consider? Can the client afford the proposed solution? THIS IS A CORE ELEMENT OF EPB.

EBP Each element of EBP requires careful consideration. There may be more than one appropriate approach to management from your perspective as a clinician. Each may be able to be delivered to the client. Their needs and preferences may decide the approach you select. In EBP, the deliberate and skilful integration of each of these elements is used to derive the best evidence based solution for each individual.

Why use EBP? Client centred Mindful and reflective Up to date As a professional you have a responsibility to act: – on the basis of the best evidence, – in the best interests of others and – to maintain the good reputation of your profession by acting within the professional code of conduct (obtainable from the AHPRA website)

Why use EBP? The best research evidence is likely to be safer and more effective than alternative treatments. Integrating this with your clinical expertise and practice context can help you and the patient decide on the best management to meet their needs and expectations and Using EPB should produce the best outcome for the patient or client.

Why use EBP? Funders, policy makers and purchasers of health services have an interest in obtaining value for money and best benefit where there is competition for finite resources. Using EBP helps demonstrate that your practice is underpinned by the best available evidence and should provide the best client outcome.

Finding Evidence Each specific client question requires a comprehensive literature search To ensure your search and findings are comprehensive you need to – have a clear question – look in the best and most current places – be able to understand and synthesise the evidence you locate

Defining or Refining your question Use a PICO format: – Patient / Population – Intervention – Comparison – Outcome

Example: Quantitative Does the use of a specific leg strengthening exercise program(I) increase levels of leg muscle spasticity (O) in children with spastic diplegic cerebral palsy (P) more than an aerobic exercise program(C)?

Example: Qualitative Do individuals with Parkinson disease (P) prefer (O) therapy sessions that are individual (I) more than group sessions (C)?

Example: Diagnostic test Is …………. Test (I) better than ……………… (C) at identifying ……………. (O) in adults with an acute knee injury (P)? The answer will be in terms of those correctly identified and those missed

Example: Prognostic indicators Does a 10m Incremental Modified Shuttle Walk Test (I equivalent) allow a more accurate prediction of fitness (O) than the 6Minute Walk Test (C) in patients with coronary artery disease (P)?

PICO Work out your next clinical question: P I C O Format into a sensible and answerable question

Hierarchy of Evidence How do we decide what constitutes strong evidence? How do we decide if ‘evidence’ is not useful due to ‘bias’? In theoretical terms a hierarchy of evidence describes research where strategies have been used to reduce bias in the study.

Hierarchy of Evidence diagram Before you start to search for evidence it is useful to understand the weighting given by scientific communities to various types of studies. This is traditionally called a hierarchy of evidence [3] and will help you understand why some research papers are considered to carry more weight than others. In this section we will consider a hierarchy of evidence in relation to intervention or quantitative studies and work from the lower levels of evidence to the highest.

Anecdotal Evidence Ideas, editorials and opinions are considered the lowest point in the hierarchy of evidence as they may be anecdotal and are subject to individual bias. Opinions can be useful as they often provide ideas that are helpful in formulating a research question. In particular they can be helpful when generating a research question based on the experience of a client.

Single Case Study Single case studies, however well they are conducted, give us evidence of the response of one individual to the stimulus or intervention used. In the case of an extremely rare condition, this may be the only evidence available. However it may be that this one individual has an extreme case of a problem or does not respond to an intervention in the same way as others. Single case studies are therefore not considered to provide a high level of evidence that can be generalised from the individual to the population.

Series of case studies A case study series may then provide a slightly better understanding of the responses of a small group of individuals to an intervention. This would be considered stronger evidence, however the group may have been selected very carefully for the study and again may not reflect the experience of a broader sample.

Case controlled studies A case-controlled study where each individual is matched to someone receiving the alternative treatment or where each individual may receive both a control and an intervention provides slightly stronger evidence in that it gives a comparison of the effect of two possible interventions on the same individuals. The strength of this type of study can be increased by randomising the order in which the two possible ‘treatments’ are provided.

Randomised Controlled Trials All participants will be randomly assigned to receive one treatment or the other. The randomisation process should be sufficient to ensure a spread of participants in each side of the trial. The larger the number of participants the more likely it is that this will be true.

RCT with ‘blinding’ Randomised controlled trials with ‘blinding’ of intervention, assessors and individuals generally produce the strongest evidence. In these trials there are multiple strategies used to ensure that the results are not due to bias on the part of a participant or researcher and that any systematic differences are most likely the result of the intervention.

Qualitative Studies Well designed qualitative studies that have used a number of strategies to ensure appropriate sampling, data collection and interpretation have similar lack of bias to a RCT. The opinions of a group of clients, gathered in a qualitative research study can be a valid and useful form of evidence to answer questions about their experience of an intervention or of their health care.

Systematic Reviews A systematic review (SR) of the literature is undertaken to find all the evidence around a question – not just the evidence that agrees with your thinking or that has a particular finding. Because there has been a long history of bias towards publishing studies that have positive findings rather than also publishing studies that have not found any differences between interventions, this can mean that even the best systematic reviews have a bias towards the treatment or intervention.

Systematic Review A systematic review relies on the use of a systematic approach to searching for, finding and reviewing every paper relevant to the question of interest. A number of strategies are used to increase the likelihood of finding all of the relevant information

Systematic review strategies Identify and use ALL databases that cover the field of interest (we will go through this with multiple databases in workshop 2) Identify and use ALL terms that describe the elements of your question – If your question has been generated using a PICO framework then think of alternative terms for each of the P, I, C & O elements. – These will be combined using ‘and’

Systematic review strategies When you are thinking of search terms remember to include: Alternative terms such as: ‘Heart attack’ or ‘Myocardial infarction’ ‘Physiotherapy’ or ‘Physical therapy’ ‘Podiatrist’ or ‘Chiropodist’

Systematic review strategies Use available help: – MeSH (Medical Subject Headings) – Librarian – Discuss or brain storm with colleagues – Check wording in any papers you have already found – Check professional guidelines for alternatives

Preparation for Workshop 2 Ensure you have a working Athens log in Review your knowledge of on-line databases Think about what databases might be most appropriate for your question

Preparation for workshop 2 Think about any limitations you may want to place on your search – Date – Gender – Human – Adult – Language

Preparation for Workshop 2 Prepare a search strategy that includes: – your search terms – the databases you should search – the ‘and’ & ‘or’ logic See if you can locate any guidelines or that are important for your question (professional or diagnosis-related)