Introduction to Evidence-Informed Practice October 2017

CCGI Introduction Our Vision: Our Mission: Enhance the health of Canadians by fostering excellence in chiropractic patient care Our Mission: Develop evidence-based CPGs and best practice recommendations Facilitate their dissemination & implementation within the chiropractic profession CCGI vision and mission is to help clinicians understand the importance of best practice, to provide them with resources and help them to use evidence-informed practice (balancing best research, clinician’s expertise and patient preference) in their daily clinical practice. CCGI’s role is also to inform patients on how their clinician uses best practice recommendations.

What do you think of when you hear: Evidence-informed practice What do you think of when you hear: Evidence-informed practice? Evidence-based medicine? Evidence-informed healthcare? Ask you audience to think about this and give you some feedback.

Evidence-Informed Practice (EIP) Clinical expertise Patient values & preferences Best research evidence CLINICAL DECISION Clinical context It’s important to emphasize that EIP includes all three aspects, the best research evidence available at the time, clinical expertise and patient values and preferences. The clinical decision is made at the intersection of these and will depend on the judgment of the clinician. The clinical decision involves all three aspects

Evidence-Informed Practice (EIP) Definition: The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients TAKE HOME POINT: Best evidence, clinical expertise and patient values and preferences: all three aspects of the model are equally important! So it is important to know about current best evidence and to think about how to apply it appropriately when making clinical decisions for each patient. The clinician’s expertise matters. And the values and preferences of the patient should be taken into account.

Evidence-Informed Practice Statement Canadian chiropractors adopt evidence-informed practice principles to guide clinical decision making by integrating their clinical expertise, patient preference and values, and the best available scientific evidence. This is the evidence-informed practice statement that was approved in 2014 by the CCGI guideline steering committee and has now been approved across Canada in almost all provinces. It can be found on the CCGI website as well as on provincial websites. The EIP statement is approved by colleges and regulatory boards in 9/10 Canadian provinces, and is currently pending approval in Nova Scotia

Why would you use evidence-informed practice?

Why use EIP? ↑ chance of positive patient outcomes ↑ patient satisfaction ↓ risk of harm to the patient Facilitate effective and honest communication with patients Improve cultural authority of chiropractic Enhance integration and communication in multidisciplinary environments Evidence is a common language! These are the reasons why EIP can make a difference in clinical practice, increased chances of positive patient outcomes and patient satisfaction as well as reduced risk of harm. Satisfied patients also make good business sense. It also helps patients to feel that their clinician is being honest when they can see that they are following recommendations. It improves the cultural authority of chiropractic and helps the profession to be recognized by other healthcare professionals who speak the same language.

EIP Misconceptions EIP/research = allopathic medicine EIP is a rulebook/cookbook There is no ‘chiropractic’ research Researchers don’t understand practice realities and want to tell us what we can’t do vs. what we can/should do Volume of new research is too large, making it impossible to stay current There are lots of misconceptions about EIP. Some people think it refers to allopathic medicine, or that it is restrictive because they feel it lays down rules about what clinicians should do. Others feel that there is not enough research being done, or that researchers don’t really understand how clinicians work in practice. Perhaps they think there are many different results and that recommendations keep changing so it’s hard to know what is best practice. They may be worried about changing the way they work, or not sure how to find the best evidence. Or they feel they don’t know enough about research and how to interpret results in scientific papers. Perhaps they feel they don’t have the time.

What are some barriers to implementing eip in your Practice What are some barriers to implementing eip in your Practice? What are potential solutions? Ask your audience to give you their impressions of why it can be difficult to work in this way. Do they feel it is too time consuming? Could it change the way they work? Are they worried that they might have to spend longer with patients? Do they know what it would involve? Do they know where to look for information?

Clinician Challenges Lack of time and/or motivation Personal beliefs regarding research: Doesn’t reflect my practice/patients Statistics too complex Too much information! Don’t know where to look Ask people to think about or talk about what it is that could prevent clinicians from working in this way.

Clinical Practice Guidelines This is where we explain what Clinical Practice Guidelines are and why they are important and useful for clinicians.

What is a Clinical Practice Guideline? CPGs are a comprehensive collection of: Current best evidence regarding etiology, diagnosis & treatment of a condition Expert opinion & consensus Practice-based recommendations Who puts these together? Researchers, clinicians and patient reps – people we should listen to! It’s a massive undertaking! CPGs summarize the latest best evidence and provide recommendations for what treatments should be offered based on the most recent research. They are put together by expert researchers, clinicians and patient representatives so that they are designed to be used in real life. It can take several months or years to produce a CPG.

CPG Development Clear Question Update & Revise Literature Search Study Selection Critical Appraisal Data Extraction Analysis Recommendations Dissemination Update & Revise CPG Development This diagram shows the process from starting with a question (what is the best treatment for x, y or z?), followed by a search of recent literature on the subject, removing papers that are not relevant, extracting and analysing results and creating recommendations based on the research. After, the recommendations are forwarded to clinicians and eventually updated and revised when new research comes out.

Hierarchy of Evidence The highest quality of evidence is what is called summary research, which is systematic reviews, meta analyses and guidelines. These summarize the best evidence from the highest quality trials. Original, or unfiltered research is also interesting because it tells us about examples from clinical practice, but the results often lack scientific quality so it is not usuallly included when developing guidelines.

CPGs – Key Points for Clinicians CPGs are ‘Living EIP documents’ = they are updated regularly CPGs are a tool to support clinical reasoning NOT standards of care/practice NOT a substitute for a practitioner’s experience CPGs contain practice recommendations linked to best evidence Clinical Practice Guidelines are not documents which are set in stone. They develop and change as new research becomes available. They are not a rule, they are a tool to support clinical reasoning. The clinician’s experience is also an important part of the decision. They contain practice recommendations which are linked to best evidence so clinicians can be sure that they are offering best care possible.

Remember… EIP is the rational integration of best available research, your clinical experience/expertise and what the patient wants CPGs help guide decision-making regarding diagnosis, treatment and patient management Patients should always be treated as individuals who can have multiple health problems and risk factors – humans are complex!

Useful resources for clinicians Here are some ideas for where to find resources on EIP and CPGs.

on guidelines and best practice The Canadian Chiropractic Guideline Initiative website is your essential guide to the latest news on guidelines and best practice Visit the CCGI website at www.chiroguidelines.org where you can find the latest guidelines and resources for clinicians and patients. www.chiroguidelines.org Visit us today!

New low back pain guideline Fall (2017) The CCGI team has had a very busy year. The new guideline on the treatment of low back pain is has been submitted by the Guideline Development Group and is currently under review. We expect it to be released later this fall.

With accompanying resources for clinicians……. Practitioner guide Algorithm Summary of recommendations Accompanying tools and resources for clinicians will soon be available. These include the practitioner guide, algorithm and summary of recommendations.

….and patients A new series of exercise & yoga videos for LBP New patient handouts CCGI business cards New patient resources will include a new series of exercise and yoga videos for LBP based on the most recent recommendations. Patient handouts for LBP have been created in collaboration with the design team at the OCA, and the business cards with links to the exercise videos are already available for download on the website.

CCGI knowledge brokers Dr. Kent Stuber (AB) and Dr. Gaelan Connell (BC) We are pleased to welcome Dr. Kent Stuber and Dr. Gaelan Connell, new CCGI knowledge brokers. Dr. Stuber and Dr. Connell launched a new series of bi-weekly podcasts, where they interview invited guests about topics such as how to build a successful evidence–informed practice and how clinicians can get more involved in research. Dr. Stuber is assisting with the Practice-Based Research Networks. Dr. Connell is focusing on the best practice collaborator and opinion leader program. Both are helping CCGI to create new tools and resources for clinicians and patients. Check out their new series of

Practice-Based Research Networks Dr. Katherine Harman & Dr. Peter Stilwell, NS Communication styles used by chiropractors consulting with patients with LBP CCGI is currently funding 2 PBRNs (Québec and Nova Scotia). A new call for applications was launched in mid-September for the 2018-19 funding round. Applications proposing the use of online data collection tools such as Care Response will be given priority. The aim is to encourage implementation and collection of similar patient reported outcome measures (e.g., disability, pain, quality of life, satisfaction with care questionnaires) across the Canadian PBRNs and eventually in the chiropractic profession. Dre. Andrée-Anne Marchand & Dr. André Bussières Qc Promoting self-management strategies for spine pain

Opinion leaders and best practice collaborators program NS ON MB BC 16 CCGI opinion leaders and over 100 best practice collaborators are helping us to promote best practices across Canada. The online competency training program for our Best Practice Collaborators is now available nationwide. Modules include training for collaborators on how to prepare for educational outreach visits and using social media. The regular online cafés for collaborators are proving to be an excellent way to stimulate discussion on the dissemination of best practices.

You can also take CCGI educational learning modules CCGI resources include the webinar series and learning modules delivered in collaboration with CMCC Continuing Education offered at no cost to Canadian chiropractors This 30-minute free learning module is a great introduction to EIP and is fun and educational. It is housed at CMCC Continuing Education.

Find out more about what CCGI is doing and how you can participate Follow CCGI on social media! CCGI has now over 260 followers on Twitter, and over 300 followers on LinkedIn and YouTube. Our YouTube videos have been watched over 40, 000 times since we launched our channel in September 2015. Follow us on social media to find out all the latest news.

At the Canadian Chiropractic Guideline Initiative we believe in teamwork and collaboration. Visit our website and find out how we can work together to bring best practices to chiropractors in Canada and across the world. www.chiroguidelines.org