Evidenced – Based Practice Critical Inquiry (PTH 511) Presentations 4& 5 Evidence-Based Practice I: Definition – What is it? Evidence Based Practice II: The 5 Levels of Evidence. By Michael Parker, PT, PhD, FACSM

Evidence-Based Practice: “A Professional Responsibility” What is Evidence-Based Practice (EBP)? How is EBP different than just applying research results to clinical practice? How is EBP Done? Why should we use EBP?

What is Evidence-Based Practice (EBP)? In its Infancy: Unclear if EBP is adopted beyond the APTA & University PT Programs (Academia) EBP is clearly a critical component of quality patient care EBP is a guide to clinicians for efficient, consistent, high quality patient care.

Evidence-Based Practice (EBP) is the integration of best research evidence with clinical expertise and patient values in making your clinical decision. The best research evidence is patient-centered. clinical expertise is effective use of your clinical skills to quickly identify the patient’s health status & diagnosis, unique risks and benefits of potential treatments, & the patients values & expectations. patient values are unique preferences, concerns,expectations each patient brings to the clinical encounter.

EBP is the Addition of The Best Research Evidence Available to The Formulation of a Clinical Decision Clinical Decision Clinical Circumstances Clinician Expertise of The Physical Therapist Best Research Evidence Patient Values or Preferences

What EBP Isn’t Not just reading a professional journal or the recent research on a regular basis. Not just attending Continuing Education courses on a regular basis.

What EBP Is:Not just applying research results to clinical practice- EBP is a more structured process. Applying the knowledge from a journal (research results) and from a Continuing Education Course to a Specific Patient Problem or Patient Question

EBP – Patient Questions Come from The PT Practice Areas Diagnosis Prognosis Intervention Etiology Harm Use the PICO method to formulate your clinical research question.

The Steps of EBP: How EBP is done. Actions 1 Convert a patient problem into a specific question. Using the PICO Method. 2 Search the literature related to the question. 3 Critically evaluate the pertinent literature 4 Integrate the literature with other clinical factors to make a decision about clinical care. 5 Add the information & decision into clinical practice 6 Re-eval the outcome, & ask another question

Example of Patient Problem as A Clinical Question : How EBP is done. From the Intervention – Practice Area. Patient Problem: Herniated lumbar Disk. Clinical Question: Is static lumbar traction an effective intervention? (For PICO add information about Patient, Comparative Rx, & Outcomes)

Searching The Literature for Evidence Related to The Specific Question : How EBP is done. Two Routes to Use: Information Mastery. Systematic Reviews/Meta-analysis have already answered the specific question . Traditional Approach. Personally Perform a systematic search and appraisal of the literature for specific elements of the specific patient question being asked using a Specialized and Standard Databases.

Use of Systematic Reviews from Specialized Databases to Answer a Clinical Question : How Information Mastery EBP is done. The Systematic Review/Meta-Analysis has already: Asked a Clinical Question Searched and Appraised the Articles using pre-defined rigorous criteria Made a Recommendation for Clinical Practice

Specialist Databases Use a Specific Study Design : How EBP is done. Study Design: Meta-Analysis/Systematic Review Level I Evidence Specialist Databases Combines data from many primary studies (PS). Summarize PS using rigorous criteria Cochrane Database of Systematic Reviews DARE Others Clinical Guidelines Produced from Conclusions Hooked on Evidence-APTA POEMS

The Traditional Approach to Answering a Clinical Question “The clinician independently reviews and evaluates the literature with the goal of answering a clinical question.”

Traditional Approach : Clinician Reads the Literature & Makes-up Her/His Own Mind Study Design Primary Studies Randomized Control Trial Level II Evidence Most rigorous, cause & effect, best for diagnosis & intervention questions Cohort Studies Level III Evidence Data collected over a period of time, best for prognosis & etiology questions. Case-Control Series Subjects with problem matched to control, best for etiology questions Case Studies Level IV Evidence Single patient with unusual problem or Rx – course of care described

Presentation 5 - Evidence Based Practice II: The 5 Levels of Evidence.

Evaluating the Literature: Assigning Levels of Trust via Parker’s Qualitative Continuum Level I Evidence: Excellent, Most valid, reliable; “you can trust this most”. Level II Evidence: Good to Excellent Level III Evidence: Fair to Good Level IV Evidence: Fair Level V Evidence Poor to Fair

Level I Evidence1,2 Systematic Reviews/Meta-Analysis Summary of many well-designed randomized controlled trials (RTC) Authors describe specific methods to search, critically evaluate and synthesize the results of research to answer a clinical question. 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt://www.jr2.ox.ac.uk/bandolier/band12/b12-1.html, February 1995.

Level II Evidence1,2 A Randomized Controlled Trial with a large sample size (n), which is representative of the defined population Random group assignment Most valid design for confirming effects of an intervention 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt://www.jr2.ox.ac.uk/bandolier/band12/b12-1.html, February 1995.

Level III Evidence1,2 Non-Randomized Trials These quality planned designed trials include: Pre-Post (Before-After) Single Group Pre-Post Cohort Groups (prospective, moving forward) Case-Controlled Study Groups (retrospective) 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt://www.jr2.ox.ac.uk/bandolier/band12/b12-1.html, February 1995.

Level IV Evidence1,2 “Non-Experimental Studies” from more than 1 clinic/”center or research group” includes evidence from: Case Reports Single Case Designs 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt://www.jr2.ox.ac.uk/bandolier/band12/b12-1.html, February 1995

Level V Evidence1,2 Expert Opinions or “Clinical Expertise” These are Opinions of “respected authorities” based on: Clinical evidence Descriptive studies Reports of “expert committees” 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt://www.jr2.ox.ac.uk/bandolier/band12/b12-1.html, February 1995

Other Ratings of Levels of Evidence: A, B, C1,3 Level A: RCT > 100 patients (with multi-center & meta analysis) RCT < 100 patients (with > 1 institution & meta-analysis) Well Conducted (has control group) Cohort Study 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 3Hadorn et al. 1996

Other Ratings of Levels of Evidence: A, B, C1,3 Level B: Well conducted case-control study RCT with 1 or more major methodological errors. RCT with 3 or more minor methodological defects. Case Reports or Single Case Design 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 3Hadorn et al. 1996

Other Ratings of Levels of Evidence: A, B, C1,3 Level C: Expert opinion 1Dockter MK. Evidence-Based Practice: PTH 635. 2004-5. 3Hadorn et al. 1996

PT in Terms of Science: A Developing Profession- Why do EBP? The Challenge: Scientific Evidence to validate physical therapy practice and provide an Evidence-Base for a clinical decision is often INADEQUATE.

Evidence-Base for Practice is Frequently NOT Adequate Bridging the Evidence-Gap in PT Practice Clinical Decision Effectiveness Evidence PT’s Clinical Expertise Patient’s Preference Clinical Judgment Harm Intervention Patient Problem Primary Research Needed