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

2. 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)

3. 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)

4. “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: 71-2. BMJ 1996; 312: 71-2.

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

6. 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)

7. The Evolution of Evidence-Based Practice

8. Formal introduction in 1992. 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

9. 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

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

11. InternetResourcesforSEARCHING

12. TRIP (Turning Research Into Practice) TRIP (Turning Research Into Practice) http://www.tripdatabase.com/ TRIP (Turning Research Into Practice)

13. Mental Health Resources Mental Health Resources http://www.mentalhealth.com Mental Health Resources

14. SUM Search SUM Search http://SumSearch.UTHSCSA.edu/cgi- bin/SUMSearch.exe SUM Search

15. Cochrane Library Cochrane Library http://www.cochrane.org/ Cochrane Library

16. Drug Reference Site Drug Reference Site www.rxlist.com Drug Reference Site

17. NASWNASW - http://www.naswdc.org NASW

18. Urban Institute Urban Institute www.urbaninstitute.org Urban Institute

19. 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

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

21. 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.

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

23. Quick search: Demonstration TRIP www.tripdatabase.com www.tripdatabase.com PubMed Clinical Queries www.pubmed.gov www.pubmed.gov

24. Hands-on Formulate a focussed question – Use your own question – Record the search terms you’re using Run a quick search on TRIP www.tripdatabase.com www.tripdatabase.com Run a quick search on PubMed Clinical Queries www.pubmed.gov www.pubmed.gov

25. 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

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

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

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

29. 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”

30. 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

31. Perform a search on PubMed www.pubmed.gov

32. 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

33. 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: http://www.thecochranelibrary.com http://www.thecochranelibrary.com

34. Resources Cochrane Library www.thecochranelibrary.com www.thecochranelibrary.com PubMed www.pubmed.gov www.pubmed.gov TRIP www.tripdatabase.com www.tripdatabase.com Other sources – CEBM web-site – EBM tools www.cebm.net www.cebm.net

35. Help Finding the Evidence tutorials: – http://www.bodleian.ox.ac.uk/medicine/information_skills/scr eencasts http://www.bodleian.ox.ac.uk/medicine/information_skills/scr eencasts PubMed – Short online tutorials – Quick guides to PubMed – basics, MeSH search and MyNCBI http://www.nlm.nih.gov/bsd/disted/pubmed.html

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

37. www.cebm.net How many randomized trials are published each year

38. 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)

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. ANY QUESTIONS?