Evidence-Based Practice: Introduction and Application

NORMA J. STUMBO, PH.D., CTRS, FALSEDUCATION ASSOCIATES

JAMIE BENNETT, TRS, CTRSUNIVERSITY OF UTAH

Evidence-Based Practice:

Introduction and Application

Session Outcomes2

• Identify relationship between outcomes and EBP

• Identify 3 reasons why EBP is important to your practice and profession

• List five steps of EBP

•Understand Coping Skills program as example

• Explain how to transfer to your programs and practices

Section I

•Client Outcomes: The Why

•Evidence-Based Practice: The How

3

History of EBP in Medicine

Middle Ages:Medicine –Technically did not heal you, faith healed you.

Neo-Classical Period

Mid 1800’s

“The fastest knife in the West End”

Johns Hopkins Hospital – Mid 1800’s

Early 1900’s

The End Result Concept

Earnest Amory Codman

Earnest Amory Codman’s Cartoon

American College of Surgeons > The Joint Commission

Why are Outcomes Important?

• External Accreditation• Third Party Payers• Health Care Consumer Groups

• It’s the Right Thing to Do!

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What are Outcomes?

• Observable changes that result from intervention (Client status, functional status, well-being, care satisfaction, cost/resource utilization

• Changes over specified time

• Clinical results

• Results of performance

• Direct effects of service

• Difference between input (assessment baseline) and output (discharge)

• Straightest line between A and B

• Both planned and unplanned

• Both beneficial and harmful

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Client Outcomes

Client characteristics at end of treatment

(re-assessment)

(e.g., health status, functional status,

quality of life, etc.)

Client characteristics at baseline

(assessment)

(e.g., health status, functional status,

quality of life, etc.)

InterventionEntry Exit

Difference between Point A/Entry and Point B/Discharge= Outcomes

13

Typical Categories of Outcomes

•Change in clinical status • Effect of tx. on pt. symptoms

•Change in functionality• Effect of tx. on pt. lifestyle

•Change in utilization of services• Effect of tx. on using future services

•Recidivism • Patterns of relapse or re-entry

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Outcome Qualities

• Identifiable/Measurable

• Achievable

• Demonstrable/Documented

• Predictable/Causal—direct result of intervention

• Meaningful

• Predetermined—target behavior BEFORE intervention

• Accountable—deliverable every time

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Outcome Measure Selection

• Relevant/important to clients

• Result from intervention

• Compatible with theories (TOA) and practice

• Incorporate into existing client & program documentation e.g. objectives

• Understandable by professionals and caregivers

• Data collection processes quantify results

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Outcomes Terminology

• Effectiveness

• Efficacy

• Effectiveness research

• Outcomes-based management research

• Patient outcomes research

• Near-patient testing

• Evidence-based practice

• Practice-based evidence

• Clinical practice improvement

• Clinical importance

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Methods for Defining and Measuring Outcomes in TR

• Formal Literature Analyses

• Clinical Practice Guidelines

• Programmatic Data

• Treatment Networks

• Theory in Action Research

• Research Agendas

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What Do We Know For Sure?

•Outcome measurement depends on:• Specification of important, meaningful

outcomes

• Systematic programming/intervention (standardized practice)

• Valid and reliable client assessment

• Accurate and meaningful documentation/records

• Systematic program evaluation and efficacy/effectiveness research

• YOU!!! (yes, YOU!!!)

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Therapeutic Recreation Outcomes

•What are important TR outcomes?

•What outcomes are important in your setting?

•What TR service model do you use in your practice?

•What are the needs of your clients?

•What are the goals of your programs?

•What outcomes do you program for?

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What are Important Outcomes of TR Intervention?

•Your Views…

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What is Evidence Based Practice? The How

• Evolves from systematic study and research

• Evolves from wisdom about outcomes expected from standardized clinical intervention

• Targets outcomes based on standardized interventions

• Promotes selection of treatments which have some evidence

• Improves predictability and causality of service outcomes

• Provides regulators and consumers with assurance of increased quality & reduced risk

• Involves applying results of outcomes research to improve day-to-day TR practices

• Leads to development of protocols

22

Why Evidence-Based Practice Needed?

Three concerns surfaced:

•many physicians relying on personal judgment rather than research for treatment of patients

• new knowledge exploding at almost direct, inverse relationship to time available to read and absorb it

•managed care eroding independence of physician decisions

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Why Do Healthcare Practices Need to Change?

The structures, incentives, and forces at work in the U.S. health system produce exactly what we should expect in the quality of care for chronic disease: highly variable patterns of care, widespread failure to implement recognized best practices and standards of care, and the persistent inability of provider systems to achieve substantive changes in patterns of practice. Moreover, after more than two decades of effort to improve clinical care management and to promote the adoption of evidence-based standards, these variations [still] persist. (Coye, 2001, p. 44)

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Produced need for…

Systematic collection of data, over time, through near-patient research studies as well as the clinician’s reflective approach in applying this information in daily work with clients

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Evidence Based Practices

• Range of evidence: clinician wisdom, anecdotes, case studies, pilot/exploratory studies, experimental designs, RCTs

• Integrate outcome research into practice by identifying outcomes expected from standardized clinical interventions

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Evidence-Based Practice: Research Informing Practice

Therapeutic Recreation Practice

Therapeutic Recreation Research

Evidence-Based Practice

Practice Based Research: Practice Informing Research

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Definitions of Evidence-Based Practice

• The aim of evidence-based healthcare is to provide the means by which current best evidence from research can be judiciously and conscientiously applied to the prevention, detection, and care of health disorders.

• Process of systematically reviewing, appraising and using clinical research findings to aid in the delivery of optimum clinical care of patients.

• Evidence-based healthcare extends the application of the principles of evidence-based medicine to all professions associated with healthcare, including purchasing and management.

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Definitions of Evidence-Based Practice

• Evidence-based medicine is conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise and patients' own values and expectations with best available external clinical evidence from systematic research.

• Evidence-based healthcare is, at its simplest, the idea that care should be based as closely as possible on evidence from well-conducted research into effectiveness of healthcare interventions, thereby minimizing problems of underuse, overuse, and misuse.

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Definitions of Evidence-Based Practice

• Ability to track down, critically appraise (for validity and usefulness), and incorporate this rapidly growing body of evidence into one’s clinical practice has been named ‘evidence-based medicine.’

• Collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and research-driven evidence. The best available evidence, moderated by patient circumstances and preferences, applied to improve quality of clinical judgments and facilitate cost-effective healthcare.

• Reliance on current scientific evidence to reach medical decisions.

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Definitions of Evidence-Based Practice

• Evidence-based practice can be described as selection of treatments for which there is some evidence of efficacy

• Evidence must be gathered through well-designed and meaningful research efforts with client groups and be applicable to daily practice

• Evidence-based practice also is termed empirically

validated treatment, empirically supported treatment, empirically evaluated treatment, empirical practice, research-based practice, research utilization, evidence-based treatment, and evidence-based healthcare

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What is Evidence-Based Practice?

That is, through evidence-based service delivery, each practitioner should feel confident that she or he is providing the best possible care that is known to produce the most desirable, intended, and meaningful outcomes.

32

EBP = Focus on Best Practices

• Evidence-based healthcare usually involves systematic research – and better yet, the accumulation of systematic research – as applied by conscientious specialists who have the ability to synthesize the research and incorporate it into daily practice decisions with clients. Its aim is to reduce wide variations in practice based solely on clinicians’ preferences or personal experiences, eliminating the worst practices, and embracing the best practices

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What Does This Mean for You?

• Evidence-based clinical judgment: • is neither solely evidence nor judgment

• requires understanding of requirements to make satisfactory clinical decision

• increases with opportunity and practice

• reduces but does not eliminate clinical uncertainties

• is currently grounded in Western, allopathic, and professionalized approach to medicine.

• Evidence-based healthcare is process of life-long, self-directed, problem-based learning in which caring for patients creates need for clinically important information about diagnosis, prognosis, therapy, and other clinical and healthcare

34

Supporting Evidence-Based Practice

• Evidence-based practice can be accomplished in three ways:

• through learning the five steps of evidence-based practice,

• seeking evidence collected by others

• adopting protocols written by other who have done evidence-based practice research.

• Evidence-based practice includes performance data from quality improvement efforts, consensus recommendations of recognized experts, and affirmed experience in addition to research findings.

• Ultimate expectation of evidence-based service delivery is improved, informed, and more consistent healthcare for all clients.

35

Steps to Evidence-Based Practice

1. Formulate a clear clinical question from a patient’s problem.

Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi?

2. Search databases for relevant clinical evidence

3. Appraise the evidence.4. Implement and use findings in practice.5. Evaluate the impact of change in

practice.

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Definition of EBP

Evidence Based Practice means conducting or using research to inform the design and delivery of therapeutic recreation practice.

(McCormick & Lee, 2001)

Purpose

“The overall aim of EBP is to reduce wide (and unintended) variations in practice, and instead use the best, accumulated evidence possible to inform, enlighten, and direct practice.”

(Stumbo, 2011.

Pg. 4)

Client Outcomes!

Intervention

Entry Exit

Difference between Point A/Entry and Point B/Discharge

= Outcomes

(Stumbo, 2003)

Client Outcomes!

Intervention

Entry Exit

Difference between Point A/Entry and Point B/Discharge

= Outcomes

EBP 5 Steps!

(Stumbo, 2003)

Steps to Evidence-Based Practice

1. Formulate a clear clinical question from a patient’s problem.

Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi?

2. Search databases for relevant clinical evidence

3. Appraise the evidence.4. Implement and use findings in practice.5. Evaluate the impact of change in

practice.

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Coping Skills Application

STEP ZERO: Cultivate a spirit of inquiry

TR is more than just activity provision!

TR is Process that starts with:

•Specifying outcomes (don’t start with activity first!)

•Looking at research

•Choosing and implementing best practice interventions

•Documenting and evaluating outcomes of interventions

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Coping Skills Application

Step 1: Formulate a clear clinical question.

Ask questions using PICOT formatP – Population of interestI – Intervention or area of interest C – Comparison intervention or groupO – Outcome(s) desiredT – Time frame

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P - Population of interest

• Characteristics? Age(s)? Diagnoses?

•What general needs exist within this population?

•What outcomes of intervention are desired?

• Example:• Clients lack appropriate coping skills when

stressed

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I - Intervention or area of interest

•What are best practice interventions based on needs/desired outcomes?

• Example:• What interventions are best used for

improving coping skills?

45

C - Comparison intervention or group

•What population studied in the research is closest to my group?

• Are skills specific to this group or are they universal?

• Example:• Are coping skills unique to at-risk youth or

are they universal for everyone needing to manage stress?

46

O - Outcome(s) desired

•What change(s) are possible with this group?

•What are the target behaviors of the interventions?

•What should clients understand as a result of these interventions?

• Example:

• Possess array of effective coping skills to manage stress

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T - Time frame

• How long are the programs described in the research?

• How long are clients at my facility?

•What can realistically be accomplished within this time frame?

• Example:• Agency’s average length of stay is 3 days (or

2 weeks or 4 months, etc.)

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Step 1: Clinical Question

•What coping skills do children need in order to manage stress well and sustain a healthy lifestyle across the lifespan?

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Step 2: Search Databases

University or Hospital Library

www.scholar.google.comwww.guideline.govwww.findarticles.comwww.cochrane.org www.clinicalevidence.comwww.ncbi.nlm.nih.gov

www.samhsa.govwww.ahrq.govwww.bmj.comwww.MedScape.comwww.jstage.jst.go.jpwww.doaj.org

www.samhsa.govwww.ahrq.govwww.bmj.comwww.MedScape.comwww.jstage.jst.go.jpwww.doaj.org

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Coping Skills: Keywords Searched

• Coping Skills

• Coping Skills AND Children

• Coping Skills AND Healthy Lifestyles

• Coping Skills AND Adolescents

• Coping Skills AND Adults

• Coping Skills AND People with Disabilities

• Coping Strategies

• Life Skills

• Self-Efficacy

• Perceived Control

• Coping Flexibility

• Coping Skills AND School Systems

• Coping Skills AND Stress

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Step 3: Appraise the evidence

•Articles Appraised: 72

•What did the evidence suggest?

•Was there a theory used in the research?

•Was there an intervention implemented?• What was implemented? With who? What

duration?

•What techniques were used to facilitate the intervention?

•Was there a statistical significance?

•What OUTCOMES did they find?

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Step 4: Implement and use findings in practice

Coping Skills/Strategies: Specific efforts, both behavioral & psychological, people employ to master, tolerate, reduce, or minimize stressful events.

Psychosocial Working Group, 1998

Significant stress in early childhood can trigger amygdala hypertrophy and result in hyperresponsive or chronically activated physiologic stress response, along with increased potential for fear and anxiety.

Tottenham, Hare, Quinn, et al.

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Step 4: Implement and use findings (cont’d)

Step 4: Implement and use findings (cont’d)

Two Types of Coping Skills

• Problem-solving strategies are efforts to do something active to alleviate stressful circumstances. (Cognitive)

• Emotion-focused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. (Emotion)

Psychosocial Working Group, 1998

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Step 4: Implement and use findings (cont’d)

Health and Lifestyle Impact•Effective coping skills are associated with positive social outcomes.

•Empirical evidence suggests that coping inflexibility leads to problematic social functioning.

•Evidence suggests a relation of coping strategies to health outcomes.

(Mayeux & Cillessen, 2003; Richard & Dodge, 1982)

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

(World Health Organization)

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Out of 72 Articles Appraised

•Stress Management (59)• Cognitive Restructuring (54)

• Interpersonal Skills Training (53)

• Problem Solving (51)

• Conflict Resolution (34)

• Relaxation (23)

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Step 4: Implement and use findings (cont’d)

Step 4: Implement and use findings (cont’d)

Overall Outcomes:

•Increase perceived control over managing daily behaviors and emotions.

•Increase ability to manage stressors.

•Increase ability to communicate effectively with peers and support system.

•Increased coping flexibility.

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Step 4: Implement and use findings (cont’d)

Specific Outcomes:

•Client will self-identify physiological signs of stress (increased heart rate, shallow breathing, etc.)

•Client will initiate controlled breathing within one minute.

•Client will remove self from situation within two minutes.

•Client will initiate one cognitive-based coping strategy (e.g., thought stopping, redirection, etc.) within two minutes.

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Step 4: Implement and use findings (cont’d)

Most Common Time Frame of Interventions

• 8 - 10 weeks in length

• 1- 2 Sessions per week

•1 – 2 hours in duration per session

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Step 5: Evaluate impact of intervention in practice

•How well did the intervention work? •What percentages of clients reached their intended outcomes?

•For what groups did it work best? Least?

•What part of the intervention still needs to be modified?

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Steps to Evidence-Based Practice

1. Formulate a clear clinical question from a patient’s problem.

Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi?

2. Search databases for relevant clinical evidence

3. Appraise the evidence.4. Implement and use findings in practice.5. Evaluate the impact of change in

practice.

62

Changing How We Do Business

•What did you learn about the PROCESS?

•What did you learn about OUTCOMES?

•What impact could EBP make on your services?

•What impact could EBP make on client outcomes?

•How will you apply this to your daily practice?

•What other resources are needed to

implement EBP?

•What is your next step?

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The Challenge

• Finding related and relevant research• www.scholar.google.com• www.findarticles.com• www.cochrane.org • www.clinicalevidence.com• www.bmj.com• www.MedScape.com• www.jstage.jst.go.jp• www.doaj.org

• Reading and applying research to practice

•Developing/delivering evidence-based services

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Your Turn65

•Questions?

•Comments?

•Thoughts?

Session Outcomes

• Identify relationship between outcomes and EBP

• Identify 3 reasons why EBP is important to own practice and profession

• List five steps of EBP

• Understand Coping Skills program as example

• Explain how to transfer to own programs and practices

66

Thank You!67

Norma J Stumbo, Ph.D., CTRS

njstumbo@gmail.com

Jamie Bennett, TRS, CTRS

jme.bennett33@gmail.com

Facilitation of TR Services: An Evidence-Based and Best Practice Approach to Techniques and Processes, 2011, Venture Publishinghttp://venturepublish.com/product.php?id=172