CDIS 5400Dr Brenda Louw 2010

Evidence Based PracticeClass 3 September 15 2010

Objectives

Demonstrate: Knowledge and understanding of an EBP

approach Skill to perform 5 steps of EBP in clincial

practice

Readings Schiavetti et al.,2011 Chapter 8, pp 369-381

Overview

Concept of EBPI Levels of evidence

Steps of EBP Clinical

application

Where does evidence based practice come from?

Not just a recent trend adopted from medicine!

New paradigm in health care emphasizing importance of scientific evidence in guiding clinical decision making

Fundamental to ethical practice Part of total clinical process

Why the fuss?

Growing awareness of limitations of expert opinion as sole basis for clinical decision making

Growing demands from clients, medical insurance for accountable, quality services that make a difference

EBP orientation potential to improve the quality of the evidence base supporting clinical practice in SLP, ultimately improving the quality of clinical services to clients

What is Evidence Based Practice? ASHA definition 2005

EBP refers to an approach in which current, high quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions

EBP in Communication Disorders Position Statement 2005. www.asha.org

Principles of EBP

Current Best Evidence

Clinical Expertise

Client Values

EBP

In other words:

EBP is advocated by ASHA to guide the clinical decision making process which synthesizes: Current best evidence collected from

objective clinical research Clinical expertise and experience Sensitivity to emotional needs, values,

perspectives of clientsEllis, Pollard, Ramig & Dodge, 2006

Interpretation:

According to Dollaghan,2004, p 4 EBP offers a framework and set of tools by

which we can systematically improve in our efforts to be better clinicians, colleagues, advocates and investigators-not by ignoring clinical experience and patient preference but rather by considering these against a background of the highest quality scientific evidence that can be found

EBP supports strong client-centered approach to intervention

EBP requires honest doubt about a clinical issue, awareness of one’s own biases, respect for other positions, a willingness to let strong evidence alter what is already known, and constant mindfulness of ethical responsibilities to patients

How is EBP different from the methods clinicians have always tried to use in clinical practice?

Assumes that external supports will be needed for clinicians to do their best

Highlights the desirability of clinician-researcher connections in the research-application process

Stems from the premise that integrating information from these 3 types (research evidence, clinical expertise, client preference) as part of decision making is immensely challenging

Not all evidence is equally usefulSome research evidence is more clinically relevant

than othersFor example:

• research on normal children versus on children with sound system disorders

• physiological research versus treatment efficacy research

• research aimed at identifying possible etiological factors versus studies of diagnostic accuracy (e.g., sensitivity and specificity) of specific measures

Not all sources and summaries of research evidence are of equal quality

Consider each of the following as a possible source of evidence for a clinical decision: Your favorite instructor from grad school An article in the Leader An article in an ASHA journal A series of articles in several journals by several teams of

researchers A workshop presenter’s comments An advertisement in the Convention program A course review paper you prepared in grad school

==> Concerns about these inequalities have led to the preparation of systematic reviews of the literature based on hierarchies of evidence quality/evidence weighting systems

Levels of evidence

Hierarchy : strong(I) to weak(IV) Evidence obtained from : www.asha.org/members/ebp/ assessing.htm

A Sample Hierarchy of Research Evidence (Dollaghan et al., 2004)Level Description

Ia Well-designed meta-analysis of >1 randomized controlled trial

Ib Well-designed randomized control trial

IIa Well-designed controlled study without randomization

IIb Well-designed quasi-experimental study

III Well-designed non-experimental studies (case studies, correlational study)

IV Expert committee report, consensus conference, clinical experience of respected authorities

A hierarchy of methods for synthesizing evidence

(McCauley & Hargrove, 2004)

What’s being valued in this hierarchy & in other strategies for identifying an evidence base

Independent confirmation & converging evidence

Experimental control achieved through: Use of control groups Random assignment to groups Use of blinding as possible

Avoidance of subjectivity and bias Documentation of the size of effects (not

just statistical significance)--How important is the difference seen between groups?

Relevance and feasibility

Levels of Evidence

It’s easy to make the mistake of thinking that certain kinds of designs guarantee high-quality evidence In reality, studies with highly ranked

designs can yield invalid or unimportant evidence just as studies with less highly rated designs provide crucial evidence

Learn how to weigh several dimensions of quality, not just research design, in evaluating external evidence

Systematic Reviews

Time saving in searching for evidence Systematic review: comprehensive

synthesis of scientific literature on a specific clinical question, conducted using systematic methods and explicit criteria Eg Nelson et al 2006 systematic review of

screening speech and language

Continued…

A systematic review is a critical assessment and evaluation of research (NOT simply a summary) that attempts to address a focused clinical question using methods designed to reduce the likelihood of bias.

The goal is to synthesize the literature being reviewed in order to increase its accessibility and its signficance from conclusions taken from a larger group of studies a high-quality systematic review is considered by

many to be the premier form of evidence for answering clinical questions

Benefits of Systematic Reviews Comprehensiveness and transparency of the

review are increased, while bias is reduced Potential for increasing the transfer of

knowledge to practice Potential for helping readers understand more

about the generalizability and consistency of findings Systematic reviews can provide insights into reasons

for the heterogeneity of findings, such as differences in study methods or participant characteristics, which may limit readers’ ability to apply findings to individual cases.

Guidelines

EB clinical practice guidelines powerful tools to help SLT and parents make best possible decisions re intervention

Guidelines: 1step further than reviews by producing practice recommendations based on systematic reviews

Hierarchy Evidence Base Level IV expert opinion based on

clinical experience, descriptive studies, reports

ASHA 2008 Roles and Responsibilities of SLP in EI: Guidelines(www.asha.org) Guiding principles based on INTERNAL EVIDENCE:

Consumer input and preferences Provider experiences and observations Recognition of evolving societal values,

research , policies eg IDEA 2004, recommended practice documents

EXTERNAL EVIDENCE: Peer reviewed systematic empirical research

Clinical Application : EBP In 5 steps

1 Identify a particular issue or problem at hand (posing a clinical question)

2Search the literature for relevant research( searching for evidence)

3 Evaluate the research evidence ( appraising evidence) 4 Making and implementing clinical

decision 5 Evaluating the decision(Dollaghan, 2004)

Two Methods to “doing” EBP: “Push” and “Pull” Methods “Push” – alerts us to new information

“Just in Case” learning

Developing our knowledge of EBP information sources and terminology Improving access to databases summarizing relevant evidence (EBP

websites; systematic reviews including the Cochrane Collaboration, U.S. Department of Health and Human Service’s Agency for Healthcare Research and Quality, and the Scottish Intercollegiate Guideline Network; meta-analyses; practice guidelines)

“Pull” – access information when needed “Just in Time” learning

Synthesis of the existing evidence so that is useable Generation of more clinically relevant evidence

(Glasziou; McCauley)

Information(pulls) steps in EBP

Ask a question Get some articles Evaluate the evidence Apply the findings Integrate science with craft (values,

preferences, experiences)

Step 1 : Ask a question

Need to ask a foreground question rather than a background question

What’s the difference between a background question and a foreground question? Background questions

ask for general knowledge about a condition, via a question word (who, what, where, when, how, why)

Foreground questions ask for specific information and include PICO

components (Patient/Problem, Intervention, Comparison intervention, Outcome)

Foreground questions are the focus for EBP

Background Questions

What’s the best treatment approach for children with phonological disorders? (minimal pars)

Is it better to evaluate a child’s phonology by analyzing a language sample, or by a standardized test? (standardized)

Is oral motor therapy more effective than phonological intervention?

Foreground Questions

About treatment: In toddlers who are late talkers, does phonological stimulation lead to greater phonetic inventory gains than no treatment?

About diagnosis: For identifying phonological error patterns in 4-year-old children, is the HAPP-3 substantially more accurate than the CAPES ?

Step 1: Formulate a foreground question

Re-write your question to specify:

PP the patientpatient and/or problemproblem of interest

II the interventionintervention, defined broadly to encompass clinical decisions about diagnosing, treating, prognosticating

CC the comparisoncomparison intervention OO the clinical outcomeoutcome of interest

e.g.

E.g. Can parents be trained (P) to deliver an EI

programme (I) to young children with CLP which will result in positive changes ( C) in speech characteristics? (O)

(Scherer et al 2008)

For preschool children with moderate to severe phonological impairment, does “X” result in greater system-wide changes than training “Y?”

Step 2 : Search External evidence

Locating evidence : search engines, web sites,journals, books

Search terms: more general yield more results

Ensure articles are data based and not tutorials

List articles to review Review according to appraisal questions Prioritize evidence

Step 3 Evaluate the evidence Evaluate evidence ito of 3 components

A Validity B Importance C Applicability

Step 3 a Validity:

Was it randomized? Was it prospective? Was there full disclosure of participant

enrollment and loss? Were the participant groups similar? Was it blinded?

Avoid bias and confounding

Step 3 b

What were the results? Statistical significance Practical significance(effect size) Functional significance (social validity)

What was the precision of the results?– Range within the true value falls with 95%

confidence (confidence interval)

Step 3 c Application

Can it be applied to my client?

Can it be done here?

Forms for step 3

Key Appraisal Points Worksheet

Summary CAT (Critical Appraisal of Therapy)

Step 4: Decide if evidence should change your clinical practice Were there differences in

methodology that might be related to differences in study results?

Were there differences in terms of generalization measures?

Continued…

Other considerations? Time in intervention overall severity

Step 5 Integrate Science with Craft Can I apply this approach in my

clinical setting?

Will this approach work with my clients?

Evaluate your performance

What will clinicians ultimately be asked to do within EBP? Ask answerable clinical questions of the research

literature Find best current evidence concerning these

questions [systematic reviews, etc. as these are prepared]

Critically assess evidence for validity and relevance [understand hierarchies of evidence]

Within the context of the individual, integrate this evidence into decisions about client care

Communicate with clients so they can participate in an evidence based decision and effect consensus decisions, which are then implemented and assessed

(Robey, Apel, Dollaghan, Ellmo, Hall, et al., 2004)

Mechanisms for Bridging the Research to Practice Gap

Too often, the onus for turning CDIS into an evidence-based profession is put on the practitioners

The onus is really on the trainers of the practitioners, the researchers, and the policy-makers

(Justice, 2004)

ASHA

http://www.asha.org/Members/ebp Web based tutorials EBP Compendium of clinical practice

guidelines and systematic reviews Evidence Maps –current best evidence

e.g. For ASD http://www.ncemaps.org/Autism-Current-Best-Evidence.php

Future directions:

Call for high quality clinical research Facilitate access to research findings Translating research into usable practice

guidelines, protocols Encouraging use of EBP approach

amongst practitioners

In conclusion

EBP apply 5 steps of EBP to a clinical intervention

question evaluate the validity, importance, and

applicability of selected studies integrate the evidence with clinical

experience, values, and preferences

Skill to do comes from doing Ralph Waldo Emerson