EBP Chapter 1

Evidence-based medicine

Evidence-based medicine

the consciousness, explicit, and judicious use of current best evidence in making decisions about the care of individual patients

Evidence Based Practice

taking into account the research evidence, your practice experience, and the client's values when making clinical decision

EBP is multifaceted and includes:

- external scientific evidence
- practitioner's experiences
- client/family/caregiver situation and values

External Evidence is typically obtained from

- research articles
- scientific journals

Steps of the Scientific Method

1. Ask a question
2. Gather information
3. Formulate a hypothesis
4. Test/Implement the hypothesis
5. Exam and report the evidence

Important characteristic of the Scientific Method

replication

Importance of Practitioner Experience in EBP

- Research cannot keep up with clinical practice
- Diversity of clients
- Different settings
- pragmatic (logistical) constraints of the "real world"

The reflective practitioner

incorporates theory into their decision-making

Client-centered practice

- Emphasizes the client's choice
- Appreciated the client's expertise in their own life situation

Shared decision-making

- Client shares personal values and lived experience/ client has final word

- Practitioner shared research and clinical experience/ acts as trusted advisor

Why evidence based practice?

- Carries more weight when backed with evidence
- Increases the confidence of clients & colleagues
- Improves quality of service
- Facilitates communication w/ colleagues, agencies, and clients
-Receive more positive outcomes

Process of EBP

(Mirror Scientific Method)
1. Formulate a question based on a clinical problem
2. Identify relevant evidence
3. Evaluate evidence
4. Implement useful findings
5. Evaluate the outcomes

1. Formulate a question based on a clinical problem

1. Identification of a problem
2. Formulation of a question to narrow the focus

Common types of questions

-Efficacy of an intervention
-Description of a condition
-Prediction of an outcome
-Lived experience of a client
-Usefulness of an assessment

2. Identify relevant information; evidence should include:

- Client's experience & values
- Practitioners experience
- Research

3. Evaluate the Evidence

- Strength
- Applicability

3. Evaluation of evidence strength includes

- sample size
- study design
- outcome measures used

3. Evaluation of evidence applicability includes

- practice situation/setting
- client circumstances

4. Implement useful findings

Collaborative!!
-shared decision making
-apply evidence

5. Evaluate the outcome

Achieved goals:
- provided desired information?
- meet client's goals?
- prediction was consistent w/ client's outcome
- client's lived experience resonated with research evidence

Questions on Efficacy of an Intervention

P= population/participant
I= intervention/exposure
C= comparison/control
O= outcome

Efficacy (common design methods)

- randomized trials
- nonrandomized trials
- pretest/posttest
- single subject

Usefulness of an assessment (common design methods)

- psychometric methods
- reliability studies
- validity studies
- sensitivity/specificity studies

Description of a condition (common design methods)

- incidence & prevalence studies
- group comparisons
- surveys/interviews

Prediction of an outcome (common design methods)

- correlation & regression studies
- cohort studies

Client lived experience (common design methods)

- qualitative studies
- ethnography
- phenomenology

Levels of Evidence

a hierarchal system to evaluate the strength of evidence for efficacy questions

Randomized controlled trial

- at least 2 groups (experimental & control/comparison)
- participants are randomly selected
- an intervention must be applied to the experimental group

Nonrandomized controlled trial

- at least 2 groups (experimental & control/comparison)
- participants are not randomly selected
- an intervention must be applied to the experimental group

Single group trial w/ pre- and posttest (pre-experimental)

- 1 group (experimental, no control/comparison)
- comparison comes from variation between pre-intervention assessment & post-intervention assessment

Systematic Review

Analysis of an accumulation of two or more randomized studies

Level I Evidence

Systematic Review

Level II Evidence

Randomized controlled trials

Level III Evidence

Nonrandomized controlled trial

Level IV Evidence

One group trial with pre & post test (no control)

Level V Evidence

Case reports and expert opinion

What is the significance of randomized trials

Eliminates bias that could confound the finding of a study

Internal Validity

ability to indicate that the intervention, rather than another influence caused the outcome (causation > correlation)

Drawback of Level IV evidence

Variation of scores could be due to natural maturation/healing or placebo affect

Which evidence is often used for initial pilot programs

Level IV because there are fewer resources required

Research designs used in usefulness assessments

- Validity
- Reliability

Reliability study

how consistent the result are across different conditions

Validity study

Ability of an assessment to measure what the assessment is intended to measure

Research designs used in assessment studies

- Sensitivity
- Specificity

Sensitivity

proportion of individuals who are accurately identified as possessing the condition of interest

Specificity

the proportion of individuals who are identified as not having the condition of interest

Research designs used in descriptive studies

- Prevalence
- Incidence
- Cross section research
- Longitudinal research

Prevalence

Proportion of a population found to have a condition

Incidence

risk of developing a condition within a period of time
ex: 784,000 adults over the age of 65 developing this disease in 2019

Cross-sectional research

data collected at a single point in time

Longitudinal research

data collected over an extended period of time

Designs used in predictive studies

- cross sectional
- longitudinal (higher level of evidence)

Designs about client's lived experience

(qualitative)
- interviews
- observed extensively in natural contexts

Critically Appraised Topic (CAT)

Summarized evidence of several studies regarding a topic; geared towards application
- often published by professional organizations

Critically Appraised Papers (CAP)

Analysis of a single study
- includes identification of strengths and weaknesses of a study

Clinical Bottom Line

summary statement of a CAP with condensed recommendations from the author

The PICO format is most consistently applied to which type of research?

Efficacy

The question "Which factors are most correlated with fall risk?" would best be answered with what type of question?

Prediction of an outcome

What feature of systematic reviews make them stronger?

Repetition

PICO question format

Includes:
Population, Implementation, Control/comparison, and Outcome

ex: "In adults with arthritis (P) what is the effect of occupational therapy (I) compared to those not receiving care (C) on reduced levels of pain (O)"