Section #1 - Evidence Based Practice

Why EBP?

• Reduce

  • Unexplained variation in practice

  • Potential or actual harm from previous approved medications and medical devices

  • Medical errors

  • Costs of health care

What is evidence-based practice?

Implies the use of evidence in clinical decision making instead of unquestioning reliance on knowledge from experts, teachers, or familiar practice habits

Why should evidence based practice be used alongside clinical expertise?

• Evidence is not a replacement for clinical expertise

• Evidence is used to fully inform decision making rather than using one clinical expertise perspective

What is clinical expertise?

Ability to use skills and past experience to rapidly identify each patient’s unique health state and weigh professional interventions

What is clinical research?

Clinically relevant research into diagnostic tests prognostic markers and interventions

What is patient characteristics?

Unique preferences, concerns and expectation of each patient which must be integrated into decision-making

What is local standard of care?

• Reflects initial understanding of clinical phenomena that diagnostic and treatment approaches are made based on biological plausibility and anecdotal (personal) experience

• “This is what I’ve always done”

Does evidence evolve and change?

Yes, previous treatment methods thought to be beneficial can later reveal differing results, or even past evidence presented can be found to be not backed consistently

What is evidence based PT practice (EBPT)?

• Open and thoughtful clinical decision making about patient’s care

• Considers best evidence available with clinical judgement

• Integrates a patient’s preference and values and considers social context of PT services provides to optimize outcomes and QoL

What are EBPT focus areas?

• Examination

• Diagnosis/Assessment

• Prognosis

• Intervention

• Outcomes

What are the EBPT processes?

1. Question formation

2. Search for relevant research

3. Critical appraisal of evidence

4. Determination of applicability of evidence

5. Consideration of evidence in combination with

   • Clinical expertise

   • Patient values and preferences

What are perceived barriers to use EBPT?

• Statistics phobia

• Difficulty recognizing strong research

• Combination of clinical expertise (none as student)

• Limited access to evidence

• Not the way they practice in the real world

How can you incorporate EBM into clinical practice?

• Understand peer reviewed evidence and its benefits

• Differentiate between research vs opinion driven information

• Be critical consumers

• Recognize clinical decisions based on theory vs decisions based on data

  • Authority vs research

• Become comfortable with uncertainty

Why is important to be comfortable with the fact that uncertainty exists within EBP?

Leads to questioning and growth and ultimately better patient care

Is decreasing uncertainty always beneficial?

• Yes and no

• Ex: CE, “experts”, and non-peer reviewed writings can do more harm than good

Define evidence

Actual data collected on patients

Define theory

Overarching belief that may or may not be correct and may or may not apply to individual patients

What is the basis of a theory in PT?

Basic science research/knowledge in anatomy, physiology, biomechanics, histology, and more

What is theory good for?

• Essential for almost all clinical decisions

• Can guide some decisions but those decisions should not be purely justified by theory alone

What is evidence application?

Used of clinically applied data when available without the use of theoretical arguments

Do theory and evidence support each other?

• Not necessarily

• Ex: Ultrasound or superficial head have strong theory but little evidence

Is all evidence equal?

No, there is a ranking of levels of evidence from highest quality to least

What are the levels of quality of evidence? (highest to lowest)

• Systematic review of randomized trials

• Single randomized trial

• Systematic review of observational studies with patient important outcomes

• Single observational studies with patient important outcomes

• Physiological studies

• Unsystematic clinical observations

• Expert opinion

Where does evidence come from?

• Peer reviewed journal based literature

• Textbooks

• “Experts”

What is the main source of evidence?

Peer reviewed journal based evidence

Why is peer reviewed evidence considered the gold standard?

Represents a collective wisdom that likely comes closest to tell the truth

What is the gold standard for evidence?

Peer reviewed journal based evidence

How is evidence base practice applied?

1. Ask

2. Acquire

3. Appraise

4. Apply

5. Assess

What is an example of the application of evidence based practice?

1. Ask: Patient has a problem and we are unsure of the best approach

2. Acquire: Convert problem into and answerable question (PICOS)

3. Find and then appraise the evidence (judge)

4. Apply: Apply evidence to patient if appropriate

5. Assess: Assess the results of applying the evidence

Why is questioning important?

Allows you to better provide care to the specific patient’s treatment and management

What is a background question?

• Broad disorder related questions

• “Who, what, where, when, why, and how?”

What is a foreground question?

• Patient specific questions to understand their management

• Diagnosis, prognosis, risk factor, intervention

What question type should be prioritized?

Foreground

Describe characteristics of background questions

• Questions that apply to clinical topic for all patients

• True of the world in general

• General who, what, where, when, why, and how questions

Describe characteristics of foreground questions

• Relate to patient specifically

• Considers aspects of given person or group of people

• Provides answers that can directly improve a meaningful outcome to person or group

What are the benefits of foreground questions?

• Inclusion and exclusion criteria are clearer

• Greater likelihood of producing clear messages for clinician

• Easier for PT to determine relevance

What does PICOS stand for?

• Population

• Intervention

  • Exposure, prognostic, diagnostic tests

• Comparison

• Outcomes

  • and time frames

• Study design

Why is PICOS beneficial in using?

Allows for easier way to read and understand evidence based research