Chapter 3 - Evidence Based Decision Making (EBDM)

What is evidence based decision making? (EBDM)

EBDM combines

• Research evidence +

• Clinical expertise +

• Patient preferences/values

2 fundamental principles of EBDM

1. Evidence alone is never sufficient

• Research doesn’t tell clinician what to do

2. Levels of evidence

• Not all evidence are equal

• There’s a heirarchy of evidence

  • Higher up = stronger evidence but less studies

Hierarchy of evidence

2 categories of evidence sources

• Primary research

• Secondary research

Primary research

• Original research studies

2 types of studies

1. Experimental studies

2. Nonexperimental/ observational studies

1.Experimental studies

• Tests hypothesis for cause n effect, researchers must

  • Control or manipulate variables such as effectiveness of treatment

  • Use complex study design that includes RCT or controlled trials

Basically

Wants to know if treatment works → gives 1 group treat and compare → active control

Randomized Controlled Trial (RCT)

• A type of experimental research design

• Strongest design for demonstrating cause and effect

2.Nonexperimental or observational studies

Study where researcher does not give treatment, intervention, provide exposure

• Does not manipulate variables

• Cohort studies

  • Can’t give tobacco = harm

  • Will follow people who already smoke — follow to see who has cancer

  • Forward (prospective)

• Case-control studies

  • Recruit those who have cancer to see if it’s caused by tobacco

  • Backwards (retrospective)

Cohort & case studies = Used for conditions that already exist

• For things where testing it = harm

Cohort vs Case control summary

Cohort	Case-Control
Starts with exposure	Starts with outcome/disease
Follows forward	Looks backward
Usually prospective	Usually retrospective
Exposure → outcome	Outcome → past exposure

Secondary research

Research that’s already been conducted and then analyzed by researchers

• Pre-appraised or filtered research

Examples

• Meta-analyses (MAs)

• Systematic reviews (SRs) ww

• Critical summaries

Evidence pyramid list

Level 1

• Clinical practice guidelines

• Meta-analysis

• Systematic reviews

• Randomized controlled trials (Individual can be lvl 1)

Level 2

• Cohort studies

Level 3

• Case-control studies

Level 4

• Case reports/case series

Level 5

• Narrative reviews

• Expert opinions

• Editorials

Animal/laboratory studies are at the bottom because they do not involve human subjects.

Systematic review

• collects and evaluates multiple individual studies addressing the same question

Meta-analysis

• Statistically combines data/ results from multiple studies

Clinical practice guidelines (CPG)

• No research design

• Experts review SRs and MAs on clinical practice guidelines

Basically

• Research evidence → experts evaluates it → clinical recommendataions

• Evidence can change over time

  • New studies can support or challenge old recs

  
  

• DH are ethically responsible in staying current

  • Use best evidnece when proposing treatment

  • Treatment provided must be documented

Evidence based decision making: Practical application

Evidence based practice is possible thru

1. Online scientific databases (PubMed & Cochrane Library)

2. Access to computers, devices, internet

Skills needed to apply EBDM (The 5 A’s)

• Ask

  • Convert need/ problem into clinical question that can be answered

• Access

  • Conduct computer search to find best external evidence

• Appraise

  • Critically evaluate for validity, usefulness, clinical applicability

• Apply

  • Use evidence in clinical practice

• Assess

  • Evaluate process of your performance (outcome of care)

How is EBDM used in everyday practice?

Step 1

• Asking good questions (PICO process)

Step 2

• Conduct an efficient Online search

Step 3

• Critically appraise evidence for validity and usefulness

Step 1: Asking good questions (PICO)

P = Patient/Population/Problem

• Who is patient/ problem you’re addressing?

I = Intervention

• What interventions considering?

C = Comparison

• Comparing the intervention against what?

O = Outcome

• What outcomes you want?

Example

P: Client at risk for root caries

I: Chlorhexidine varnish

C: Fluoride varnish

O: Prevention of root caries

For a client with ______, will ______ compared with ______ be more effective in preventing ______?

Step 2: Conduct an efficient online search

• Use PubMed (Access to MEDLINE — largest scientific database)

• Filter by article type

Start by

• Intervention & Comparison

  • Fluoride varnish AND chlorhexidine varnish → Search

  • Article type → Meta-analysis (MA) then systematic review → Keep checking down the list

  • Include the P (root caries) if no results

Step 3: Critically appraise evidence for validity and usefulness

1. Are the results of the study valid?

Check if the study was done right (Critical appraisal)

2. What are the results?

Look at researchers conclusion

3. Will the results help in caring for my client

Benefits, risk, application to client, intervention appropriate?

Statistical significance vs clinical significance

Statistical significance

• Results were unlikely to occur by chance

• probability is p-value

  • p < 0.05 (null)

  • Means less than 5% probability observed in difference occurred by chance

Clinical significance

• Statistics can show major significant but doesnt mean its also clinically significant

  • 1 treatment has tiny difference in clinical attachment levels (stat sig)

  • But clinically, this could be due to error

• No stat significance between 2 treatments, but it’s clinically sig if 1 treatment takes less time than the other and both = gold standard

Statistically significant ≠ clinically significant

Step 4: Apply the results of the appraisal, evidence in clinical practice

• Evaluate research and apply to patient

• Don’t follow research blindly

Following research with client (mrs. sanchez)

• Share evidence and clinical judgment with client

• Client makes informed decision

  • Client with similar risk may choose something different

• Both are = evidence based choices

Step 5: Evaluate the process of your performance

• Assess

  • Evaluate outcome of care

  • (Did patient improve? Did intervention method work?)

  • MUST SELF REFLECT

    • no self reflect = trial n error

EBDM is continuous process

• Don’t do it once, you keep repeating