Evidence Based Treatment (Chapter 2)

What should be considered when looking at which treatment should be used? (1→3, 1→1, 1→1)

• Effectiveness

  • Does the treatment work?

  • How does it work?

  • For whom does it work?

• Efficacy

  • Does it help?

• Efficiency

  • Cost-benefit ratio

Why is it important to make clinical actions explicit?

• Communication

• All involved parties know clearly what will occur

11 step basic treatment plan (Wilson et al., 2003)

1. Specify the behaviour to be changed

2. Decide whether an operational def is required

3. State treatment goals/aims

4. Measure the problem (baseline measurement)

5. Consider motivators/reinforcers

6. Plan treatment

7. Begin treatment

8. Monitor treatment progress

9. Evaluate treatment

10. Change if necessary

11. Plan for generalisation

Example with 11 steps

1. Specify the behaviour to be changed: perseveration

2. Decide whether an operational def is required: repeating a word/action/thought long after it is appropriate/relevant

3. State treatment goals/aims: apply relevant word/action/thought during context switching

4. Measure the problem (baseline measurement): time how long it takes to use correct/appropriate word/action/thought

5. Consider motivators/reinforcers: specific positive feedback + reminders when perseveration continues

6. Plan treatment

7. Begin treatment

8. Monitor treatment progress: measure every day

9. Evaluate treatment: evaluate fortnightly

10. Change if necessary: adjust goals (more or less ambitious)

11. Plan for generalisation: to real world settings, e.g. conversations

Example for step 5

• Use specific positive feedback

Example for step 6

• Who, when, where, how often, which strategies

Evidence-based medicine (EBM): factors considered (4)

• Clinical research literature

• Pathophysiology understanding

• Clinical experience

• Patient preferences

Diagram of how EBM is used in clinical decision-making + 2 notes

1. Patients have more say in decision-making now (collaborative decision-making)

2. Search for evidence, evaluate quality

What can undermine EBM? (1)

• When professionals stick to their own habits/rules/practices rather than considering + implementing what the most recent research suggests would be suitable

Randomised control description (3)

• Random assignment to control + experimental group

• Control → placebo, experimental → treatment

• Double blind (patients + researchers don’t know who is receiving treatment)

What are RCTs generally used for?

• Studying treatment efficacy

Single-case experimental design (SCED) description (1, 1→2)

• One participant/series of participants is experimentally studied

• Measure baseline, then measure during intervention, then maybe after

  • So patient acts as their own control

When are SCEDs used? (2)

• Rare cases

• High variability in interest population

What does the power of SCEDs lie in? (1)

• The number of measurements, rather than the number of participants

How can the external validity of SECDs be increased? (1)

• By replicating the design with more participants

How are SCEDs viewed/considered? Note?

• Usually considered lower quality research than RCTs, systematic reviews + meta-analyses

• However, SCEDs are now ranked as level 1 research by the Oxford Centre for EBM

How can clinicians consider evidence from all the available research to date?

• By looking at evidence-based guidelines, which are written by experts who have synthesised evidence from journal articles

Examples of organisations/bodies that write evidence-based guidelines (3)

• American Heart Associations

• Australian National Health and Medical Research Council (NHMRC)

• INCOG (write neuropsych guidelines)

Economic evaluation def

• Comparing costs + consequences of possible courses of action

Examples of economic evaluation w brief description (2)

• Cost-benefit analysis: monetary benefit from treatment vs no treatment

• Cost-effectiveness analysis: compares treatment A to treatment B based on natural clinical outcomes such as “cost per additional year of life gained”

Which types of interventions are of specific interest in the field of economic evaluation + why?

• Self-management interventions

  • Cost-effective for more than one population

• Chronic disease (including acquired brain injury)

  • Due to high social + financial burden

Considerations in evidence-based practice (3)

• Does the treatment work?

• Does the treatment help this patient (aligning with their specific goals)?

• What are the costs/benefits?