Week 7 Lecture - EBP, Clinical Prediction Rules, and Outcome Measures

The entire journey w/ a pt

Evidence-Based Practice (EBP).

The recommended route w/ a pt

Clinical Practice Guideline (CPG).

The decision aid along the route w/ a pt

Clinical Prediction Rule (CPR).

Three aspects of EBP

Best evidence available, patient values, clinical expertise

Clinical Prediction Rule (CPR)

A research-derived tool combining patient findings to estimate diagnosis, prognosis, or treatment response.

Treatment-response CPR's

Estimates which patients are more likely to improve with a specific intervention

Prognostic tool model

Helps PT's predict likely future outcomes and guide goal setting, education, and follow-up

TWIST Algorithm

A clinical prediction rule used to estimate time to independent walking after stroke.

Clinical Practice Guideline (CPG)

Systematically developed recommendations to assist clinician and patient decisions for specific clinical conditions

One tool within the process of EBP

Benefits of CPG

Improve consistency of care, reduce unnecessary variation, summarize large amounts of research, promote evidence-based interventions, improve quality of care, identify interventions with little or no supporting evidence

Limitations of CPG

No perfect, may become outdated, high-quality evidence may be lacking, recommendations may not apply to all patients, multiple conditions may not be addressed by one guideline, differing patient preferences

Why do systematic reviews/meta analysis exist

Primary source studies can have conflicting results....so we summarize the evidence as a systematic review or meta analysis to provide us with the best available answer.

Step 1 of systematic review

Clinical question/PICO

Step 2 of systematic review

Search strategy determined. Which databases and criteria will be used to select articles?

Step 3 of systematic review

Databases (PubMed, PEDro, CINAHL, Cochrane, etc.) are mined based on inclusion and exclusion criteria

Step 4 of systematic review

Articles that meet criteria are reviewed (Prisma Flow Diagram)

Step 5 of systematic review

Data and/or results are extracted

Step 6 of systematic review

Quality is assessed (study bias, heterogeneity, and publication bias is evaluated) and recommendations are made

Heterogeneity

Variation between studies - how much we trust the overall estimate across studies

I² Statistic

The percentage of variability across studies in a meta-analysis due to heterogeneity. How much heterogeneity

I² values

Lower the value, the better - less heterogeneity (studies are very similar)

Funnel Plot

A statistical graph used to identify publication bias or small-study effects in systematic reviews.

Funnel Plot - symmetrical funnel

Less concern for publication bias. Studies are symmetrically distributed around the pooled effect.

Funnel Plot - missing studies on left

Possible missing small studies with negative or null results

Funnel Plot - missing studies on right

Possible missing small studies with positive results

Funnel Plot - top and bottom

Large studies at the top, small studies at the bottom

Patient-Reported Outcome Measure (PROM)

A standardized questionnaire completed by the patient measuring their health, symptoms, or function.

PROM captures...

Information that cannot be directly objectified

Performance-Based Measure vs. PROM

Performance measures test actual physical ability; PROMs capture the patient's perceived ability.

Three Categories of PROMs

Generic, region-specific, and disease-specific measures.

Generic PROM

Able to compare patients across diagnoses

Region PROM

More clinically specific and responsive to change in the targeted condition

Disease/Disorder PROM

Items are related to overall function but also the impact of the disease/disorder

Outcomes research

Outcomes research examines what happens to patients after healthcare is delivered.

Efficacy

How well an intervention works under ideal, highly controlled research conditions.

Effectiveness

How well an intervention works in real-world clinical practice.

Patient-Centered Outcome

An outcome focusing on functional goals meaningful to the patient, such as climbing stairs.

Registry/Large Database Research Strengths

Real-world patients

Multiple settings

Longitudinal tracking

Ability to study uncommon outcomes

Practice benchmarking

Identification of treatment variation

Supports quality improvement

Registry/Large Database Research Limitations

Missing data

Inconsistent data entry

Variable definitions

Selection bias

Loss to follow-up

Confounding variables

Differences in patient complexity

Limited control over interventions

Association does not prove causation