Best Available Evidence: A New Clinical Decision Tool to Guide Critical Thinking

Transcription

1 Best Available Evidence: A New Clinical Decision Tool to Guide Critical Thinking

2 DIFM DPG-DPBRN Joint Research Project DIFM DPG PBRN Study of Critical Thinking Skills of IFM RDNs

3 JAND Publications

4 Mixed Methods Study Think Aloud Case Study Coded Transcripts Using NCP Standardized Language California Critical Thinking Disposition Inventory (CCTDI) Health Sciences Reasoning Test with Numeracy (HSRT-N)

5 California Critical Thinking Disposition Inventory Truth-Seeking Open-Mindedness Analyticity Systematicity Confidence in Reasoning Inquisitiveness Maturity of Judgment

6 Health Sciences Reasoning Test with Numeracy Analysis Interpretation Inference Evaluation Explanation Induction Deduction Numeracy

7 Results- Critical Thinking Assessments Critical Thinking Highest score: Inquisitiveness Strong scores: Confidence in Reasoning, Open-Mindedness, Maturity of Judgment, Analyticity, Systematicity, and Truth-Seeking Health Sciences Reasoning Strong score: Induction, Explanation, Analysis and Inference Moderate score: Deduction, Numeracy, and Interpretation Weak score: Evaluation

8 Findings- Critical Thinking IFM RDNs possess a high degree of critical thinking skills which are important to diagnostic and therapeutic decision-making IFM RDNs possess strong Inductive reasoning skills which aid decision making in times of uncertainty Lowest scores in Evaluation may lead to misjudging the quality of information used to support an intervention or a lack of objective assessments of interventions Strong critical thinking skills are important to accurately evaluate the significance of patient data, as well as the outcomes of any intervention when limited evidence is available Findings lead to development of DIFM s Best Available Evidence Tool to aid in clinical decision making process

9 Best Available Evidence Decision Tool Practice Applications

10 How Do I Access DIFM s Best Available Evidence Tool?

11 Are probiotics effective for prevention of C. diff-associated diarrhea? Is a Paleolithic diet effective for Type 2 diabetes? Is SAM-e effective for depression in adults? Is apple cider vinegar effective for GERD? Is higenamine supplementation safe and effective for enhancing athletic performance?? Does hydrolyzed collagen reduce intestinal permeability?

12 Best Available Evidence Decision Tool- Steps in the Search for the Best Available Evidence Step 1 Formulate Decision Tool Question Step 2 Gather/ Classify Evidence Step 3 Critically Appraise Evidence Step 4 Summarize Evidence Step 5 Grade Evidence/ Make Practice Decision

13 Strength of the Evidence- Grading Criteria Grade I Good/ Strong Grade II Fair Grade III Limited/ Weak Grade IV Expert Opinion Grade V Not Assignable Studies of strong design, clinically important, consistent results; results free of doubt about generalizability, bias, and design flaws; and large sample sizes with adequate statistical power. Studies of strong design, but inconsistent results from different studies or doubts about generalizability, bias, and design flaws or sample size. Alternatively, studies of weaker design, but consistent results. Limited number of studies of weak design. Studies of strong design unavailable or studies done are inconclusive due to lack of generalizability, bias, design flaws, or inadequate sample size. The conclusion consists solely of statements of medical commentators based on their clinical experience, unsubstantiated by research studies. There is no evidence available that directly supports or refutes the conclusion. Source: 2016 Evidence Analysis Manual: Steps in the Academy Evidence Analysis Process

14 How Common Are Research Gaps in Evidence-Based Nutrition and Dietetics Practice? COMMON! EAL published more than 40 SR s Analyzed ~5,700 articles Made ~ 1,100 conclusion statements About 22% received Grade V / Grade Not Assignable(to support or refute the conclusion) Research gaps exist in ALL practice areas, including IFM

15 MNT Effectiveness When Provided by an RDN in Medical Team, Weight Management, Lipid Metabolism, GI Disorders & Special Needs

16 Grade III-V Evidence in Nutrition Care Practice Areas

17 Grade III-V Evidence in Nutrition Care Practice Areas

18 Mouseover Glossary Terms Supplemental Resources Hyperlink Formulate decision tool question, include: Population, patient, or problem Intervention, procedure, or approach Comparison intervention (if necessary) Outcomes

19 Decision Tool Example 1- Are Probiotics Effective for Prevention of C. Difficile-Associated Diarrhea (CDAD)? Cochrane Systematic Review 31 RCTs, 8,672 subjects 27 studies rated high quality (GRADE criteria) Authors conclusions- moderate certainty evidence suggests probiotics are effective for preventing CDAD. Short term use of probiotics appear safe in patients who are not immunocompromised or severely debilitated. Hospitalized patients, particularly those at high risk of CDAD, should be informed of potential benefits and harms of probiotics.

20 Decision Tool Example 2- Is S-adenosylmethione (SAMe) Effective for Improving Depression in Adults?

21 Decision Tool Recommendation Proceed with caution Grades III-V evidence indicate moderate-high uncertainty Ensure intervention is within SOP/SOPP, state licensure laws, organizational policy Consult, refer, coordinate interdisciplinary care Collect patient important outcomes and PROMs in ANDHII Check for new published research frequently

22 Decision Tool Example 3- Is a Paleolithic Diet Effective for Insulin Resistance, Glycemic Control, or Type II Diabetes?

23 Of RCTs, choose larger, representative sample sizes Consider author s use of blinding to prevent bias Consider date published, if possible within 5 years Prioritize reading in order of most recent to least recent Critically appraise full text articles (not abstracts)

24 6 trials of Paleo diet for insulin resistance, metabolic syndrome, or T2DM Total subjects = 199 Limited number of studies, weak design, low number of subjects studied, lack of generalizability, inconclusive Decision Tool Recommendation If choosing to implement intervention, proceed with caution Basing a clinical decision on a single or few research studies means using relatively low levels of evidence Advise client to discuss intervention w/ primary care provider and any specialists prior to implementation Collect patient important outcomes and PROMs in ANDHII Check for new published research frequently

25 Decision Tool Example 4- Does Hydrolyzed Collagen Supplementation Reduce Intestinal Permeability?

26 Decision Tool Recommendation Proceed with caution Ensure intervention is within SOP SOPP, state licensure laws, organizational policy Advise client to discuss intervention with all healthcare providers prior to implementation Consult, refer, and coordinate interdisciplinary care if possible Collect patient important outcomes and PROMs in ANDHII Check for new research frequentl

27 Decision Tool Example 5- Is Apple Cider Vinegar Effective for GERD in Adults? Decision Tool Recommendation Recommend alternative interventions with stronger level of evidence Collect patient important outcomes and PROMs in ANDHII Document benefits, risks, side effects and monitor for clear trends Some benefit, some don t; no clear trend

28 Decision Tool Example 6- Is Higenamine Supplementation Safe and Effective for Enhancing Athletic Performance? Some clients had rapid heart rate Decision Tool Recommendation Do not proceed with intervention Negative trends in PROMs or high risk of harm outweighs benefit to clients

29 Best Available Evidence Decision Tool Other Recommendation Considerations Benefits, Risks, and Harms Potential Costs Conditions of Application Recommendation Strength Minority Opinion Advise on potential benefits, risks, and harms of implementing recommendation Advise on potential costs of implementing recommendation Advise on conditions where recommendation may not apply, other conditional considerations Advise on strength of recommendation, inconsistent results (+/ findings), industry funded research Advise on scientific uncertainty or scientific disagreement

30 Supplemental Resources 2018 Code of Ethics for the Nutrition and Dietetics Profession Scientific Decision-Making: Scientific Integrity Principles Source: JAND July 2018 Source: JAND September 2015