1/24/15. In pursuit of evidence- based prac8ce. Accessibility of Available Evidence. Today s Purpose BUT FIRST... Levels of Evidence (LOE)

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1 Speeding Up the EBP Process: Using Evidence that is Appraised, Available, and Ready To Go In pursuit of evidence- based prac8ce Clinician s best judgment How do we gain access to available evidence? Cailee E. Welch, Ph.D., ATC Assistant Professor of Athletic Training A.T. Still University Clinical Practice Site Coordinator Athletic Training Practice-Based Research Network (AT-PBRN) Pa:ent s values and circumstances Best available evidence Accessibility of Available Evidence Today s Purpose Direct Access (%) Clinicians' Direct Access to Resources Discuss sources of evidence that are already appraised Identify where these resources can be found BUT FIRST Systema:c Peer- Reviewed Clinical Professional Cochrane Medline/Pub NATA Think Reviews and/or Journal Ar:cles Predic:on Rules Literature Databases Med Databases Tanks Meta- Analyses FREE ACCESS!! Textbooks Websites NATA Posi:ons Statements Welch et al, 2011 Differentiate levels of evidence (LOE) and grades of recommendation (GOR) Discuss how LOE and GOR differ between commonly used scales Levels of Evidence (LOE) Oxford Centre for Evidence-Based Medicine (CEBM) Level of Evidence Scale A critical evaluation of an individual research article that rates the quality of evidence based on the research design of the study Numeric rating system (eg, 1, 2, 3) Does NOT always take clinical applicability into consideration Most common scales: CEBM & SORT 1

2 CEBM Levels of Evidence Scale Level 1 1a: SR of RCTs 1b: Individual RCTs 1c: All or none studies Level 2 2a: SR of cohort studies 2b: Individual cohort studies 2c: Outcomes research Level 3 3a: SR of case- control studies 3b: Individual case- control Level 4 Level 5 Strength of Recommendation Taxonomy (SORT) Level of Evidence Scale Separates disease-oriented vs. patient-oriented evidence LEVEL 1 High Quality Patient-Oriented Evidence LEVEL 2 Low Quality Patient-Oriented Evidence LEVEL 3 Disease-Oriented Outcomes Bench Research Anecdotal Evidence Expert Opinion Disease-Oriented Evidence Patient-Oriented Evidence Include intermediate, histopathologic, physiologic, or surrogate (alternate) results that may or may not reflect improvement in patient outcomes Examples: Blood sugar levels Blood pressure Respiratory flow rate Coronary plaque thickness Things that matter to the patient and help them live longer and better lives Examples: Reduced morbidity Reduced mortality Symptom improvement Improved quality of life Lower cost hxp://doctormurray.com/health- condi:ons/high- blood- pressure/ hxp:// Quality- Life- Project.html Strength of Recommendation Taxonomy (SORT) Level of Evidence Scale SORT Level of Evidence Flowchart Level 1- CEBM Level 4/5- CEBM 2

3 Comparisons Between CEBM & SORT Level of Evidence Scales Centre for Evidence- Based Medicine (CEBM) Strength of Recommenda8on Taxonomy (SORT) Level 1 Level 1 Level 2 Level 3 Level 4 Level 2 Level 4 Level 5 Level 3 Grades of Recommendation (GOR) A critical evaluation assigned to a body of evidence (ie, a group of articles) relating to the same topic Letter rating system (eg, A, B, C) Along with validity of the studies, a GOR also considers other factors Eg, cost, ease of implementation, reproducibility throughout various clinical settings Most common scales: CEBM & SORT Oxford Centre for Evidence-Based Medicine (CEBM) Grade of Recommendation Scale Strength of Recommendation Taxonomy (SORT) Grade of Recommendation Scale STRONG MODERATE CONFLICTING INSUFFICIENT GRADE A Basis for Recommenda8on Consistent level 1 studies B Consistent level 2 or 3 studies or extrapola:ons from level 1 studies C D Level 4 studies or extrapola:ons from level 2 or 3 studies Level 5 evidence or troublingly inconsistent or inconclusive studies of any level Extrapola:ons are where data are used in a situa:on that has poten:ally clinically important differences beyond the original study situa:on. Grade A B C Basis for Recommenda8on Consistent, good- quality pa:ent- oriented evidence Inconsistent or limited- quality pa:ent- oriented evidence Consensus, disease- oriented evidence, usual prac:ce, expert opinion, or case series for studies of diagnosis, treatment, preven:on, or screening CONSISTENT: Most studies found similar or at least coherent conclusions (explainable differences) Strength of Recommendation Taxonomy (SORT) Grade of Recommendation Scale Strength A B C Basis for Recommenda8on Consistent, good- quality pa:ent- oriented evidence Inconsistent or limited- quality pa:ent- oriented evidence Consensus, disease- oriented evidence, usual prac:ce, expert opinion, or case series for studies of diagnosis, treatment, preven:on, or screening INCONSISTENT: Considerable varia:on among study findings and lack or coherence SORT Grade of Recommendation Flowchart Is this a key recommenda:on for clinicians regarding diagnosis or treatment that merits a label? Yes Is the recommenda:on based on pa:ent- oriented evidence (i.e, an improvement in morbidity, mortality, symptoms, quality of life, or cost)? Yes Is the recommenda:on based on opinion, bench research, a consensus guideline, usual prac:ce, clinical experience, or a case series design? No Is the recommenda:on based on one of the following? Cochrane Review with a clear recommenda:on U.S. Preven:ve Services Task Force Grade A recommenda:on Clinical Evidence ra:ng of Beneficial Consistent findings from at least two good- quality randomized controlled trials or a systema:c review/meta- analysis Validated clinical decision rule in a relevant popula:on Consistent findings from at least two good- quality diagnos:c cohort studies or systema:c review/meta- analysis of the same No Strength of Recommenda:on not needed No Strength of Recommenda:on = C Yes Yes Strength of Recommenda:on = A No Strength of Recommenda:on = B 3

4 1/24/15 Comparisons Between CEBM & SORT Grade of Recommendation Scales Centre for Evidence- Based Medicine (CEBM) Grade A: Consistent Level 1 studies Strength of Recommenda8on Taxonomy (SORT) Grade A: Recommenda:on based on consistent and good- quality pa:ent- oriented evidence Grade B: Consistent Level 2 or 3 studies or extrapola:ons from Level 1 studies Grade B: Recommenda:on based on inconsistent or limited- quality pa:ent- Grade C: Level 4 studies or extrapola:ons oriented evidence from Level 2 or 3 studies Caveats of LOE & GOR There are more than 100 grading scales used within the medical literature Example: two groups of articles with a grade B Question: Which scales were used? ** Take Home Message ** Don t disregard evidence solely based on the level or grade ra8ng Grade C: Recommenda:on based on Grade D: Level 5 evidence or troublingly consensus, usual prac:ce, disease- inconsistent or inconclusive studies of any oriented evidence, case series for studies level of treatment or screening, and/or opinion Van Lunen BL, Hankemeier DA, Welch CE. Evidence- Guided Prac/ce: A Framework for Clinical Decision Making in Athle/c Training. Thorofare, NJ: SLACK. An:cipated Publica:on Date: February, Systematic Reviews Appraised Sources of Evidence Narrative of the critical evaluation of a research question through an exhaustive search of the available evidence, followed by the appraisal, selection, and synthesis of many resources Systematic reviews Meta-analyses Position statements * Compila8on research * Critically appraised topics Critically appraised papers Evidence-based reviews Examine mul:ple findings from similar studies that look at a similar clinical ques:on Meta-Analyses A quantitative assessment of the pooled statistical results from studies that have met the inclusion criteria within a systematic review Statistical analyses are conducted with all of the data from the individual studies included in the SR Can be completed on most study designs Randomized Controlled Trials (RCTs) preferred More variables were controlled within the study Developed by: Define an appropriate health care question Search the literature Assess the studies Combing the results Place findings in context Attempts to bring the same level of rigor to reviewing research evidence as should be used in producing research evidence Systematic Reviews & Meta-Analyses Considered the highest level of evidence Considerations for generalization You can only use the information from the study based on the clinical question that was asked Cannot expand information to address other questions not directly investigated One study does not equate to a definite answer Most clinical problems are multi-faceted Need to be supported by additional findings Different populations, different parameters, different variables 4

5 Example Let s consider a study that focused on the effects of a one week intervention of talocrural joint mobilizations for the treatment of dorsiflexion deficits with individuals who have a history of past ankle sprains, and the outcome was that the mobilizations increased dorsiflexion range of motion. From this study, you would not be able to deduct: 1. Joint mobilizations increase ROM for all joints within the body 2. Joint mobilization treatment has lasting effects beyond the first week 3. Joint mobilizations also increase the functional abilities of individuals Systematic Reviews & Meta-Analyses?? Where Are They?? Cochrane Database of Systematic Reviews Leading resource for systematic reviews in healthcare NOT freely accessible Institutional/company license Free access?? Journal of Athletic Training PubMed Google Scholar Systematic Reviews Journal of Athletic Training Position Statements Statement of position and/or stance from one group/ organization Used in a variety of areas (ie, policy, literature, legislation) NATA Position Statements Provide recommendations for practice Other organizations Position Statements Position Statements 5

6 Position Statements Things to Consider Be aware of disclaimers! Critically Appraised Topics (CAT) Appraisal of numerous studies (typically 3-5) that each focus on the same clinical question or topic of interest 1. Clinical scenario 2. Focused clinical question 3. Summary of search, best evidence appraised, and key findings 4. Clinical bottom line 5. Strength of recommendation * Summarizes the evidence 6. Search strategy in rela:on to par:cular 7. Inclusion and exclusion criteria clinical scenarios * 8. Results of search 9. Summary of best evidence 10. Implications for practice, education, and future research 11. References CATs?? Where Are They?? International Journal of Athletic Therapy & Training Journal of Sport Rehabilitation Other organizations Occupational therapy Physical therapy Critically Appraised Papers (CAP) & Evidence-Based Reviews (EBR) 1-2 page analysis of a single research study Purpose: to determine if the reported results are valid, reliable, and applicable to clinical practice 1. Clinical question 2. Clinical bottom line 3. Summary of key evidence 4. Strengths/Threats to internal validity 5. Strengths/Threats to external validity 6. Strength/Threats to statistical validity 7. Level of evidence 8. Application 1. Abstract 2. Commentary CAPs and EBRs?? Where Are They?? International Journal of Athletic Therapy & Training Potential Clinical Questions Journal of Athletic Training How to use evidence that is and to help you begin to answer your clinical questions! 6

7 Clinical Question Example Critically Appraised Topic Journal of Sport Rehabilitation Can lower extremity injuryprevention programs effectively reduce ACL injury rates in adolescent athletes? Clinical Question Example Critically Appraised Topic Journal of Sport Rehabilitation Do prophylactic ankle braces reduce the incidence of acute ankle injuries in adolescent athletes? Clinical Question Example Critically Appraised Topic Journal of Sport Rehabilitation Is low-level laser therapy combined with an exercise program more effective than an exercise program alone in the treatment of adults with shoulder pain? 7

8 Clinical Question Example Evidence-Based Review IJATT In adults, what biomechanical differences exist between barefoot and shod running? Take Home Points 1. LOE & GOR provide a good starting point to determine the quality of evidence available Do not disregard available evidence immediately Thank you! 2. There are several resources available that include evidence that has already been appraised Will help reduce the time it takes to search the evidence 3. Become familiar with resources that are freely accessible Again, will help reduce the time it takes to search the evidence Cailee E. Welch Ph.D., ATC Assistant Professor of Athletic Training cwelch@atsu.edu atpbrn.org 8