Bringing the Evidence into Hi-Def:

Transcription

1 Bringing the Evidence into Hi-Def: `Nita Ferree, MAIS, AHIP, University of Florida, Health Science Center Libraries, Gainesville, FL. Consuelo Maun Kreider, MHS, OTR/L, University of Florida, College of Public Health and Health Professions, Occupational Therapy Program, Gainesville, FL. Presented at AOTA April 16, 2011 Philadelphia, PA

2 Background on EBP Traditionally, patients have been treated based on: What has always worked What experts in the field say What is published in textbooks 2

3 However It takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice. = 17 years of practice Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington. D.C. National Academy Press Westfall, J. M., Mold, J., & Fagnan, L. (2007). Practice-based research - "Blue Highways" on the NIH roadmap. JAMA, 297(4), p

4 But Physicians are Still Using 1. Textbooks 2. Humans (other people) 3. Personal libraries 4. Electronic resources 5. Internet Davies, K., The information-seeking behaviour of doctors: a review of the evidence. Health Info Libr J, (2):

5 and so Are OTs Textbooks, 12% Library, 2% Other, 1% Internet, 26% Information Sources N=243 named 412 sources Journals, 18% CE, 20% Other People, 21% Evidence Based Practice: Where do Occupational Therapists Turn for Answers to Clinical Questions? Online Survey,

6 Barriers to OT EBP TIME -> Large, busy caseloads 1, 2 ACCESS -> Many resources cost money 1 KNOWLEDGE -> Where to search 1, 2 -> How to search 1, 2 -> How to interpret, appraise the literature/evidence 1,2 The science is intimidating! 2 1. Mount, J., Kern, S. Delicana, J., Levitiski, B., Michlik, E. & Tran, T. (2006). Environmental supports and barriers to physical and occupational therapists using evidence based practice in a neurological rehabilitation setting. Journal of Neurological Physical Therapy, 30(4), McCluskey, A., & Lovarini, M. (2005). Providing education on evidence-based practice improved knowledge but did not change behaviour: a before and after study. BMC Medical Education, 5:40, doi: / Retrieved 6 February 20, 2011 from

7 Other Very REAL Barriers Many years refining specific interventions Incompatibility of proposed changes Private practices may lose clients if they do not provide therapy that the clients expect EBP ain t child s play! McCluskey, A. & Cusick, A. (2002). Strategies for introducing evidence-based practice and changing clinician behaviour: A manager s toolbox. Australian Occupational Therapy Journal, 49,

8 Definition of Evidence-Based Practice The integration of best [current] research evidence with our clinical expertise and our patient s unique values and circumstances. Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2d ed. Edinburgh: Churchill Livingstone, Image: Centre for Evidence Based Medicine 8

9 SO WHAT SHOULD WE BE DOING? 9

10 The Very First Thing to Do is make a librarian your new BFF. 10

11 The Process: Four Steps of Evidence Based Practice Step 1: Ask an answerable question Step 2: Identify the best type of research study to answer the question. Step 3: Determine the best resource(s) or database(s) to search. Step 4: Evaluate the evidence based upon the patients preferences and your clinical expertise. 11

12 Step 1 ASK AN ANSWERABLE QUESTION 12

13 P I C O Your question should include this information: P Patient or Problem Describe the relevant characteristics of the patient. I Intervention Which intervention are you considering? C Comparison Is there an alternative to compare with the intervention? O Outcome What do you hope to accomplish or affect? 13

14 Examples of PICO P Patient or Problem In elderly males or females I Intervention Will Tai Chi C Comparison Yoga O Outcome Improve balance? P Patient or Problem In patients who have suffered a stroke I Intervention And received constraint induced movement therapy C Comparison [none] O Outcome Are functional gains sustained after one year? P Patient or Problem In children with Attention Deficit Disorder I Intervention Does dietary sugar C Comparison O Outcome [None] Affect function? 14

15 Step 2 IDENTIFY THE BEST TYPE OF RESEARCH STUDY TO ANSWER THE QUESTION 15

16 What Type of Study Is Best? If your question is one of Suggested Best Type of Study Treatment Therapy Intervention Population Description Prognosis Etiology Instrumentation Evaluation (diagnosis) Meta-analysis if available, or Systematic/Narrative Reviews RTCs Cohort Studies Case Studies/Series Expert Opinion Meta-analysis if available, or Systematic/Narrative Reviews Cohort Studies Case Control Studies Case Study/Series Expert Opinion Meta-analysis, if available or Systematic/Narrative Reviews Psychometric Studies Expert Opinion Adapted from: Miller PJ, Jones-Harris AR. The evidence-based hierarchy: is it time for change? A suggested alternative. Journal of Manipulative and Physiological Therapeutics Jul-Aug;28(6):

17 Identify the Best Type of Research Study Evidence-Based Levels of Evidence Meta- Analysis Systematic Reviews Randomized Controlled Trials Cohort Studies Case-Control Studies Case Reports, Case Series Editorials, Expert Opinion Adapted from: Evidence Based Nursing: Evidence Based Practice in the Health Sciences. Levels of Evidence. 17

18 Step 3 DETERMINE THE BEST RESOURCES TO SEARCH (FOR FREE) 18

19 Hierarchy of Resources Meta- Analysis Systematic Reviews MEDLINE (PubMed) TRIP Google, Google Scholar Randomized Controlled Trials Cohort Studies Case-Control Studies Guidelines Clinical Tools (i.e. UpToDate) Critically Appraised Topics (i.e. OTCATS, OTSeeker, BestBETs) Textbooks Case Series, Case Reports Editorials, Expert Opinion 19

20 Finding the highest level of evidence Meta-Analysis is a subset of Systematic Reviews Meta-Analysis PubMed TRIP Systematic Reviews PubMed TRIP OTSeeker Randomized Controlled Trials PubMed TRIP OTSeeker 20

21 Free Resources PubMed Google Scholar Google.com search: Netting the Evidence TRIP OTSeeker OTCATS BestBETS 21

22 PICO Example SEARCHING THE FREE RESOURCES 22

23 The Clinical Question Should my patient go home? Or should my recommendation be for assisted living or an adult child s home? 23

24 Should my patient go home? Vs. going to assisted living or an adult child s home? RESTATEMENT # 1: In elderly clients with cognitive decline, what OT interventions will contribute to safety with independent living P = In elderly patients w/ cognitive decline I = What OT interventions will contribute to C = (none) O = Safety with independent living 24

25 Should my patient go home? Vs. going to assisted living or an adult child s home? RESTATEMENT #2: What factors will contribute to safety at home for elders with cognitive decline/impairment? P = In elderly patients w/ cognitive decline I = (none) C = (none) O = Safety with independent living 25

26 RESTATEMENT # 1: In elderly clients with cognitive decline, what OT interventions will contribute to safety with independent living P = In elderly patients w/ cognitive decline I = What OT interventions will contribute to C = (none) RESTATEMENT #2: What factors will contribute to safety at home for elders with cognitive decline/impairment? P = In elderly patients w/ cognitive decline I = (none) C = (none) O = Safety with independent living O = Safety with independent living 26

27 RESTATEMENT #1: In elderly clients with cognitive decline, what OT interventions will contribute to safety with independent living? P = In elderly patients w/ cognitive decline I = What OT interventions will contribute to C = (none) O = Safety with independent living Best types of research: Meta-analysis, systematic reviews, RTCs Potential Sources: PubMed?, OT Seeker? OT Cats? TRIP?... Potential search terms: Occupational therapy, cognitive decline, safe ADLs, aging, independent living, aging in place 27

28 RESTATEMENT #2: What factors will contribute to safety at home for elders with cognitive decline/impairment? P = In elderly patients w/ cognitive decline I = (none) C = (none) O = Safety with independent living Best types of research: Overviews, basic or descriptive research, population studies, qualitative studies Potential Sources: PubMed?, OT Seeker? OT Cats? TRIP?... Social sciences (ssrn.com; apa.org), ERIC Potential search terms: Cognitive decline, safe ADLs, aging, independent living, aging in place 28

29 Every OT s Quandary OT vs. PT Permission granted by Erin O'Brien D:\VLC\vlc.exe 29

30 What are your clinical questions? RESTATING in PICO format 30

31 PUBMED 31

32 Search using keywords PubMed Limits: Narrow search by date, language, article type, and availability of full-text articles etc. My NCBI: -> Store and rerun searches -> updates -> Customize filters Advanced Search: Search builder and History Clinical Queries: Limits to specific clinical questions Single Citation Matcher: Verify or locate hard-to-find citations MeSH Database: Search Medical Subject Headings 32

33 A Quick PubMed Search 33

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37 Clinical Queries Take note of search number 37

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40 Google scholar Netting the Evidence Filter GOOGLE 40

41 Google Scholar 41

42 Google the Netting the Evidence filter Netting the Evidence 42

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46 TRIP DATABASE 46

47 Turning Research into Practice = TRIP Database 47

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51 OTSEEKER 51

52 OTSeeker 52

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57 AOTA S EVIDENCE BASED PRACTICE & RESEARCH LINK 57

58 AOTA s Evidence-Based Practice & Research 58

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60 A peek at an AOTA CAT 60

61 OTCATS 61

62 OTCATS 62

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65 BESTBETS 65

66 Best Evidence Topics = BestBETs 66

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69 What about when you re only looking for one specific article? USING PUBMED S SINGLE CITATION MATCHER 69

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72 So many resources, so little time OTHER RESOURCES 72

73 Other Resources for other Types of Education Questions -> ERIC Anthropology/Sociology -> Social Science Research Network Psychology -> APA Databases Engineering, Technology -> US Government Science Portal 73

74 Step 4 EVALUATE THE EVIDENCE Source (Journal) Research type Article Methods section 75

75 Evaluating the Source Journal Status Peer- Reviewed, Refereed or Juried? Practice Journal? 76

76 What is a journal impact factor? Impact factor is the average number of citations received per paper published in a specific journal during the two preceding years. It is used to compare different journals within a certain field. 77

77 Where do you find it-for free? SCImago: 78

78 OT Journals Ranked by SCImago 79

79 Authors Rankings Online survey of 1 st or corresponding authors of peer reviewed articles in 18 Occupational Therapy journals. They were asked to rate the journals based on 11 quality indicators. Total Sample: 554 Completed Survey: 184 Reprinted with permission from the Australian Occupational Therapy Journal, Vol. 54, Roger, S.et.al., Quality and impact of occupational therapy journals: Authors perspectives, , copyright 2007, John Wiley & Sons, Inc. 80

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81 Evaluating the Research Type Some research terms Some understanding of Research design Scientific method Research continuum 82

82 Terms you need to know (aka Jargon) Case studies & case series: unique clinical observations/ treatments Cross-sectional studies: snap shot descriptive Case-control studies: comparing characteristics of people who have a diagnosis to those who don t 83

83 Prospective cohort studies: follow same group over time Outcomes studies: results following an intervention Randomized controlled trials: controlled experiments Systematic reviews & meta-analyses: summative analyses of existing research 84

84 Even more jargon... From the Methods Section Parallel group comparison: each group gets a different intervention Paired (or matched) comparison: each group member is matched to someone specific in the other group Within subject design: looks at changes made within each subject following the tx 85

85 Single blind: Subjects are blinded Double blind: Subjects + Investigators Crossover: each subject gets the intervention + the control conditions Factorial design: effect of 2 or more variables on the outcome 86

86 Revisiting the Hierarchy 87

87 AOTA s Evidence-Based Literature Review Project Levels of Evidence I. SR; MA; RCT II. 2-group nonrandomized if question is answered by an intervention study III. 1-group nonrandomized IV. Single-subject; descriptive; case series; case report V. Editorials, Expert Opinion Gutman, S. A. (2008). State of the journal. American Journal of Occupational Therapy, 62(6),

88 But, what about the rest of our clinical questions? Real Life Clinical Questions Aren t as Simple as Is intervention X better than intervention Y for client Z? Basic Research How will my client s cultural beliefs affect willingness to follow through on the home activities I recommend? Instrument Can I use the LOTCA to assess cognitive functioning for a child with autism? Efficacy What is the best way to give a home exercise program for a child who has two homes/joint custody and attends an afterschool care program? 89

89 Stages of Scientific Method in Clinical Research 1. Observation & description 2. Hypothesis explaining clinical implications 3. Hypothesis to predict outcomes 4. Clinical experiment 5. Summaries of clinical research 90

90 Reading the Article Identify the research design Where the design fits in the Hierarchy or the Continuum of research Research type consumed How research can be incorporated into practice Understand meaning of results 92

91 Evaluating the Article 1. What specific clinical question did it address? Why was study done? What clinical questions? 2. What type of study? a) Primary or secondary? b) Types of primary: experiments, clinical trials, surveys 3. What type of research? Intervention, instrument development/testing, prognosis, causation 93

92 Evaluating the Methods section 1. Does this new research add to what is already known? In what way(s)? 2. Who was it about? 3. Did the design match the question asked? 4. Was bias minimized or avoided? 5. Was the study large enough (or long enough) to make the results credible? 94

93 PUTTING IT ALL TOGETHER 95

94 EBP An APPROACH to practice Clinician is aware of the evidence It s strength How it bears on her/his clinical practice A PROCESS Development of evidence-based knowledge Attitude Awareness Creativity Judgment Consultation 96

95 3 legs of EBP 1. Clinical expertise 2. Client & family 3. Science Baily, B. J., Johnson, J. T., & Newlands, S.D. (2006). Head and Neck Surgery Otolaryngology, 4 th ed. Philadelphia, PA: Lippincott, Williams, & Wilkins (pg 37) 97

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98 Questions for thought Is EBP different from what you thought it was? How is it different? How are you already practicing EBP? How can you contribute to the evidence? 100

99 Giving Back Contributing to the Evidence OT CATS BestBETs AOTA Clearinghouse coming in July 101

100 Thank you! Nita Ferree Research librarian Consuelo Kreider Links to free evidence: ieldwork/educators/ UF OT fieldwork educators Special thanks: Emily Pugh 102