SLP is a scientific field. SLPs are clinical scientists. Why EBP? Why EBP? 12/12/2013. Disclosures

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1 Evidence-Based Practice: Definitions and Practical Application Patrick Coppens, Ph.D., CCC-SLP SUNY Plattsburgh Disclosures Relevant financial relationship: I am receiving an honorarium from GSHA for this presentation Relevant nonfinancial relationship: none to disclose GSHA Atlanta February 8, 2014 SLP is a scientific field Science & Pseudoscience Science Objective (testable) True scientific method Evolves with knowledge Pseudoscience Subjective (untestable) May sound scientistic. No. Belief-based. Does not change. Based on traditions, anecdotes. Pseudoscience is a body of belief and practices but seldom a field of active enquiry; it is tradition bound and dogmatic rather than forward looking and exploratory (Bunge, 1984, p. 41). SLPs are clinical scientists Gather information about client Observe and measure behaviors Apply therapy Draw clinical conclusions based on measurements Write up results EBP provides a strategy to ensure that all clinical decisions are of the highest quality and represent the best possible service to the client Why EBP It s the ethical thing to do! Clinical decisions based on sound. Minimizes intuition and other unsupported claims = data-driven care. Best care for best outcome. Reduce disparities and variation in care Recognizes that not all is created equal! Limits the value of expert opinion. Explicitly includes the client s values, preferences, etc. Why EBP Everybody wins when EBP is applied! clinicians are ethical, accountable clients are well-served insurance companies get a good service that works for their rehabilitation $ 1

2 What ASHA says. (ASHA position statement, 2005) It is the position of the American Speech- Language-Hearing Association that audiologists and speech-language pathologists incorporate the principles of -based practice in clinical decision making to provide high quality clinical care. In making clinical practice -based, audiologists and speech-language pathologists acquire and maintain the knowledge and skills that are necessary to provide high quality professional services, including knowledge and skills related to -based practice. What ASHA says. (ASHA Code of Ethics, 2010) Principle of Ethics I Rule B Individuals shall use every resource to ensure that high-quality service is provided Principle of Ethics II Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance Access Time Barriers to EBP use Reported Problem Lack of or Insufficient Contradictory Limited training in EBP and research. Lack of information literacy skills. Solutions Barriers to EBP use: one caveat. Reported Problem Time Solution Not only the responsibility of the SLPs. The PARIHS framework (Promoting Action on Research Implementation in Health Services) recognizes Organizational Culture and Climate as partly responsible for the good implementation of EBP. (Kitson et al., 1998) Successful implementation = Evidence + Context + Facilitation Advocacy is the solution here (at the individual and ASHA levels) EBP: Skills to hone Scientific thinking Always doubt observed relationships: a brain is easy to fool!!! Be a skeptic (including for your own work). Always think of alternative explanations. Learn to say why Some clinicians readily trust information reported by authority figure or friends. Armed with your scientific and critical thinking skills, it is now time to tackle EBP 2

3 Dollaghan (2007). Evidence-Based Practice Evidence-Based Practice Best external scientific Practice Based Evidence Patient preferences and values Clinical Decision Dollaghan (2007); Lof (2011) Topics to be discussed EBP components 1. Patient values, preferences, circumstances 2. Best external : iii. Strength of methods 3. Practice-based B. Evaluating the Topics to be discussed EBP components 1. Patient values, preferences, circumstances 2. Best external : iii. Strength of methods 3. Practice-based B. Evaluating the Clinical Decision Patient preferences and values 1. Patient Values, Preferences, Circumstances We know how to do this: make it functional. EBP (Dollaghan, 2007): 1. Choice of goals: find agreed upon objectives, but may require counseling. 2. Choice of approach: all must be based on EBP, but client preferences and/or circumstances may tip the balance. Possible ethical dilemma: client requests a discredited approach. 3

4 Patient Values, Preferences, Circumstances Conclusions: What should we do 1. Listen to the client/family 2. Understand needs but also limitations (financial, transportation, support, etc.) 3. Develop common goals but without compromising your prognosis. Counsel if needed. 4. Use form to compare 2 possible Tx approaches. Access Time Barriers to EBP use Reported Problem Lack of or Insufficient Contradictory Limited training in EBP and research. Lack of information literacy skills. Solutions Topics to be discussed EBP components 1. Patient values, preferences, circumstances 2.Best external : iii. Strength of methods 3. Practice-based B. Evaluating the Best external scientific Clinical Decision 2. Best External Evidence The PICO question: Population/Patient Intervention Comparison Outcome Which is the best treatment for aphasia In aphasic adults (P) does Semantic Feature Analysis Tx (I) lead to significantly improved naming (O) as compared to no treatment (C) Including all 4 characteristics will: make the information gathered more relevant for the particular client facilitate the search process. Trade-off: level of specificity will increase relevancy but make literature search more difficult. 4

5 Dollaghan (2007). Lemoncello & Fanning (2011). 12/12/2013 E.g. (Gillam & Gillam, 2008): Which type of intervention, computer based (I), group pullout (C), or individual (C), provided to preschool children with speech and language impairments (P) results in the greatest improvement on measures of phonemic awareness (O) For example, look at: ASHA EBP compendium : ASHA maps: ANCDS websites: practice a PICO question: For example, look at: Public databases: TBI resources: Cochrane collaboration: Contact your local university. Contact the author. Look at: iii. Strength of methods Judge the importance of the results Importance of critical and scientific thinking There are good resources available There are forms (or create your own) 5

6 Gillam & Gillam (2008). 12/12/2013 Is the review of the literature thorough Have the authors ignored some important element Is there a reasonable research question based on the lit review Is the question clinically relevant for your purpose ASHA levels of Level Ia Ib IIa IIb III IV Description Well- designed meta-analysis of >1 randomized controlled trial Well-designed randomized controlled study Well-designed controlled study without randomization Well-designed quasi-experimental study Well-designed non-experimental studies (e.g., correlations, case studies) Expert committee report, consensus conference, clinical experience of respected authorities 6

7 iii. Strength of methods Essentially 3 broad avenues of inquiry: Statistical issues: do the stats fit the design Internal validity issues: are there alternate explanations for the observed results External validity issues: are the results generalizable to other individuals Statistical issues E.g.: alpha = 0.05 Correlation and causation Between-subject vs. within-subject Internal validity threats: E.g.: An external variable intervenes during the experiment. Maturation or spontaneous recovery effect. Precision of measurement: validity and reliability of tests and measures, calibration of instruments. Inter- and intra-rater reliability. Unequal groups. Floor & ceiling effects External validity issues: E.g.: Is the sample representative You can only generalize to the same subjects. You can t generalize to other settings. Multiple Treatment Interference: if there are multiple steps or sequential treatments, the generalization can only occur to people who receive the same sequence of steps Examples for practice: Find the possible confounding variables: An investigator measures language comprehension in 10 male and 10 female elderly subjects without dementia in the presence of 4 different levels of ambient noise. An investigator asked severe stutterers to have a conversation with a close friend and a conversation with a stranger in the clinical setting to investigate the effect of conversation partner on stuttering frequency. Best External Evidence Conclusions: What can we do Practice PICO. Get familiar with the websites and databases. Rely on guidelines, systematic reviews, meta-analyses. Use local university contacts. 7

8 Best External Evidence Conclusions: What can we do Use critical thinking. Use scientific thinking. Develop an easy-to-use form. Practice evaluating articles. Update statistical knowledge, get familiar with internal and external validity threats (e.g., general research method books). And most importantly, do not do this for all clients at once! (Robey, 2011) Best External Evidence Robey (2011): A medley: Clinicians came to EBP as competent and experienced clinicians (and) were engaged in ongoing professional-development learning activities the process of EBP begins with clinicians choosing a certain aspect of practice for enhancement target only one clinical decision for improvement and then move to another must enforce realistic limits on their time Access Time Barriers to EBP use Reported Problem Lack of or Insufficient Contradictory Limited training in EBP and research. Lack of information literacy skills. Solutions Use databases. Use ASHA. Ask your local university. Lots of review articles exist, USE THEM. Use a simple evaluation form. Tackle 1 topic at a time. Ask a different question for your search Seek closest possible applicable. generate your own (see below) Which is strongest Topics to be discussed EBP components 1. Patient values, preferences, circumstances 2. Best external : iii. Strength of methods Practice Based Evidence Clinical Decision 3.Practice-based B. Evaluating the 3. Practice Based Evidence Complements external : effectiveness (clinical setting) instead of efficacy (controlled environment). This must be more than subjective experience: Practice-Based Evidence. The same critical and scientific thinking must be applied to clinical work. Controls are still necessary to draw reasonable conclusions. If there is no, provide it! But you need a supported rationale. The same PICO principle applies to daily clinical application: In a chronic patient with Broca s aphasia (P) does Semantic Feature Analysis Tx (I) lead to significantly improved naming (O) as compared to traditional stimulation approach (C) In this case, you are attempting to answer the question yourself 8

9 Dollaghan (2007). 12/12/2013 B. Evaluating the The problem is to defend against confounding variables. how confident am I that the therapy caused the observed improvement as opposed to another competing variable (maturation) 2 areas to watch: Measurement Measurement Establish a stable pre-tx baseline. Make sure your measurements are valid define your scoring protocol carefully use other scorers or multiple scorers (inter-rater reliability) The traditional pre/post design (or ABA) has problems: it is difficult to conclude on the success of the therapy. What we like to see: 9

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11 Practice Based Evidence Conclusions: What can we do A. Use a client-specific PICO question. B. Apply the same critical and scientific thinking to your clinical work: Watch quality of measurements Watch design set up Look for confounding variables. C. Have a supported rationale for trying something new. D. If there is no in the lit., report yours! Barriers to EBP use Reported Problem Access Time Lack of or Insufficient Contradictory Limited training in EBP and research. Lack of information literacy skills. Use databases. Ask your local university. Solutions Lots of EBP articles exist, USE THEM. Tackle 1 topic at a time (Robey 2011). Generate your own : Always have a sound rationale, try it, and report it! Ask a different question for your search Seek the closest possible applicable. Which is strongest (see Evaluating the Evidence) That s why you are here. That s why you are here. patrick.coppens@plattsburgh.edu References American Speech-Language-Hearing Association. (2005). Evidence-based practice in communication disorders [Position Statement]. Available from Dollaghan, C. A. (2007). The handbook for based practice in communication disorders and sciences. Baltimore, MD: Paul Brookes. Gillam, S., & Gillam, R. (2008). Teaching graduate students to make -based decisions. Topics in Language Disorders, 28(3), Goldacre, B. (2008). Bad science. New York, NY: Faber & Faber. References Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of based practice: a conceptual framework. Quality in Health Care, 7, Lemoncello, R., & Fanning, J. L. (2011, November). Practice-based. Seminar presented at the ASHA meeting. San Diego, CA. Lof, G. L. (2011). Science-based practice and the speech-language pathologist. International Journal of Speech-Language Pathology, 13(3), Lum, C. (2002). Scientific thinking in speech and language therapy. Mahwah, NJ: Lawrence Erlbaum. Robey, R. (2011). Treatment effectiveness and -based practice. In L. L. Lapointe (Ed.), Aphasia and related neurogenic language disorders (pp ). New York, NY: Thieme. 11