Evidence Based Practice Efficient and Effective EBP Search Strategies to Enhance your Practice Beth Cloud, PhD, PT Jena Ogston, PhD, PT Peter Rundquist, PhD, PT Synthesis of Patient goals Therapist expertise Research foundation Objectives 1. Describe the benefits and limitations of different research study designs and levels of evidence 2. Identify 5 commonly used search engines and/or websites that link to a clinical question that is relevant to the participants clinical practice 3. Demonstrate efficient search skills in various search engines and websites including, but not limited to PICO, rehabmeasures.org, pubmed Clinical Queries, and ptnow.org. 4. Based on a clinical question, identify the form of research and conduct an efficient search Overarching Goal decreasing practice variation and standardizing care around best practice patterns to maximize clinical outcomes and cost effectiveness (Cleland et al, 2008, p. 476) What it is Documenting and testing elements of clinical practice through rigorous and objective analysis and scientific inquiry. (Portney and Watkins, 2000 p. 3) the judicious use of current best evidence in making decisions about the care of individual patients (Sackett, 1996) Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values. (Sackett, 2001, p. 1) Barriers to EBP Gaps in knowledge Patients improve despite evidence to the contrary Productivity standards Reliance on clinical expertise Resource availability Time consuming 1
APTA 2020: http://www.apta.org/vision2020/ Evidence based practice is access to, and application and integration of evidence to guide clinical decision making to provide best practice for the patient/client. Evidence based practice includes the integration of best available research, clinical expertise, and patient/client values and circumstances related to patient/client management, practice management, and health care policy decision making. Aims of evidence based practice include enhancing patient/client management and reducing unwarranted variation in the provision of physical therapy services. Qualitative vs. Quantitative Research Quantitative Experimental Positivist Empirical Qualitative Naturalistic Inquiry Post-positivist Constructivist New Vision (adopted 2013) Transforming society by optimizing movement to improve the human experience Principles: quality commits the profession to establish and adopt best practice standards. Value: includes accountability in demonstrating that services are safe, effective, patientcentered, timely, efficient and equitable Qualitative vs. Quantitative Research Method Quantitative Qualitative Theory A priori: Deductive Ground-up: Inductive Number and selection of Groups, random Small number, purposive subjects Measurement tools Instruments Human Type of data Numerical Language (Descriptive) Manipulation Present Absent Control Maximized Minimized Research Methods Qualitative: Generally applied to descriptive or exploratory Subjective, narrative, measurement is based on openended questions, interviews and observations Quantitative: Descriptive, exploratory (correlative), experimental Numerical data under standardized conditions Study Classifications Qualitative Phenomenology evaluates narratives of individuals to determine meaning; gives a better understanding of what is associated with a specific clinical phenomenon Grounded Theory development of a theory after analyzing qualitative data Ethnography focused on understanding how culture affects attitudes, beliefs, and behaviors 2
Levels of Evidence Study Classifications Quantitative Intervention Studies Randomized controlled trials Quasi-experimental research designs Prognostic Cohort studies Case control studies Diagnostic Accuracy Levels of Evidence 1a. Systematic Review with homogeneous RCTs 1b. Individual Randomized Controlled Trial 2a. Systematic Review with homogeneous cohort studies 2b. Individual Cohort Study or low quality RCT (< 80% return) 2c. Outcomes research 3a. SR with homogeneous case control studies 3b. Individual case control study 4. Case series and poor quality case control study 5. Expert opinion Sackett et al 2000 Study Classifications Intervention Randomized controlled trials Participants randomized to intervention group May apply masking (of participants and/or investigators) Quasi-experimental designs Lacks control/ randomization Possible designs Repeated measures (within subject) Non-randomized groups (between subject) Case study or case series (single subject or multiple cases) Definitions SR literature summary utilizing specific methodology to review individual articles RCT randomized into experimental and control group Cohort Study experimental and control cohorts Outcomes Research population based Case control retrospective cohort Case series report on outcomes; no control Sackett et al 2000 Study Classifications Prognostic Cohort studies Following individuals over time May consist of groups that differ by some quality or exposure Outcome is disease/condition of interest Heart disease No heart disease Stroke No stroke Case-control studies Evaluating previous exposure or effect of a quality/characteristic Groups will consist of individuals with or without the disease/ condition of interest Heart disease No heart disease CASE S Stroke CONTRO LS No stroke 3
Sensitivity Study Classifications Diagnostic Accuracy % of cases who tested positive among those that have the disease SNOut If Sensitivity is very high a Negative test will rule the disorder Out few false negatives Interpreting the Literature Reliability Validity Responsiveness Specificity Study Classifications Diagnostic Accuracy % of cases who tested negative among those that do not have the disease SPIn If Specificity is very high, a Positive test will rule the disorder In few false positives Reliability The consistency of an instrument in measuring what it is designed to measure Intra and Inter-Rater Test-Retest Relative Absolute Combination Mixed Method Sequential Explanatory: qualitative after quantitative Adds depth (explanation and interpretation) Validity Are the authors conclusions Believable Useful Sequential Exploratory: quantitative after qualitative Adds breadth (generalization) 4
Validity Internal How did the investigator lessen intervening variables that could confound the results? External Who does this research apply to? Construct Operational definitions Statistical conclusion Is there truth in measurement and inference? Overarching Considerations When reading and/or planning studies, find measures that have good reliability, responsiveness, and validity Evaluate and/or design studies that have well constructed design and control elements to allow for the detection of meaningful difference Make sure the outcome measures validly represent the concept being studied Reliability versus Validity Additional Definitions Resource rehabmeasures.org Statistics review Responsiveness Search Engines, Resources Ability of an instrument to detect change when it has occurred Minimal Detectable Change Minimal Clinically Important Difference General PubMed: http://www.ncbi.nlm.nih.gov/pubmed/ Scopus: http://www.scopus.com/ Cochrane Library: http://www.cochranelibrary.com/ Trip: https://www.tripdatabase.com/ Google/Google Scholar: https://scholar.google.com/ Rehab Specific PEDro: http://www.pedro.org.au/ PTNow: http://www.ptnow.org Rehabilitation Measures Database: http://www.rehabmeasures.org 5
Search Strategies Studies of Intervention Example Medical Subject Headings (MeSH) Terms: https://www.nlm.nih.gov/mesh/ Purpose: provide a hierarchically-organized terminology for indexing and cataloging of biomedical information Search for MeSH terms: https://www.nlm.nih.gov/mesh/mbr owser.html Boolean Operators Assist with focusing the scope of a search Basic Boolean operators AND OR NOT Search engines may automatically use or facilitate use of these In individuals who have had a stroke, how does the use of functional electrical stimulation compare to an ankle foot orthosis in terms of resultant gait speed? MEDLINE/PubMed PICO Trip PICO PubMed Clinical Queries Studies of Intervention PICO Patient/Problem, Medical Condition Intervention Compare to (optional, alternative intervention) Outcome (optional) Stroke Functional Electrical Stimulation Ankle Foot Orthosis Gait Speed Sample Clinical Question: In individuals who have had a stroke, how does the use of functional electrical stimulation compare to an ankle foot orthosis in terms of resultant gait speed? Clinical Practice Guidelines Systematically developed statements designed to facilitate evidence-based decision making for the management of specific health conditions. CPGs incorporate evidence from research and clinical expertise. Intervention Search Engines PICO templates MEDLINE/PubMed - http://pubmedhh.nlm.nih.gov/nlmd/pico/piconew.php Trip - https://www.tripdatabase.com/#pico PubMed Clinical Queries - http://www.ncbi.nlm.nih.gov/pubmed/clinical Clinical Practice Guidelines (CPGs) Guidelines are systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances. (Scalzitti, 2001) Consider systematic reviews, clinical prediction rules, clinical practice guidelines as other sources for intervention information 6
Purpose of CPGs 1. Make evidence based practice efficient and realistic 2. Make the best available research evidence directly applicable to clinical practice 3. Integrate research evidence with knowledge from clinical experts 4. Consider research evidence with consideration for patient perspectives Systematic Reviews vs. Clinical Guidelines Focus is on a single topic Developed by a few researchers/authors Based on best evidence Broad clinical focus Developed by a diverse group and numerous researchers Based on best evidence, expert opinion, and patient input Resources for CPG s National Guideline Clearinghouse (NGC) http://guidelines.gov Joanna Briggs Institute www.joannabriggs.ed u.au/ ICSI - Institute for Clinical Improvement (Click on the "Guidelines and More" link at the top) http://www.icsi.org/ TRIP Database http://www.tripdatab ase.com http://guidelines.gov/ http://www.pedro.fhs. usyd.edu.au/ (PEDro) Examples of CPG s in PT 1. Neck & low back pain guidelines (Childs JD et al., 2008) 2. Torticollis: (Burch et al., 2009) 3. Development of DVT s (Riddle et al., 2005) 4. Ankle and knee fractures (Steill et al., 1992; Stiell et al., 1995) Limitations of CPG s Very general May be lacking as research is either lacking and/or low quality or rigor Ptnow.org: Agree II tool 7
Types of CPR s I. Diagnostic: probability that a patient has a particular condition II. Prognostic: likely outcome of patients with a specific condition III. Interventions: which patients are likely to respond to a type or set of intervention(s) Other ways to locate scientific evidence 1. Use a single article & work backwards 2. Become a regular reader of selected journals 3. Push technology (e.g. RSS feed) 4. Review Journals: ex: Clinics in Sports Medicine Types of CPR s: Examples I. Diagnostic: Ottowa ankle rules II. Prognostic: Dionne et al. (2005) predictors on return to work in patients with LBP III. Interventions: Hicks et al. (2005) stabilization exercises in persons with nonradicular LBP PTNow.org One stop shop for APTA members Article search Rehab Reference Center Clinical Summaries Tests CPGs Cochrane reviews Creation of CPR s 1. Create the CPR -identify factors with predictive value 2. Validation -reproduction in various populations EBP toolkit resources Pick 2: Pubmed, CINAHL, Pedro, Outcome measures: rehabmeasures.org One stop shop: ptnow.org 3. Conduct Impact Analysis -evaluate clinical decision making (cost difference?) 8
What is in your toolkit? 2 push resources: 2 pull resources: 9