Evidence-Based Practice: Applying Research Outcomes to Inform Clinical Practice KATHRYN M YORKSTON, PH.D. CAROLYN R BAYLOR, PH.D. REHABILITATION MEDICINE UNIVERSITY OF WASHINGTON SEATTLE
Clinician Impression of EBP 2 Alien Scary Trendy Intriguing Exciting Le May et al, 1998
What do you mean by best? 3 EBP is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of an individual patient. (Sackett et al, 1996) Best possible evidence Best available evidence Dijker, 2009
Sources of Evidence Clinician Expertise Should it work? Research Evidence Does it work? Client Values and Preferences Do I want this treatment?
Benefits of EBP To improve outcomes by evaluating quality & consistency of treatment To link stakeholders Clients understanding of options & participating in shared decision-making Clinicians filtering & evaluating information Researchers understanding gaps in knowledge Educators teaching students to make systematic decisions Policy makers identifying best practices
Universal Challenges of EBP Clinical trials are expensive and time consuming Results are difficult to translate to a particular individual Minimal important differences are typically not specified (Make, 2007) Consumer skepticism (Carmen et al, 2010)
Let s Be Reasonable 7 An (In)practical Example from PD Four dopamine agents to combine Groups (young vs old) A comparison result in 512 limbs Power analysis result in 133 S per limb (N= 68,096) Montgomery & Turkstra, 2003
Challenges for SLP Our treatments are multidimensional Our clients form a heterogeneous group Our treatments must be considered in the context of personal factors out of our control Gold standard for research design is debatable
Finding the most helpful research 9 Narrative Review: conducted by experts using informal, subjective methods to collect & interpret information Systematic Reviews: comprehensive search for relevant studies on a specific topic, studies indentified & appraised according to predetermined & explicit methods Meta-analysis: statistical combination of studies to estimate effect size.
Elements of a systematic review 10 Study question Search strategy Inclusion & exclusion criteria Data abstraction Study quality and validity Data synthesis and analysis Funding or sponsorship
Grading the Strength of Evidence 11 Quality: aggregate ratings extent to which bias was minimized Quantity: # of studies, sample size, effect size Consistency: similar findings using similar and different designs
Databased Search Medline CINAHL PsychInfo Gray Area Searches Searching for Evidence 12 Edited books with data-based chapters Ancestral searches of reference lists
Sampling Bias All studies that are or should have been published Studies that have been published Articles that have been indexed Ideal situation all relevant studies Relevant articles among the ones retrieved Articles retrieved from specific search strategy
Phase I: Hypothesis testing Phases of Research 14 Experimental manipulation Phase II: Formulation of tx protocols Case reports / Small groups Phase III Studies with controls
ANCDS (http://www.ancds.org) Topic Year of Number Publicatio of n Articles Acquired Apraxia of Speech 2006 59 Aphasia: Overall Language Performance 2007 73 Aphasia: Lexical Retrieval 2008 123 Aphasia: Syntax 2006 63 Aphasia: Speech Production/Fluency Aphasia: Written Language - Reading Aphasia: Written Language - Writing Aphasia: Alternative Communication Dementia: Simulated Presence Therapy Dementia: Group Reminiscence Therapy Dementia: Spaced-Retrieval Training DementIa: Caregiver Active Cognitive Stimulation 2009 28 2008 56 2007 52 2005 75 2006 5 2006 7 2005 18 2007 14 Topic Year of Publicati on Number of Articles Dementia: Caregiver Education 2007 7 Dementia: Computer-Assisted 2005 3 Cognitive Interventions Dementia: Montessori-Based Intervention Dysarthria: Loudness, Rate or Prosody Dysarthria: Spasmodic Dysphonia & Related Disorders Dysarthria: Behaviorial Management of Respiratory/Phonatory Dysfunction 2006 5 2007 51 2003 103 2003 35 Dysarthria: Velopharyngeal 2001 33 Function TBI: Behavioral Intervention 2007 65 TBI: External Aids for Memory 2007 54 TBI: Behavioral & Social 2005 59 Interventions TBI: Direct Attention Training 2003 6 TBI: Intervention for Executive 2008 15 Functions Unilaeral vocal fold Paralysis 2006 92
Different Approaches 16 Description of candidacy Flow charts of clinical decision-making Statement about best practices Reformatting raw data
Issues Better Candidate Poorer Candidate Soft palate Flaccid Severe spasticity Rate of change Stable or slow Rapid improvement Resp/Phon Adequate Poor Function Articulation Adequate Poor
History/Referral Information Speech Characteristics Physical Examination Assessment of Respiratory/Phonatory Function MANAGE REDUCED FUNCTION Adequate Function Improve respiratory support Improve coordination/control Improve phonatory function Hypoadduction Hyperadduction Nonspeech tasks Postural adjustments Speech tasks Prosthetic assistance Nonspeech tasks Speech tasks Physical strategies to enhance adduction Trigger better speech w/ loudness training Nonspeech techniques Speech tasks Follow- up with progressive disorders Measurement of Outcomes Good Poor Maintenance Consider AAC
Statement about current practice 19 Botox injection as a treatment for adductor SD results in a substantial degree of improvement for a substantial percentage of patients, with benefits generally lasting for three to four months. There are no known serious side effects of Botox treatment for SD Botox injections for SD vary in terms of dose amount, site (e.g., unilateral versus bilateral), and technique (e.g., percutaneous versus transoral).
100 Habitual Semantic Cues 80 Word Intelligibility 60 40 20 0 Most 0 5 10 15 20 25 30 35 Severity Ranking Least
An Apt Analogy EBP is like smelling salts, an antidote to the fuzzy-headedness of the past, and noxious but welcome relief. Montgomery & Turkstra, 2003
Great news: They re doing more systematic reviews 22
References Academy of Neurologic Communication Disorders and Science (ANCDS). http://www.ancds.org Dijkers, M. (2009). When the best is the enemy of the good: The nature of research evidence used in systematic reviews and guidelines. Austin, TX:SEDL: National Center for the Dissemination of Disability Research. Le May, A., Mulhall, A., & Alexander, C. (1998). Bridging the research - practice gap: exploring the research culture of practitioners and managers. Journal of Advance Nursing, 28(2), 428-437. Make, B. (2007). How can we assess outcomes of clinical trials: the MCID approach. Journal of Chronic Obstructive Pulmonary Disease, 4(3), 191-194. Montgomery, E. B., & Turkstra, L. (2003). Evidence-Based Medicine: Let's be reasonable. Journal of Medical Speech-Language Pathology, 11(2), ixxii. Sackett, D. L., Rosenberg, W., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence-based medicine: what is it and what it isn't it. British Medical Journal, 312(7023), 71-72.