Evidence Based Practice

Roger HawcroftJuly 2011

Objectives

To Provide an overview of EBP Outline some resources from which

you can extract available evidence Provide a basis from which to develop

skills in searching for evidence

INTRODUCTION

What is Evidence Based Practice?

“using the best research evidence available, along with clinical expertise and patient values to inform decisions regarding clinical practice”

(Sackett, 2000)

Evidence-Based Practice

CLINICAL SKILLS &

EXPERIENCE

PATIENT PREFERENCES,

VALUES &

CIRCUMSTANCES

EVIDENCE

EBP

The Aims of EBP To produce guidelines for practice using the most

current and comprehensive research Minimise inappropriate variability in practice Identify strengths and weaknesses in existing

research Guide potential research To improve the quality and safety of clinical

decisions

The role of EBP

EBP is about USING research, not DOING research

Researchers Practitioners direct publish or research by disseminate identifying areas research of need, and providing evidence feedback regarding

effectiveness of research evidence.

Those doing research

Those using research

Effective practice

Another way to think about it...The Practitioner

ConsidersPerson / Problem / Environment / Evidence

Applies Clinical Reasoning, Judgement and Experience

Decides Action / Treatment which will most effectively

produce the desired outcomes for the patient

STEPS IN EBP

(Adapted from: Bennett & Bennett, 2000; Sackett et al, 2000)

Steps in EBP...

1. QUESTION: Convert the need for information into an answerable question.

2. FIND: Search for the best evidence

3. APPRAISE: Critically appraise the evidence. Consider: validity; results; applicability.

4. INTEGRATE: Integrate evidence with clinical expertise with patient attributes and APPLY to practice.

5. EVALUATE: your effectiveness and efficiency in executing steps 1-4. How could you improve your performance?

Focus of this session

• Step 1 - The Question• Step 2 - Searching for Evidence

STEP 1 – THE QUESTION

The Question

Formulate a searchable question: Mind Map

– particularly useful for study and survey type questions

PICO - particularly useful for clinical questions

arising directly from patient care

Why spend time on the question?

Clarifies the issue or problem Helps focus your ideas Identifies key concepts & relationships Provides key search terms Gives you a starting point Often indicates a search strategy Shortens search time and improves chance

of obtaining appropriate results

A clinical problem or question arises out of the care of the patient so start here.

A 45 year old male with alcohol issues presents after his third relapse following GP counselling on a monthly basis.

He has heard about cognitive and behavioural therapy and asks you whether this is a treatment option that decreases the likelihood of relapse.

Consider

How can this clinica problem be translated into a searchable format?

PICO

Translates a clinical question into a searchable format

Patient

Intervention

Comparison

Outcome

PICOPopulation or patient Who are the relevant patients? – Generalise.

Intervention or Indicator What is the management strategy, diagnostic test or

exposure that you are interested in? ( eg. cognitive therapy, surgical procedure, diagnostic test, medication, etc.)

Comparison What is the control or alternative management strategy, test

or exposure with which you will compare your intervention?

Outcome What are the patient-relevant consequences of the

exposure in which you are interested? – What do you want to happen?

Translate the following question into PICO format

A 45 year old male presents after his third relapse following GP counselling on a monthly basis for alcoholism.

He has read about cognitive and behavioural therapy and asks you whether this is a treatment option that decreases the likelihood of relapse.

PICO

Patient: 45 yr old Male Alcoholic

Intervention: Cognitive Behaviour Therapy

Comparison: Counselling

Outcome: Abstinence

Practice makes perfect

Think of a clinical situation / problem and translate it into a searchable question using PICO.

Activity

Clinical Questions

Does cognitive behaviour therapy improve function in adults with chronic fatigue syndrome more effectively than bed rest?

Does having arthritis affect an elderly person’s quality of life?

Step 2 – Finding the evidence 50 new randomised trials published per day

- 2000 per year

1000 new publications added to MEDLINE per day - 5000 new articles published per day

an estimated 2 million new articles published each year.

(MEDLINE comprises approximately 20% of the world biomedical literature)

What are you aiming to find?

ClinicalRelevan

ce

High

Low

ValidityLow High

Vast bulk scientist to scientist - not YET so relevant to clinicians

High quality relevant studies

Levels of evidence (4S & 5S)

Clinical Evidence

Up-To-Date

Cochrane Library

EBMR

Medline PsychInfo

Systems

Synopses

Syntheses

Studies

Computerised Decision Support Systems

Evidence-based journal abstracts

Systematic Reviews

Original journal articles

Evidence-based mental health

Summaries Evidence-based textbooks

Where to search - 1

Decision Support / Point of Care

. Match information from individual patients with the best evidence from the research that applies. Rare – would use an electronic patient record matched to a knowledge-base

Where to search - 2

Summaries

– Clinical evidence database - Evidence based textbooks

.Integrate best evidence from the lower layers, also drawing on systematic reviews to provide a full range of management options for a given health problem.

Where to search - 3

Synopses

Evidence based journal abstracts eg. Evidence-based mental health journal

Succinct descriptions of an individual study or systematic review

Where to search - 4

Syntheses & Meta-analyses

Cochrane Library Evidence Based Medicine Reviews (EBMR) Database of Abstracts of Reviews of Effects

Provide reliable and up-to-date information on the effects of interventions in health care and rigour of studies reviewed. Usually consider only 1 aspect of management, i.e. a single drug.

Where to search - 5

Studies – (Original journal articles)

Medline - Medical perspective Cinahl - Nursing perspective Psychinfo - Psychological literature

Provide reliable and up-to-date information on the effects of interventions in health care and rigour of studies reviewed.

STEP 2. - FINDING THE EVIDENCE

Keyword Searching

Seaches on the word or words entered: Automated i.e. no human intervention Searches for a TEXT match between the

search term and the same TEXT within the source material

Eg. Search term = “Bipolar disorder” Result = Includes any source which includes

the TEXT “Bipolar” & the TEXT “disorder”

Keyword Searching - 2

The resulting of using the “Bipolar disorder” search term might thus include:

• Bipolar : case studies and clinical trials• Bipolar disorder: treatment & diagnosis• Clinical diagnosis of respiratory disorders• Disorder – a history of civil disobedience

Attributes of Keyword searching

Will find articles whether relevant or not because it does not consider the concepts involved – only the text.

Often produces an impractically large result set

Can be useful if multiple terms are correctly combined on specific field searches

Is most effective when searching for precise and unique names, for example “Efexor”

Subject searching

Searches using pre-defined subject headings: Has prior mediation because expert indexers read

and evaluate source materials and then allocate appropriate subject headings according to the concepts discussed in the source material.

Subject headings are consistently applied by use of approved headings contained in an index, such as MeSH [Medical Subject Headings]

Attributes of Subject Heading searching

Finds relevant material because the source material will only be found if it has been allocated the relevant subject-heading because it discusses that concept.

Is more precise because the subject-headings are controlled terms which effectively collect together materials of a similar nature

The use of a controlled index allows display of a term within hierarchical and relational context

Framing the search

Boolean operators

Boolean operators are named after George Boole, a mathematician.

The operators call for a case to be true or false

The operators dictate how items are to be combined and are:

ANDOR NOT

Using Boolean operators

All source material in the database

on Rehabilitation

All source materialIn the database

On Cognitive Behaviour

Therapy

Boolean operator: AND

Rehabilitation AND Cognitive Behaviour Therapy

FINDS

RehabilitationCognitive

Behviour Therapy

Boolean operator: OR

Rehabilitation OR Cognitive Behaviour Therapy

Rehabilitation

Cognitive Behviour Therapy

FINDS

Boolean operator: NOT

Rehabilitation NOT Cognitive Behaviour Therapy

FINDS

Rehabilitation

Cognitive Behviour

Therapy

Sources

(Some) Sources for articles …

GENERAL MENTAL HEALTH

NURSING & ALLIED HEALTH

PHARMACOLOGICAL

Medline PsychInfo CINAHL Australian Medicines Handbook

Embase PsychiatryOnline Medline Embase

MD Consult Medline MD Consult Therapeutic Guidelines

CINAHL MD Consult MIMS

Harrisons CINAHL Medline

MD Consult

(Some) Sources for clinical evidence…

Available via CKN

Cochrane

PubMed Systematic Reviews

PubMed Clinical Queries

DARE

Clinical Evidence

Up To Date

Access to QH Databases

Access to search databases and online journals in QH is via CKN (the Clinicians Knowledge Network)

• On QHEPS, CKN is at the far right of the Main Menu Bar

• From any Internet connection, go to:http://ckn.health.qld.gov.au

Next steps …

1. Question2. Find the evidence

3. Appraise the evidence critically4. Integrate & Apply the evidence to

practice5. Evaluate the outcomes

6. Feed back into the process

STEP 3. CRITICAL APPRAISAL

Critiquing the evidence

• What level of evidence do you want / need?

• Systematic reviewes of Randomised Controlled Trials

• At least one Randomised Controlled Trial• Controlled non-randomised trial• Comparative studies with concurrent control• Comparison studies with historical control• Case study series

Critiquing the evidence - 3

Do you want :

• QualitativeOr• Quantitative

Evidence?

Organising for a critical appraisalUse simple summary tables to record your observations

Source Sample Method Outcome Conclusions

Study Design Results CommentTitleAuthority

DesignPurposePopulation

InterventionOutcomeResults

Level of evidence Other issues

A tabular format assists in comparing studies and in comprehension of the information – pin each one to its paper

STEP 4. INTEGRATE WITH PRACTICE

PUTTING IT INTO PRACTICE

The first two stages in the EBP process have considered what other have done and what is indicated by synthesis of their collective findings …The next stage is to integrate this knowledge with practice through such measures as:

• Developing clinical guidelines• Formulating a plan to change practice• Undertaking further research

Applying the evidence

What is possible or appropriate will depend on individual circumstances. Three factors are known to be critical:

• The CONTEXT in which the change is made

• The nature of the EVIDENCE available• The provision of sound FACILITATION

Attributes of a good clinical guideline

• Developed by a representative team• Valid• Reproducible• Cost effective• Clinically applicable• Flexible• Clearly written• Can be clinically audited• Is reviewable

Promoting enthusiasm

A Journal Club

A journal club is a good way to promote discussion and engender enthusiasm for a project as well as assisting participants to understand and interpret information.

Clinical Library Services can assist in setting up this process.

Research

Undertaking research is a more demanding way in which to contribute to improved practice but if you are interested in this avenue then please don’t dismiss the possibility.

A great deal of help and advice is available for those who do wish to pursue this course. A good start may be to contact the Human Research & Ethics Committee Coordinator.

FURTHER INFORMATION

For further information please contact the Clinical Library Service on 07-4616-5563 or by email to: THSDLIBS@health.qld.gov

THANK YOU FOR YOUR INTEREST

Roger Hawcroftroger_hawcroft@health.qld.gov.au

07-4699-8770