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Background01 Introduction01 Background02 Evidence-basedpracticeintheAODsector04 AODEvidence-BasedPracticeModel06 References
Research tools08 RecommendedDatabasesforAODResource10 LevelsofEvidence11 AODEvidenceChecklist12 FindingoutmoreaboutEvidence-BasedMedicine14 GlossaryofEvidence-Basedterms
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AcknowledgementsThisresourcewaspreparedonbehalfoftheAlcoholandotherDrugsCouncilofAustralia(ADCA)byJaneShellingandKimberleyClarke.
FeedbackandassistancefromADCA’smembers,ADCA’sNationalResourceCentreAdvisoryCommitteeandthoseinvolvedinourevidence-basedpracticeworkshopsoverthepastyearisgratefullyacknowledged.
©2007AlcoholandotherDrugsCouncilofAustralia(ADCA)17NapierCloseDeakinACT2600POBox269WodenACT2606www.adca.org.au
ISBN978-1-876837-12-9
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Introduction
Ashealthprofessionals,thereisaresponsibilityforthealcoholandotherdrug(AOD)workforcetoensureourpracticewillachievethebestpossibleoutcomeforourtargetgrouporclient.Bestpracticeisoftendefinedbycurrentevidence;howevertherearemanybarrierspreventingalcoholandotherdrugworkersfromapplyingestablishedmodelsofevidence-basedpracticetotheirwork.Theaimofthisprojectistoassistthealcoholandotherdrugsectorinapracticalwaytomorerigorouslyresearchandfindevidencetohelpguidetheirpractice.Drawinguponprinciplesofevidence-basedpractice,andtheneedsofthebroaderAODsector,thispaperwillprovideanevidence-basedprotocolapplicabletothoseworkingtoreducedrugrelatedharm.
Background
Centraltotheprinciplesofevidence-basedpracticeisthenotionofwhatisregardedas“soundevidence”.Duetothesheernumberofresearchprojectsconductedandpublishedannually,itisoftendifficultforpractitionerstodeterminewhatevidencetheyshouldbasetheirpracticeon.Forthisreason,frameworkssuchasevidence-basedmedicinerequiretheapplicationofthehierarchyofevidenceinordertodeterminewhatevidencecanbeusedtoinformpractice(Reimer,Sawker&James2005).
Therelianceonthehierarchyofevidenceisthecauseformuchdebateregardingthevalidityofevidence-basedmedicineandevidence-basedpractice(Reimeretal2005).Thehierarchyofevidenceregardssystematicreviewsofrandomisedcontroltrials(RCT)asthe‘goldstandard’ofevidence(Sackett,Rosenberg,Gray,Haynes&Richardson,1996).Asascale,thehierarchyofevidenceusesstudydesigntorankthequalityofevidence,andaccordinglythosestudydesignswhichcarrytheleastriskofbiasandconfoundingareseentobethemostreliable(Reimer2003).
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Criticsarguethatrelyingsolelyonstudydesignasamarkerforqualitymayleadtotheexclusionofsomeformsofevidencethatmayproveuseful(Rychetnik,Frommer,Hawe&Shiell2006).Itissuggestedbyeliminatinganypossiblebiasfromastudyoneisactuallyremovingoralteringthecontextinwhichthebehaviourorinterventionisoccurring(Rychetnik&Frommer2000).Itissuggestedthatlowerlevelsofevidence,suchasthatderivedfromstudiesofacohortorlongitudinaldesign,maybemoreappropriateforinvestigatingresearchquestionsthatexplorebehavioursorinterventionsthatoccurinsocialsettings(Gowing2001).Asimilarargumentexistsconcerningtheapplicabilityoftraditionalevidenceappraisalcriteriawithinthepublichealtharenawheretheliteraturearguesthat“Goodinformationontheeffectsofthecontextandofinteractionsbetweenthecontextandtheinterventionrequiresacombinationofdifferenttypesofresearch,includingexperimental,observational,multi-levelandqualitativeapproaches”,(Rychetnik&Frommer,2000,p11).
Inrecenttimes,therehasbeenanincreasedemphasisontheimportanceoffactorssuchasclinicaljudgementandclientorpopulationgrouppreferenceinguidingpractice.Thishasledtotherecognitionofevidence-informedpracticeasanalternativetootherapproachessuchasevidence-basedmedicine,orevidence-basedpractice.Supportersoftheevidence-informedapproacharguethatthetermevidence-basedpracticediminishestheimportanceofclinicaljudgementandclientpreferences,andimpliesevidenceistheonlycontributingfactorinfluencingdecisionmaking(Nutley,Davies&Walter,2003).Evidence-informedpracticerecognisestheroleofprofessionalismindetermininghowevidenceisappliedtoparticularcircumstances(Phillips2004).
Evidence-based practice in the AOD sector
TherearemanybarrierspreventingmembersoftheAODsectorfromtransferringevidenceintopractice(RocheinRoche&McDonald2001).TheAODsectorischaracterisedasbeingunder-resourcedandoverworked,anditisoftendifficultforworkerstofindthetimeororganisationalsupporttoundergotheseeminglyvigorousprocessesneededtoapplyevidenceintopractice.
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Reimeretal2005highlightsthepracticallimitationstoapplyingevidenceintopracticewithintheAODsectoraccordingtothefollowinggroups:
>> IndividualFactors.Thisincludesfactorssuchasbeliefs,attitudesandvalues,professionaldevelopment,skillsandinterests.
>> Organisationalfactors.Includesfactorssuchasjobburnout,poorleadership,achange-adversecultureandlackoforganisationalsupportforapplyingevidenceintopractice.
>> Communityfactors.Thesefactorsareapplicabletocommunity-levelinterventionsandprograms.Factorsincludedifferingbackgroundsandtraining,differingperspectivesonprevention,lackofcommunityreadiness,andcompetingpoliticalinterests.
ConsideringthemanybarrierstoapplyingevidenceintopracticeasoutlinedbyReimeretal2005,itisarguedthatcurrentprotocolssuchasevidence-basedmedicineandevidence-basedpracticearenotentirelysuitedtotheAODsectorinAustralia.Thereisaneedforanapproachwhichisconsiderateofthemanybarriersfacedbythesector,andaimtoovercomethesebarriers.
Inaddition,oneshouldalsorecognisethattheAODsectorisbroadanddiverse.Interventionsoccurringwithinthesectorrangefromclinicallybasedtreatmentinterventionsinahospitalsetting,throughtopopulationbasedpreventativeinterventionswhichoccurinacommunitysetting.Certainquestionswithinthesectorrequireanapproachwhichincorporatesprinciplesfromanevidence-basedmedicineapproach,whileothersshouldacknowledgetheinfluencesocialandpsychologicalfactorshaveontheinterventionandadoptamoreevidence-basedpublichealthapproach.ProfessionalismandclinicaljudgementareoftenstronglyrelieduponintheAODsectorandshouldplayastrongroleindetermininghowevidenceisappliedintopractice.This‘horsesforcourses”approachiswellidentifiedwithintheliterature(Nutleyetal2003),andshouldbeonethatisadoptedintheAODsector.
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AOD Evidence-Based Practice Model
How to use the modelADCA’smodelsuggestsaprocessthatAODworkerscanapplytoassistinaddingrigourtotheirpractice,andtoprogressa“researchintopractice”paradigm.ThemostimportantaspecttorememberwhenworkingwiththeADCAmodelforevidence-basedpracticeistoadopta‘horsesforcourses’approachtoapplyingevidenceintopracticeintheAODfield.AODworkersarefacedwithmanyproblemsintheirdaytodaywork,andthetypeofproblemidentifiedcangreatlydeterminewhattypeofevidencetousetoinformyourpractice.
Ifyourproblemisonethatisrelatedtotherapy,harm,prognosis,diagnosisorintervention,ADCAstronglyrecommendsthatyouapplyanevidence-basedmedicineapproachtoansweringyourquery.Ampleinformationonevidence-basedmedicinecanbefoundintheliterature,andwehaveprovidedsomereferencestosourcesinthiskit.Thepurposeofthiskithoweverisnottoguideyouthroughaprocessofevidencebasedmedicine,butratherhelpyoufollowarigorousevidence-basedapproachtoaddressingpopulationbasedproblemswhicharemorecommontothealcoholandotherdrugfield.
Whenaproblemdoesnotfitwithinanevidencebasedmedicineapproach,itisstillimportanttoensurethatyouareapplyingfundamentalprinciplesofevidence-basedpracticeinyourwork.Thiskitoutlinesamodelforpractitionerstofollowwhenproblemsoccurwithinthescopeofprevention,healthpromotion,policyandpublichealth.Themodelfollowstheidealsoftheevidence-basedmedicinemodelbuttriestoincorporaterigourinamannermorerealistictotheAODsetting.Asdiscussedpreviously,manyAODworkersarelimitedinthetimeandresourcestheycanspendonactivitiesneededtoapplyevidenceintopractice.Inresponsetothis,ADCAsuggeststhatworkersusethismodeltoguidetheirpracticewithintheresourcestheyhaveavailable.Notallworkerswillbe
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abletospendexhaustiveamountsoftimeoneachoftheindividualsteps,howeveritisimportanttorememberthatevenapplyingpartofthemodelwillbebetterthannotapplyinganyatall.
BeforeusingthemodelItisimportanttospendsometimeonpreparationpriortoapplyingthemodeltoaprobleminyourworkplace.
Identifytheproblem.Itisimportanttoaccuratelydefinetheproblembeforeyouattempttoaddressit.Often,doingsomepreliminarydatabasesearchingcanensureyoufullyunderstandthedimensionsoftheproblem.Also,makesurethatyoudiscusstheproblemwithyourcolleaguestodetermineiftheyareexperiencingsimilarproblems.
TimeandresourceallocationYoushouldalsoconsidertheamountoftimeandresourcesthatyoucancomfortablyallocatetotheresearchprocess.Itmayalsoproveusefultodiscusstheevidence-basedpracticeprocesswithyourmanagerandimmediatecolleagues–orevengettheminvolved.Thisway,theyareawareofwhatyouaredoing,andaremorelikelytosupportyouthroughtheprocess.
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References
GowingL.2001.“Evidence-BasedPractice:FromConceptstoReality”,inRoche&McDonald,Systems,Settings,People:WorkforceDevelopmentChallengesfortheAlcoholandotherDrugsField,NationalCentreforEducationandTrainingonAddictions,Adelaide.
NutleyS,DaviesH&WalterI.2003.EvidenceBasedPolicyandPractice:CrossSectorLessonsfromtheUK.KeynotePaperfortheSocialPolicyResearchandEvaluationConference,WellingtonNZ.
PhillipsM.2004.ContinuingProfessionalDevelopmentandEvidence-InformedPractice:WorkingPaperSeriesvol.1.UniversityofBristol,DepartmentofManagement,Bristol.
ReimerB.2003.StrengtheningEvidence-BasedAddictionPrograms:Apolicydiscussionpaper.AlbertaAlcoholandDrugAbuseCommission,CanadianCentreonSubstanceAbuse,andtheNationalPolicyWorkingGroup,Canada.
ReimerB,SawkaE&JamesD.2005.“ImprovingResearchTransferintheAddictionsField:APerspectivefromCanada”,SubstanceMisuseandUse,vol40,pp1707-1720.
RocheA,2001,“WhatIsThisThingCalledWorkforceDevelopment”,inRoche&McDonald,Systems,Settings,People:WorkforceDevelopmentChallengesfortheAlcoholandotherDrugsField,NationalCentreforEducationandTrainingonAddictions,Adelaide.
RychetnikL&FrommerM.2000.AProposedSchemaforEvaluatingEvidenceonPublicHealthInterventions:AdiscussionpaperpreparedfortheNationalPublicHealthPartnership.NationalPublicHealthPartnership,VictoriaAustralia.
RychetnikL,FrommerM,HallP&Shiell.2002.“Criteriaforevaluatingevidenceonpublichealthinterventions”,JournalofEpidemiologyandPublicHealth,vol56,pp119-127.
SackettD,RosenbergW,GrayJ,HaynesR&RichardsonW.1996.“Evidencebasedmedicine:whatitisandwhatitisn’t”,BritishMedicalJournal,vol312,pp71-72.
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Recommended Databases for AOD Resources
FRee Access dAtABAsesAOd guidelines and protocols - www.adca.org.au/resource/LinkstoAODguidelinesandprotocols,availablefromADCA’sNationalResourceCentre(NRC)webpage.
drug database - www.adca.org.au/drugDrugistheonlinedatabaseofADCA’sNationalResourceCentre.Itcurrentlycontainsover63,000referencestobooks,videos,journalarticles,conferencepapers,researchreportsandunpublishedmaterialsonthehealth,socialandeconomicaspectsofalcohol,tobaccoandotherdruguse.EachmonthDrugisupdatedaddinganadditional300referencesallofwhichareavailablefromtheNRC.
cochrane Library - www.thecochranelibrary.comTheCochraneLibrarycontainshigh-quality,independentevidencetoinformhealthcaredecision-making.ItincludesreliableevidencefromCochraneandothersystematicreviews,clinicaltrials,andmore.Cochranereviewsbringyouthecombinedresultsoftheworld’sbestmedicalresearchstudies,andarerecognisedasthegoldstandardinevidence-basedhealthcare.
cork - www.projectcork.org/database_search/TheCorkdatabaseincludesover69,000itemsonsubstanceabuse,indexedbyover400terms.Itemsareprimarilyfromtheprofessionalliteratureandincludejournalarticles,books,bookchapters,andreports.Thedatabaseisupdatedquarterly. PubMed (Medline) - www.pubmed.govPubMedisaserviceoftheU.S.NationalLibraryofMedicinethatincludesover16millioncitationsfromMEDLINEandlifesciencejournalsforbiomedicalarticlesbacktothe1950s.PubMedincludeslinkstofulltextarticlesandotherrelatedresources.
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Fee-BAsed dAtABAsescINAHL - www.cinahl.com/CINAHLisamultidisciplinarydatabasecoveringthenursing,alliedhealth,biomedicine,andconsumerhealthliteraturefrom1982topresent.
Informit - www.informit.com.au/InformitisasuiteofdatabasesfromAustralasia’sleadingagenciesandinstitutionsthatindexandabstractavastrangeofAustralasiansourcesofinformation,includingtheDrugdatabase,butalsosourcesforrural,aboriginalandcrimeissues.TheNRCprovidesADCAmemberswithaccesstoRMITInformitdatbases.
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Levels of Evidence
Thereareseveraltablesshowingthehierarchyofevidencewhichcanbehelpfulindetermininghigherlevelsofevidence.Thispyramiddemonstratestheevidence-basedmedicinehierarchyofevidence.
evidence Pyramid
SunyDownstateMedicalCentre2007,Aguidetoresearchmethods,availableat:http://library.downstate.edu/ebm/2toc.htm
Cohort Studies
Case Control Studies
Case Series
Case Reports
Ideas, Editorials, Opinions
Animal Research
In vitro (‘test tube’) research
Systematic Reviewsand Meta-analyses
Randomised Controlled Double Blind Studies
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AOD Evidence Checklist
Key CheCKs Considerationsyes/no/
Can’t tell
the topic
Clarity Is the purpose/query/objective/intervention clearly stated?
Relevancy – Accurate reflection of my scenario/situation.
Is my specific query/situation addressed? Consider client/population’s age, sex, race, social background/situation.
Size Significant number of participants in study.
SettingAccurate reflection of my setting.
Rural/MetroIs the setting Australian or a country with a similar social setting?
Trustworthiness Is the study design used appropriate?
the recommendation
Results Were the results clearly stated? Were full explanations given?
Ability to Replicate Has the study already been replicated or could it be replicated in my own situation? Consider costs, appropriateness and additional resources required.
Credibility Is the action or recommendation in line with your current practice? Is it logical and reasonable?
Impact Were the negative and/or positive impacts and/or unexpected outcomes of following this course fully explained?
General Considerations
Currency Is the date when the evidence was produced relevant?Is currency an impact factor?
Organisation associated with evidence
Is this a known organisation? Do they have a particular bias or affiliation?
Author Is the author known? Does he/she have a particular bias or affiliation?
Journal Is this a well known and respected journal? Consider criteria for article inclusion.
Ethics Was any ethics approval sought or is there an ethics statement made?
Funding Has the source of funding been disclosed?
Levels of Evidence
Thereareseveraltablesshowingthehierarchyofevidencewhichcanbehelpfulindetermininghigherlevelsofevidence.Thispyramiddemonstratestheevidence-basedmedicinehierarchyofevidence.
evidence Pyramid
SunyDownstateMedicalCentre2007,Aguidetoresearchmethods,availableat:http://library.downstate.edu/ebm/2toc.htm
Cohort Studies
Case Control Studies
Case Series
Case Reports
Ideas, Editorials, Opinions
Animal Research
In vitro (‘test tube’) research
Systematic Reviewsand Meta-analyses
Randomised Controlled Double Blind Studies
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Finding out more about Evidence-Based Medicine
Forthosenewtoevidence-basedmedicinethereareawidevarietyofresourcesavailabletohelpwithunderstandingconcepts.Listedbelowareonlyafewofthemanysiteswhichareeasilyaccessible.Universities,hospitalsandhealthservicelibrariesrunevidence-basedmedicineclassesfornurses,medicalstudentsandotherhealthpersonnel-theremaybeopportunitiesforyoutoparticipatetoo.
Online ArticlesCraig,JC,Irwig,LM,&StocklerMR.2001,Evidence-basedmedicine:usefultoolsfordecisionmaking.MJA,174:248-253.www.mja.com.au/public/issues/174_05_050301/craig/craig.html
Sackett,D,1996,Evidencebasedmedicine:whatitisandwhatitisn’t.BMJ,71-72.www.bmj.com/cgi/content/full/312/7023/71
‘Howtoreadapaper’isanexcellentseriesofBMJarticlesbyTrishaGreenhalgh(alsoavailableasabook).www.bmj.com/collections/read.dtl
terminologyGlossaryofterms:astudentsguide-DenisonLibrary,UniversityofColoradodenison.uchsc.edu/SG/glossary.html
tutorialsIntroductiontoEvidence-BasedMedicine:aselfpacedtutorial-DukeUniversityMedicalCenterLibraryandHealthSciencesLibrary,UniversityofNorthCarolina.www.hsl.unc.edu/services/tutorials/EBM/index.htm
Evidence-basedmedicinetutorial–UniversityofMassachusettsMedicalSchoollibrary.umassmed.edu/EBM/index.cfm
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Web sitesCentreforEvidence-BasedMedicine–Oxfordwww.cebm.net/
EvidenceBasedMedicineToolkit–UniversityofAlberta,Canadawww.med.ualberta.ca/ebm/ebm.htm
Evidence-BasedPractice–UniversityofWesternAustraliaLibrary,seeunderEducation,training&support.www.library.uwa.edu.au
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Glossary of Evidence-Based terms Thisglossaryincludesdefinitionsfrom:OxfordCentreforEvidence-BasedMedicine2007,Glossaryoftermsinevidence-basedmedicine,availablefrom:http://www.cebm.net/glossary.asp,andRychetnik,L,Hawe,P,Waters,E,Barratt,A,&Frommer,M2004‘Aglossaryforevidence-basedpublichealth’.JEpidemiolCommunityHealth,vol.58,pp.538-545.BlindedAstudyisblindedifanyoralloftheclinicians,patients,participants,outcomeassessors,orstatisticianswereunawareofwhoreceivedwhichstudyintervention.Thedoubledouble-blindusuallyreferstopatientandclinicianbeingblinded,butisambiguoussoitisbettertostatewhoisblinded.
clinical Practice Guidelineisasystematicallydevelopedstatementdesignedtoassistpractitionerandpatientmakedecisionsaboutappropriatehealthcareforspecificclinicalcircumstances.
cohort studyinvolvesidentificationoftwogroups(cohorts)ofpatients,onewhichdidreceivetheexposureofinterest,andonewhichdidnot,andfollowingthesecohortsforwardfortheoutcomeofinterest.
cost-Benefit Analysisconvertseffectsintothesamemonetarytermsasthecostsandcomparesthem.
cost-effectiveness Analysisconvertseffectsintohealthtermsanddescribesthecostsforsomeadditionalhealthgain(e.g.costperadditionalMIprevented).
evidenceInthebroadestsense,evidencecanbedefinedas“factsortestimonyinsupportofaconclusion,statementorbelief”and
“somethingservingasproof”.Suchagenericdefinitionisausefulstartingpoint,butitisdevoidofcontextanddoesnotspecifywhatcountsasevidence,when,andforwhom.
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evidence-Based Health careextendstheapplicationoftheprinciplesofEvidence-BasedMedicine(seebelow)toallprofessionsassociatedwithhealthcare,includingpurchasingandmanagement.
evidence-Based Medicineistheconscientious,explicitandjudicioususeofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualpatients.Thepracticeofevidence-basedmedicinemeansintegratingindividualclinicalexpertisewiththebestavailableexternalclinicalevidencefromsystematicresearch.
expert Opinion usuallyreferstotheviewsofprofessionalswhohaveexpertiseinaparticularformofpracticeorfieldofinquiry,suchasclinicalpracticeorresearchmethodology.Expertopinionmayrefertooneperson’sviewsortotheconsensusviewofagroupofexperts.Whentheconceptofevidence-basedpracticewasfirstintroduced,expertopinionwasidentifiedastheleastreliableformofevidenceontheeffectivenessofinterventions,andpositionedatthelowestlevelin“levelsofevidence”hierarchies.Otherdevelopmentshavedeterminedthatrankingexpertopinionwithlevelsofevidenceisnotusefulorappropriatebecauseexpertopinionisqualitativelydifferenttotheformsofevidencethatarederivedfromresearch.Opinioncanbeidentifiedasameansbywhichresearchisjudgedandinterpretedratherthanasaweakerformofevidence.
Lay Knowledgereferstotheunderstandingthatmembersofthelaypublicbringtoanissueorproblem.Layknowledgeencompasses“themeaningsthathealth,illness,disabilityandriskhaveforpeople.”Formalidentificationandexaminationoflayknowledgeismostlyconductedthroughqualitativeformsofinquiry.Adequateattentiontolayknowledgehasbeenproposedasacriterionforcriticallyappraisingqualitativeresearch.Concernsthatsomehealthprofessionalsmaynotadequatelyvaluelayknowledgehavebeenexpressed.Layknowledgecanbedifficulttoaccessandsynthesise,andfocusonquantitativeformsofevidence
canleaddecisionmakerstoundervaluethelayknowledgethatisderivedfromnarrativesandstories.
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Meta-analysisisasystematicrevieworoverviewwhichusesquantitativemethodstosummarisetheresults.
Peer reviewisareviewofjournalarticlesbyothersinthesamefield.Peerreviewistheprimarymethodforqualitycontrolinmedicalpublishing.
Randomised controlled clinical trialiswhenagroupofpatientsisrandomisedintoanexperimentalgroupandacontrolgroup.Thesegroupsarefollowedupforthevariables/outcomesofinterest.
sensitivityistheproportionofpeoplewithdiseasewhohaveapositivetest.
specificityistheproportionofpeoplefreeofadiseasewhohaveanegativetest.
systematic Reviewisaliteraturereviewfocusedonasinglequestionwhichtriestoidentify,appraise,selectandsynthesisallhighqualityresearchevidencerelevanttothatquestion.
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