Evidence-Based Practice: Transforming Concepts into Reality in Collaborative

Care SettingsBarbara Walker, Ph.D.

Clinical Professor, Department of PsychologyProfessor, Department of Family Medicine

University of Colorado, Denver

Jeffrey L. Goodie, Ph.D., ABPP/ LCDR, USPHSAssistant Professor of Family Medicine

Uniformed Services University of the Health SciencesBethesda, MD

Helen L. Coons, Ph.D., ABPPPresident and Clinical Director, Women’s Mental Health Associates

Philadelphia, PA

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Drs. Walker, Coons and Goodie have not had any relevant financial relationships

during the past 12 months.

Faculty Disclosure

What is the scientific basis for this talk?

In this symposium, we will define evidence-based practice (EBP), introduce participants to the associated skill-set, tools and new resources for doing EBP, and illustrate how it can be translated it into both primary and specialty collaborative care settings.

Need/Practice Gap & Supporting Resources

  Describe how evidence-based practice is used for

clinical decision-making and the 5 steps associated with this process.

 Describe why it is necessary to adapt evidence-based methods for use in primary care.

List examples of evidenced based assessment and intervention strategies to improve physical and psychosocial outcomes among women seen in collaborative ob/gyn and oncology practices.

Describe how several interventions have been adapted to be effective in a primary care environment.

Objectives

What do you plan for this talk to change in the participant’s practice?

Be familiar with and be better able to use evidence-based practice skills for clinical decision-making in collaborative care settings.

Increased ability to apply gender-specific research to improve outcomes in collaborative ob/gyn and oncology settings.

Increased use of evidence-based practice strategies that have been adapted for use in primary care, specifically with regard to insomnia, weight management, and PTSD.

Expected Outcome

A learning assessment is required for CE credit.

1) List the 5 specific steps associated with clinical decision-making in evidence-based practice.

2) Name and explain how to access and search at least 2 databases that contain synthesized evidence-based research.

3) Give at least one example of how evidence based care can improve health and psychosocial outcomes.

4) Describe how evidence-based treatment has been adapted and found to be effective in primary care for treating insomnia, weight, and/or PTSD.

Learning Assessment

Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings1) Fundamentals of Evidence-Based Practice: It’s more than applying

evidence-based treatments (Barbara Walker)2) Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and

PTSD (Jeffrey Goodie) 3) Providing Evidenced Based Care to Women in Collaborative Ob/Gyn

and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes (Helen Coons)

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #October __, 20110:00 AM

Straus et. al, 2011 (4th ed.)

Sackett et. al 1997

What should I do for this particular patient in front of me?

EVIDENCE BASED MEDICINE

Best available research evidence

Patient’s values Clinical Expertise

CD

Best research available

Patient characteristics, culture and preferences

Clinical Expertise

CD

“The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (became policy of the American Psychological Association in August, 2005)

Psychology introduces EBPP in 2005

The framework

Best research available

Patient characteristics, culture, preferences

Clinical Expertise

CD

OPERATIONALIZATION :5 STEPS1st

CD

1. ASK

2. ACQUIRE 3. APPRAISE4. APPLY

5. ASSESS

TOP DOWN: What is the most effective intervention for this particular disorder?(ESTs, EB guidelines)

BOTTOM UP: What should I do for this particular patient in front of me? (Clinical Decision Making)

EBIDM: Eddy, D. Health Affairs, 24, no.1 (2005):9-17Evidence-Based Medicine: A Unified Approach

Evidence-based Practice

ASK: Questions are formulated in a specific way

Therapy Diagnosis

Background

Foreground

By Content By Format

THIS SLIDE COURTESY OF SUE LONDON RUTH LILLY LIBRARY

HarmEtiologyPrognosisCost-effectiveness

Why bother?

THIS SERIES COURTESY OF SUE LONDON IUPUI LIBRARY

High Sensitivity

High Specificity

WHAT:

WHERE:

HOW:

Scientifically synthesized literature

Specialized databases

Specialized search strategies/filters

Step 2. Acquire

Evidence that has already been (scientifically) synthesized for us:

Syntheses Summaries Systems

HOW? Start at the top

• EBP has two sides: Top-down and Bottom up (a set of clinical decision-making resources and tools)

• Common language• Setting / Context matters• Need for primary and secondary literature studies

in collaborative care• Ultimate goal is to improve outcomes

What is EBP and why is it so important in collaborative care?

www.ebbp.org has training modules

Norcross, Hagan & Koocher, 2008

To learn more…

Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD

Jeffrey L. Goodie, Ph.D., ABPPLCDR, USPHS

Assistant Professor, Dept of Family MedicineUniformed Services University

Outline

Three examples Weight Insomnia PTSD

Medical or Behavioral health providers Outcomes Challenges

Goodie, J. L., Hunter, C., Hunter, C., McKnight, T., LeRoy, K., & Peterson, A. (2005, March). Comparison of weight loss interventions in a primary care setting: A pilot investigation. Paper presented at the 26th Annual Meeting of the Society of Behavioral Medicine, Boston, MA.

Weight

Specialty Care Evidence

Identification Setting realistic goals Self-monitoring Stimulus control Exercise to maintain weight loss

"Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults.“ (1998). National Heart, Lung, and Blood Institute, NIH.

Does primary care provider delivered evidence-based behavioral interventions for weight result in more weight loss?

Procedures Enhanced Care Group

Appointment 1 Set 10% weight loss goal for first 6 months Maintenance goal for second 6 months Discuss motivators and barriers Provided w/ calorie book Food diary for 12 days

Appointment 2 (2 – 4 weeks later) Review food diary and C.A.M.E.S. Review barriers and motivators

ProceduresEnhanced Care Group, Cont’d

Appointment 3 (2 – 4 weeks later) Discuss physical activity Provided w/ pedometer

Set baseline and increase by 10% Appointment 4 – 5

Review progress. Again, discuss barriers and motivators

Appointment 6 Set maintenance goals

1 year follow-up

ProceduresMinimal Contact Group

Appointment 1 Discuss cutting calories and increased exercise

No specific tools or training provided for PCP PCP could recommend any weight loss strategy

Appointment 2 -5 Discuss any problems

Appointment 6 Plan for 6 month maintenance

1 Year follow-up

Results

1324N =

GRP

MCEC

% W

eigh

t Los

s

60

40

20

0

-20

-40

Goodie, J. L., Isler, W., Hunter, C. L., & Peterson, A. L. (2009). Using behavioral health consultants to treat insomnia in primary care: a clinical case series. Journal of Clinical Psychology, 65, 294-304.

Insomnia

Specialty Care Evidence

Stimulus control Sleep restriction Sleep hygiene Relaxation

Schutte-Rodin et al. (2008). J Clin Sleep Med.  Morin et al., (1989). Sleep Research; Morin et al., (1994), American Journal of Psychiatry.

Do CBT evidence-based treatments for insomnia decrease insomnia symptoms when delivered by a BHC in primary care?

Methods

Case Control Series (Goodie et al. 2009) 29 physician referred Primary Insomnia patients

Limited exclusion criteria Intervention delivered by BHC Attend four appointments

Assessment (30 mins) 1-2 intervention appointments (15-30 mins)

Sleep hygiene, stimulus control, sleep restriction Relaxation Supplemental book

Follow-up

OutcomesPre M (SD) Post M (SD) F η2

SII 26 (4) 15 (5) 107* 0.79SOL (min) 49 (37) 24 (27) 17* 0.38WASO (min) 41 (32) 13 (11) 19* 0.41AVGWAK (min) 29 (36) 9 (7) 9* 0.24EMA (min) 20 (16) 9 (10) 12* 0.30TWT (min) 135 (50) 52 (38) 95* 0.77TST (min) 366 (113) 404 (97) 4 0.14TIB (min) 499 (106) 459 (101) 5 0.14SE 72 (13) 88 (10) 84* 0.75

*Significant compared to α=.008; Goodie et al. (2009)

PTSD

Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, A. Peterson, A. L., and the STRONG STAR Consortium. (2011). Treatment of active-duty military with PTSD in primary care: Early findings. Psychological Services 8(2), 104-113.

Specialty Care Evidence

PTSD Treatment Prolonged exposure Cognitive processing therapy

Powers et al. (2010). Clinical Psychology Review 30(6): 635-641.; Cloitre, M. (2009). CNS Spectr 14(1 Suppl 1): 32-43.

Do CBT evidence-based treatments for PTSD decrease PTSD symptoms when delivered by a BHC in primary care?

Intervention

Adapted forms of prolonged exposure and cognitive processing therapy

Assessed and treated by BHC After initial assessment,

1 to 4 (up to 6) < 30 min appointments Weekly Homework between meetings

Procedures

Pt referred to BHC

Appointment 0

Testing

Appointment 1

Appointments 2-4

6 & 12 month Testing

Appointment 0

Duration: thirty-minute appts Brief Assessment (PCL-M) Education

Normal recovery curve; “getting stuck” Role of avoidance in maintaining symptoms Evidence for exposure-based treatments

Presentation of treatment options Primary care vs Specialty care vs Self-care

Appointment 1

“Confronting Uncomfortable Memories” workbook Write narrative of traumatic experience Answer cognitive/emotional processing questions

Prescribe as homework Goal: 30 minutes write/review daily Self-monitor SUD’s

Problem-solve homework implementation When/where of homework Barriers to completion

Appointments Two to Four(optional 5, 6)

Discuss homework completion Review SUD’s

Read narrative out loud (at least once) Read answers to processing questions out loud Socratic dialogue on problematic beliefs Re-assign writing assignment as homework BHC has option of other CP questions Encourage opportunities for in vivo exposure

Baseline Post-tx 6-month 1-year35

45

55

65

75

85

9587.5

47.5

41.3

48.4

% m

eetin

g PT

SD D

x% with PTSD Diagnosis (PSS-I)

N=24 N=17 N=16 N=11

Overall Χ2=8.95, p=0.03; All time points different from baseline (p < .01)

Baseline Post-tx 6-month 1-year35

40

45

50

55

60

55.3 (2.2)

41.7 (3.3)

39.3 (3.2)

42.4 (3.3)

Mea

n (S

E) P

CL-

M S

core

sPCL-M

N=24 N=17 N=17 N=10

Overall F=6.51, p=0.002; All time points different from baseline (p < .003)

Overall considerations

What determines evidence-based care? What outcomes should we expect? Who can provide the evidence-based care? Challenges with research in primary care

Questions

Jeffrey L. Goodie, LCDR, USPHS Uniformed Services University(301) 295-9461 jgoodie@usuhs.mil

H E L E N L . C O O N S, P H . D . , A B P PP R E S I D E N T A N D C L I N I C A L D I R E C T O R

W O M E N ’ S M E N TA L H E A LT H A S S O C I AT E SP H I L A D E L P H I A , PA 1 9 1 0 3

Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and

Psychosocial Outcomes

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #October __, 20110:00 AM

Faculty Disclosure

I have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

What is the scientific basis for this talk?

The presentation provides examples of evidenced based care in collaborative obstetrics and

gynecology and oncology settings to improve physical and psychosocial outcomes. Research on

depression in women; preparing them for diagnostic and treatment procedures; and the

important benefits of exercise will be translated.

Objectives

1)List research based interventions to assess and treat depression in women in collaborative ob/gyn and oncology settings.

2)Summarize evidenced based rational for preparing women for diagnostic and treatment procedures in collaborative ob/gyn and oncology settings.

3)Translate research on aerobic exercise to improve outcomes in collaborative ob/gyn and oncology settings.

Expected Outcome

What do you plan for this talk to change in the participant’s practice?

1)Increased focus on applying evidenced based interventions in collaborative primary care (i.e., ob/gyn) and oncology settings.

2)Increased application of gender specific research to improve outcomes in collaborative ob/gyn and oncology settings.

Learning Assessment

A learning assessment is required for CE credit.

1) Providing evidenced based care can improve health and psychosocial outcomes?

2) Actively preparing women for medical procedures in collaborative ob/gyn and oncology settings can improve health and psychological outcomes?

3) List the improved physical, psychological and cognitive outcomes associated with aerobic exercise in ob/gyn and oncology settings?

Women’s Health and Mental HealthImproving Outcomes Using EBP

Collaborative/Integrated Health Care Settings Primary Care Settings (IOM)

Internal and Family Medicine Geriatric Medicine

Pediatrics Adolescent Medicine

Obstetrics and Gynecology

Specialty Care Settings Oncology Surgery Cardiology Neurology Endocrinology PMR Other

Evidenced Based Care In Ob/Gyn and Oncology Settings

Clinical Research Depression in Women Preparing for Dx and Tx Procedures Exercise

Assessment Treatment Prevention

Patient and family Health Care System

Quality of life, loss of hope, resilience

Functioning (days of disability, quality of work)

Poor self-care Adherence to treatment

recommendations Risk/Co-morbidity for other

health conditions Obesity Cardiovascular disease Pain Medications

Impact on children and other relationships

Health care system Increased Utilization

Only 50% of adults with depression are getting treatment from a health professional

Less than half (47%) of adults who get treatment receive minimally adequate care

WHO Report (1996), JAMA (2003)

Costs of Depression

General Factors Specific

Depression rates in women

TraumaCaregiver issuesChronic stressSleep deprivationInadequate supportSES

Pregnancy Related Depression Anxiety Loss in any trimester Infertility Complications

Gyn chronic conditions Pelvic ICS Vulvar diseases

Depression in Ob/Gyn Settings

Women with Depression in Ob/Gyn Settings

Inadequate care Not evidence based/informed Partial symptom reduction without full resolution of depression Failure to address underlying issues

Misdiagnosis of medical disorder Medication complications Gender issues in etiology, assessment, treatment or prevention strategies Poor sleep quantity and quality Cognitive style Trauma history

Failure to minimize risk for relapse or prevention patient future generations

Active Application of Cognitive Treatment

Reduce and then resolve depressive symptomatology and anxiety

Markedly improve sleepCalmer, more intentional response to host of

issues with less catastrophizing, over-personalization, etc.

Earlier recognition when negative or ruminative cognitive style is present

More aware of how cognitive style impacts children

Specific strategies to reduce risk recurrent depression

Improve over-all well-being for the long haul

Evidenced Base Care in Oncology

Breast Cancer One in 8 life time risk Second most common cause of cancer death after lung cancer Over 192,370 new cases dx annually in the USA 40,610 women die annually in USA Long term survival rate for early breast cancer has improved with new

therapies – especially in younger women Prevalence rate is 2,533, 193 – survivors! Chronic disease model focused in enhancing quality of well-being and

reducing impact of late effects of cancer and its treatment

ACS 2010 FACTS AND FIGURES

Depression in Women with Breast Cancer

Women highly resilientDepression rates roughly 20% to 25%CBTMedications

Tamoxifen metabolism and antidepressants

• Jin et al (2005) J Natl Cancer Inst.

Preparing Women for Diagnostic and Treatment Procedures in Collaborative Medical Settings

Preparing women for initial and late issues Physical Cognitive Emotional Sexual Relationships Employment and professional Genetic risk across family Health and life insurance

Preparing women for challenges across disease course Different trimesters Disease recurrence Advanced and end-stage disease

Potentially Difficult Exams/Procedures in Ob/Gyn Settings

Breast exam Gyn procedures

Pelvic exam Pelvic ultrasound Colposcopy Endometrial biopsy HSG Hysteroscopy IVF procedures Dx. laps

Cystoscopy/Urodyamics GI procedures

Abdominal exam Rectal exam Endoscopy Colonoscopy

Venipunctures Anesthesia Oral or dental exam Childbirth: Vaginal or C-

section Any type of biopsy and

surgery Hysterectomy Sterotatic core biopsy/needle loc Sentinel node biopsy Lumpectomy Mastectomy Reconstructive surgery Breast reduction Cancer surgery – colon/pelvic ext.

Chemotherapy and Radiation

MRI, Cat Scan, etc. Cardiac procedures

Preparing Women for Breast Cancer Medical Procedures

Diagnostic Mammograms MRI Ultrasound guided core biopsies Stereotactic core biopsies Needle localizations Dye Injection for Sentinel Node Biopsy

Surgical Lumpectomy Mastectomy Reconstruction – several types

Treatment Chemotherapy Radiation Hormonal

Palliative Chemotherapy Shunt Nerve blocks

Preventive Mastectomies TAB, LAVH with BSO

Actively Use Evidenced Based Practice to Prepare Women for Procedures

o Provide accurate information about cancer and its treatments

o Assess patients/families fears and hopeso Facilitate decision making about procedureso Ask important questions, get second opinionso Make decisions they will trust and not regreto Mobilize informational, practical, social, and esteem

supporto Help to pace the patiento Decrease pain, bracing, and physiological reactivityo Reduce anxiety and fatigueo Increase feelings of self-efficacy, control and quality of lifeo Encourage patients to be active participants in their

recovery and healingo Impact time to recurrence and survival?

General Ob/Gyn and Oncology

Improves self esteem with sense of accomplishment

Improve body image Improved cardiovascular fitness Reduce muscle discomfort Increase strength, flexibility, coordination Decreased risk for diabetes Weight control Weight bearing exercise to build bone and

joint strength Reduced risks for falls Improve sleep Reduce hot flashes Reduce depression and anxiety Helps with cognitive functioning Improves sexual energy Improves intimate relationships Improved Quality of Life Improve immune function Improves post-surgical healing

Ob/gyn Sleep Perinatal anxiety and depression Improved pregnancy outcomes Post partum anxiety, depression,

energy, wt management, body image

Oncology Manage treatment side effects Increase energy, stamina Lymphedema symptoms Reduced risk of recurrence in ER+

breast cancers or general mortality

Benefits of Regular Exercise in Ob/Gyn and Oncology

EBC in Women’s Primary Care and Oncology

Improve health outcomesImprove mental health outcomesWomen’s well being!

Feel free to contact us

Barbara Walkerbarbara.walker@ucdenver.edu

Jeffrey L. Goodiejgoodie@usuhs.mil

Helen L. Coonshcoons@verizon.net

Session EvaluationPlease complete and return the

evaluation form to the classroom monitor before leaving this session.

Thank you!