ACBO Introduction to EBP

Introduction to evidence-based practiceDr Kirsten Challinor

https://research.unsw.edu.au/people/dr-kirsten-louise-challinor

https://www.eboptometry.com/

https://www.facebook.com/evidencebasedoptometry

https://twitter.com/EBPoptometry

Hello and welcome to the Introduction to EBP for BO. My name is Kirsten Challinor and I have an undergraduate degree in psychology from Macquarie University and a PhD in Visual Perception. I worked as a post Doctoral researcher in the UK for 5 years, first at Aston University in Birmingham and also at the University of Sussex, Brighton.My main area of research interest is in Motion Perception- that is, understanding how the human visual system processes moving items. Since 2011 I have been enjoying lecturing Optometry students at UNSW. I recently managed a large Australasian project concerned with improving evidence-based practice in Optometry graduates. I also am currently involved in 2 separate projects in the Department of Medicine here at UNSW, one project in particular is developing Online training programmes for the clinical supervisors of Medical students. I hope you really enjoy the EBP module. Chat to you soon.1

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Have you ever....

....wondered if there is a better way of assessing or treating a patient? ....had a conversation with a colleague about a technique and wanted to know if it would work?....heard a news story and questioned if the information would apply to your practice? ....been asked a question about a treatment or condition you have not heard of before?

Evidence-based Practice helps you answer these questions and more.

Optometrists, like other health professions, have a desire and clinical responsibility to help their patients see effectively and be as healthy as possible.

EBP offers a framework for deciding which course of clinical action may be most appropriate for any given patient. It is difficult to have the answer to every clinical question, particularly as patients vary. Instead, having the EBP knowledge and skills allows you answer your own individual questions - for your particular patient.

EBP should improve your practice and result in better outcomes for your patient. EBP is well-adopted by other health professions, for example medicine, speech pathology, psychology and nursing.

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Evidence based practice4

You as anEBPpractitioner (Hoffman, 2010)

EBP is the combination of the best available evidence from research, the patients preferences/circumstances, the clinical environment and the practitioners expertise.

4EBP is the combination of the best available evidence from research, the patients preferences/circumstances, the clinical environment and the practitioners expertise.EBP is also sometimes described as clinical decision making.

When we refer to evidence in the context of EBP, we are talking about the research evidence, in an ideal situation this would be the information provided by randomised controlled trials, for example.While we talk about evidence-based practice, research evidence is not, of course, the only factor to consider in clinical decision-making.We also need to consider our patients preferences and our clinical expertise. The patients values and expectations may depend on many factors such as: finances, time, abilities, habits, external pressures and prior experience.Clinical expertise consists of our own experience, knowledge and skills relevant to the clinical situation. For example, our understanding of ocular physiology and of conditions such as glaucoma, diabetes or amblyopia.As the figure here shows, the factors we use in EBP all overlap and are combined to form the basis of evidence-based practice.

Best external evidenceExternal evidence is derived from a range of sources.The best evidence is the highest quality evidence available.Sometimes we have to use lower level evidence, but when doing so we remain conscious of the fact that the evidence is questionable.

External evidence is derived from a range of sources e.g. beginning with weaker study designs such as Single Case Report/Case Series/ case control studies/ cohort studies and the most trusted study design being Randomised Controlled Double-Blind Clinical Trial.

The best evidence is the highest quality evidence available, and this is usually in the form of the findings of good quality clinically relevant research such as randomised controlled studies.

However, the word best is important here; there may or may not be high quality evidence to apply to all of our clinical questions. Sometimes we have to use lower level evidence, but when doing so we remain conscious of the fact that the evidence is questionable. We must be aware in our clinical decision making that we are using a weak form of evidence.

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Pyramid of Evidence

Go to this site and click on each of the triangle segments:https://www.eboptometry.com/content/medical-optometry/step-2-acquire/practitioners-students-teachers/step-2-acquireBased on Haynes B (2006)

Further information about the sources of evidence can be found in the pyramid of Evidence, which is a visual representation of various sources of evidence. For more detail head to the website shown and click on each of the triangle segments:

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Clinical ExpertiseThe knowledge and skills of the practitioner who has studied their area of expertise and has gained experience in that area.

Reflects undergraduate and postgraduate education, continuing education, discussions with colleagues, and experience in practice.

Evidence-based practice is not only about using research findings. It also uses clinical expertise.Clinical expertise is the knowledge and skills of the practitioner who has studied their area of expertise and has gained experience in that area.Clinical expertise reflects undergraduate and postgraduate education, continuing education, discussions with colleagues, and experience in practice.

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Patients Values and Expectations The patient may have limited time or money and may be unable or unwilling to commit to a proposed treatment method.The patient may not want to undertake the protocol for other reasons related to appearance, habit or beliefs.

Clinical decision-making needs to take into account the preferences and circumstances of the patient.The patient may have limited time or money and may be unable or unwilling to commit to a proposed treatment method.The patient may not want to undertake the protocol for other reasons related to appearance, habit or beliefs.

In addition to all of this, the clinical decision must be made in the context of the environment youre working within. You must consider the appropriateness the decision within the constraints of your practice. I saw in your introductions to this course that many of you run your own practices, so Im sure that you have an good idea about this element of EBP.

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EBP is NOT

9(Dawes, 2005) http://www.biomedcentral.com/1472-6920/5/1Focused only on RCTs.Cookbook medicine.Interested only in cost effectiveness.Intended to dictate treatments to clinicians.

An invalid criticism of evidence-based practice is that it is focused solely on external research evidence. This is incorrect, because as I have just shown you the application of EBP involves not only considering the external evidence, but combining it with your expertise, and the patient and context. It is important to weight each component equally. For example there is no point in using the best evidence if patient is unwilling, and likewise there is no point recommending a treatment that has no supporting evidence as the effect may simply be a placebo or a short term effect.

A common misconception is that evidence-based practice consists solely of critically appraise research papers. A group of experts from a diverse set of allied health professions got together in 2005 to clarify this common misconception is that evidence-based practice consists solely of critically appraise research papers.Their goal was to further define the process of evidence-based practice. The background image on this slide is of the very beautiful seaside town in Sicily, Taormina, near the Volcano, Mt Etna where the group meet.This meeting led to the production of the Sicily statement which calls for better understanding, recognition and training in EBP for health professionals. Despite this, the translation of research knowledge into practice remains a challenge for all health professions including optometry. As you can see much of the criticism targeting EBP is due to a lack of understanding regarding the real meaning or and process of EBP.

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10 The 5 step process of EBP(Dawes, 2005)

The output of that meeting described the 5 steps of learning the process of EBP.

1. The first step involves translating an uncertainty into an answerable question. That question might for example be about the best treatment for a particular condition or the best method to use in diagnosing a particular disease. 2. Once that question if formulated, the second step involves searching for the information , not any information but the best evidence available.This involves designing and conducting a thorough search strategy to answer the question that was formulated. 3. The third step involves reading and critically appraising the information for validity, clinical relevance and applicability. Did for example the authors choose an appropriate way to design their research in order to answer the question they say they are trying to answer. Did they use the right sort of testing, right patients, right stats, did they draw correct conclusions, etc. 4.The next step involves applying the results of the evidence. That means looking at your individual patients characteristics and trying to marry that with the information contained in the scientific literature5. Audit the process.

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Some example Optometry Research QuestionsCan nutritional supplements prevent dry eye symptoms in contact lens wear?Does flax seed oil improve ocular comfort in dry eye patients?What complications arise post-LASIK surgery in myopic Asians?Which contact lens solutions are most likely to induce corneal staining?

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So now let us look at each of the steps. At the first step of the EBP process, we frame a question.We would like to formulate an answerable question.

Question or TopicWhat is the effectiveness of Betadine treatment for adenoviral conjunctivitis?What is the effectiveness of punctal occlusion vs lubricant drops for dry eye?What is the effectiveness of occlusion vs Atropine treatment for amblyopia?What is the effectiveness of oral tetracycline with topical prednisolone for young males with recurrent corneal erosion?What is the effectiveness of antioxidant supplements for ARMD?Does patient education on CL complications improve CL care compliance?What is the effectiveness of full- vs part-time occlusion in amblyopia treatment?Can nutritional supplements prevent dry eye symptoms in contact lens wear?Does collagen cross-linking slow progression of keratoconus?What is the effectiveness of convergence exercises in the treatment of convergence insufficiency?Is fundus photography a sensitive method of diabetic retinopathy screening?Is prophylactic peripheral iridotomy effective in the prevention of angle closure glaucoma?What is the effectiveness of tea tree oil in the treatment of demodex?Does flax seed oil improve ocular comfort in dry eye patients?What complications arise post-LASIK surgery in myopic Asians?Which contact lens solutions are most likely to induce corneal staining? Is corneal ectasia most likely to occur in LASIK or PRK surgery for myopia?11

Ask

The PICO strategy was developed to support this part of the process by providing triggers for the identification of terms, as follows:P: Person, Patient, Population or Problem I: Intervention C: Comparison O: Outcome.

Does full-vs part-time occlusion in amblyopia (lazy eye) treatment result in letter acuity improvement?

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The PICO strategy was developed to support this part of the process by providing triggers for the identification of terms as follows

P: Person, Patient, Population or Problem. This term identifies the type of patient (e.g. gender, age group, race) and the clinical problem (e.g. condition, disease) faced.

I: Intervention. This is a more straightforward term, identifying the intervention of interest. However, this term is only relevant to questions related to intervention of some kind, such as therapeutics, lenses or referral for surgery.

C: Comparison. This term applies when the clinical question will ask about one intervention, or perhaps one diagnostic strategy, versus another. When the practitioner is interested in such a comparison, the two interventions/strategies are names as an Intervention and a Comparison.

O: Outcome. The question will refer to an outcome measure or indicator of some kind, such as visual acuity or myopia progression, and this is specified as the Outcome term.

PICO was developed for clinical scenarios in which intervention is being considered, so not all of the above four terms apply to questions that are not directly related to intervention.

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AcquireSearching for research evidenceFiltering the available evidenceSources research evidence to address clinical questionsThe pyramid of evidence

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Lets now look at the aqcuire process and how we go about sourcing the best evidence and filtering what we find.13

Searching for Research Evidence14KeywordSynonym PFlight passengerortravellerandIcompression stockings orandCno compression stockingsorandOdeep vein thrombosisorDVT

Does wearing compression stockings (compared to not wearing them) prevent DVT in passengers on long-haul flights?

Searching for Research Evidence: involves identifying terms to fit the PICO question. These search terms can be entered into a relevant database. Learning how to search the database is a skill in itself.

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https://scholar.google.com.au

https://www.tripdatabase.com

Google scholar is a very useful free search tool.Also very helpful is the Trip database because you can enter your PICO directly and also it help you filter the results according to the pyramid of evidence which we will talk about next. It is worth taking to 2mins to do the free sign up. 15

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Filtering the Available EvidenceWe must filter out the lower quality research evidence and obtain full articles describing the best quality available research evidence.To do this we consider:Currency is the Abstract recent? Relevance does the Abstract describe work that is directly relevant to your question? Quality is this evidence reliable?Tags and limiters. 17

Filtering the Available Evidence: Once the search has been completed, we may have several pieces of secondary and/or primary research evidence. We must filter out the lower quality research evidence and obtain full articles describing the best quality available research evidence.To do this we consider: Currency is the Abstract recent? Relevance does the Abstract describe work that is directly relevant to your question? Quality is this evidence reliable?

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Examples of Tags and LimitersMeSH (Medical Subject Heading)Title word PublicationTitleLanguage KeywordAuthorJournal titleLimit by:-Human-Adult-English-Publication type-Study design

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Here are some examples of how you may filter the results you acquire.18

A visual representation of various sources of evidence: pyramid of Evidence

Go to this site and click on each of the triangle segments:https://www.eboptometry.com/content/medical-optometry/step-2-acquire/practitioners-students-teachers/step-2-acquireBased on Haynes B (2006)

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Pyramid of evidence

Based on Haynes B (2006)

Secondary sources

Primary sources

For further info go to eboptometry site: https://www.eboptometry.com/content/medical-optometry/step-2-acquire/practitioners-students-teachers/step-2-acquire

Here we have a visual representation of various sources of evidence in the pyramid of Evidence.A useful way to think about sources of evidence is to classify sources into primary and secondary sources of evidence.

Primaryresearch evidence is found injournal articles publishing original research.

Secondary sources of evidence have been pre-apprised and synthetised for you by someone else and are higher up on the pyramid of evidence. They include CATS, Guidelines, Synopses and syntheses. It also includes including systematic reviews of randomized controlled trials, such as Cochrane reviews, which are valuable to busy practitioners because they address particular clinical questions.

At the top of the pyramid we have Clinical Decision Support Systems are electronic systems which provide a link between the clinical question (patient characteristics and problem) and evidence-based guidelines for care and management. Such systems are available in ophthalmology, but not Optometry.---------------------1Systems. Clinical Decision Support Systems are electronic systems which provide a link between the clinical question (patient characteristics and problem) and evidence-based guidelines for care and management. Such systems are available in ophthalmology (e.g. http://www.careemr.com/ophthalmology-emr.html) and in a range of other health care areas. CDSSs have been systematically reviewed with the aim of determining whether they improve the quality of decision making and patient care (e.g. http://jama.jamanetwork.com/article.aspx?articleid=200503). To date, it is not clear whether these systems are effective (e.g. http://www.ncbi.nlm.nih.gov/pubmed/22529043). They appear at the top of the 5S pyramid, but since there are no CDSSs available for optometry, and their effectiveness remains questionable, we should start looking for evidence at the next step on this pyramid. A useful to think about sources of evidence is to classify sources into primary and secondary sources of evidence. Secondary sources of evidence have been pre-apprised and synthetised for you by someone else and are higher up on the pyramid of evidence. They include CATS, Guidelines, Synopses and syntheses.20

Summaries: Evidence-based clinical guidelines.

2Summaries. Summaries of clinically relevant evidence can be thought of as online books that are updated regularly.

---------------------These include evidence-based clinical guidelines which are updated periodically. For example, the Canadian Ophthalmological Society provides guidelines on a range of clinical topics with relevance to ophthalmologists and optometrists http://www.eyesite.ca/english/program-and-services/policy-statements-guidelines/index.htm As well as guidelines, summaries may provide evidence-based answers to specific clinical questions. Evidence-based clinical guidelines are available for optometry specifically for therapeutic prescribers (UK College of Optometrists). 21

Summaries: Evidence-based clinical guidelines

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/di15.pdf

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp113_glaucoma_120404.pdf

Some other examples of summeries are these two sets of guidelines which are sponsored, published and updated by the Australian Government for use by health practitioners including optometrists. These provide valuable support for EBP in optometry, but dont replace the EBP process.22

American Optometric Associationwww.aoa.org

American Academy of Ophthalmologyhttp://one.aao.org/CE/PracticeGuidelines/PPP.aspx

Synopses: Databases providing abstracts of research relevant to clinic.

3 Synopses. Synopses are databases providing abstracts of research relevant to clinic. The abstracts are based on critical appraisal of the research, so the research has been reviewed, and the practitioner does not need to undertake this task.

-----------------For example, Evidence-based Medicine (http://ebm.bmj.com/) is an online journal which publishes synopses of high quality research relevant to clinical medicine. The journal sources the research by systematic search of the literature and peer review to check internal validity. Evidence-based Ophthalmology (http://journals.lww.com/evidence-based-ophthalmology/pages/default.aspx) operated in a similar way, and would include synopses of relevance to optometrists, but that journal closed in October 2011. There is currently no equivalent source of synopses available and applicable to optometrists. 24

www.thecochranelibrary.com or through UNSW library databases, EBM reviews

4Syntheses. Syntheses are systematic reviews of the literature on a particular clinical question. These include Cochrane reviews (http://www.cochrane.org/) and in particular reviews by the Cochrane Eyes and Vision Group (http://eyes.cochrane.org/). That group has produced reviews on questions relevant to treatment of glaucoma and amblyopia, for example, with direct relevance to clinical optometry. 25

Pyramid of evidence

Based on Haynes B (2006)

Secondary sources

Primary sources

5Individual studies. At this base level of the pyramid, we find all of the research that is available in the literature. To find evidence at this level, the practitioner needs to search databases such as Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) or Google Scholar (http://scholar.google.com.au/). The evidence here is not pre-appraised or filtered, except by the peer review system embedded in most publications, so the practitioner needs to spend considerable time and employ skills to select appropriately from the large pool of research and appraise the selected evidence.

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Source: UNSW Medicine online Tutorials

Individual studies themselves can also be classified into levels of evidence based on their study design as seen here.

---------------with Single Case Report and Case Series at the bottom of the pyramid followed by case control studies, cohort studies and the most trusted study design being Randomised Controlled Double-Blind Clinical Trial.Finally, although some experts might sometime seem to sit on top of the pyramid, information derived from expert opinion, lab studies or animal research sits at the bottom of the pyramid of evidence.27

AppraiseCritical appraisal is the process of assessing and interpreting evidence by systematically considering its validity and its relevance to the question. Internal validity: the extent to which the research is reliable. External validity: is an indication of the generalisability of the findings. 28

Once youve asked your question, acquired some evidenced and filtered the results, you will need to evaluate whether the evidence is any good.Apprasial is by far the biggest step of EBP. This lecture is an introduction to EBP, so Ill do my best to introduce the topic, but really learning how to appraise is a long and ongoing experience.

Critical appraisal is the process of assessing and interpreting evidence by systematically considering its internal and external validity and its relevance to the question. Internal validity is the extent to which the research is reliable; flaws and confounding factors in the methodology or the interpretation of results would reduce internal validity

External validity is an indication of the generalisability of the findings. A study with high external validity would have findings that are likely to apply to populations other than those involved in the study.

http://www.eboptometry.unsw.edu.au/content/optometry/step-3-appraise/practitioners-students-teachers/step-3-appraise

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QuestionsYesNoWere subjects randomized?The study is not likely to be biased by subject grouping. Subject allocation may cause bias.Was there a control? Is the control group within this study, or historical? There is unlikely to be a placebo effect in the treatment group. We can be less sure of this, though, if the control group data are taken from a previous study. Subjects were in therapy, but there is no comparison with those not in therapy, so we cannot know to what extent any treatment effect is due to the treatment.Is the population clinically relevant for my application?Findings may be population-specific.The findings may apply to one population but not to the population in which the therapy is to be applied.Is attrition (reduction in numbers) described?If attrition rate is low, the findings are not confounded by this factor.We do not know the results in subjects who withdraw from the study.Were experimenters and subjects blind in this trial?The findings are not biased by expectation of outcomes.The experimenters and the subjects may have unintentionally or otherwise affected the outcome.Are the subject groups comparable?The subject groups were equal at baseline, so are likely to have been similarly affected.Outcomes in the groups may differ due to factors other than the treatment.Was subject treatment equal across groups, apart from the therapy?The subject groups were equal in all respects apart from the therapy.Outcomes in the groups may differ due to factors other than the treatment.Are the results both clinically and statistically significant?The results are clinically relevant.Results may be statistically significant, but have no clinical significance. They may not be statistically significant, in which case there is no effect.

Here we have a example critical appraisal tool. It is table created by Dr Catherine Suttle that provides a simplified guideline on appraisalIn order to learn the steps in this appraisal table, we need to get our heads around the research process and stats.

There are many critical appraisal tools availible29

Glossary for CA worksheetAttrition: A gradual, natural reduction in membership or personnel.Bias: a systematic as opposed to a random distortion of a statistic as a result of sampling procedure.Blinding/masking: the participants, investigators and/or assessors remain ignorant concerning the treatments which participants are receiving. The aim is to minimise observer bias, in which the assessor, the person making a measurement, have a prior interest or belief that one treatment is better than another, and therefore scores one better than another just because of that. In a single blind study it is may be the participants who are are blind to their allocations, or those who are making measurements of interest, the assessors. In a double blind study, at a minimum both participants and assessors are blind to their allocations.Clinical significance: the practical importance of a treatment effect - whether it has a real genuine, palpable, noticeable effect on daily lifeControl group: (in an experiment or clinical trial) a group of subjects closely resembling the treatment group in many demographic variables but not receiving the active medication or factor under study and thereby serving as a comparison group when treatment results are evaluated.Randomised/randomized: set up or distributed in a deliberately random way.Placebo a) a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine. b) a substance having no pharmacological effect but administered as a control in testing experimentally or clinically the efficacy of a biologically active preparation.30

Critical appraisal- further informationhttp://www.eboptometry.com/content/optometry/step-3-appraise/practitioners-students-teachers/step-3-appraise1) Determining study design and level of evidence:2) Critical appraisal of each paper - determining any bias that would affect the results.

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In your Activity task for this part of the module you will learn more about appraisal See the EBO website for further information on these two areas of appraisal.31

ApplyCombine research evidence with our own clinical expertise to answer the question in the context of the clinical environment and with consideration of the patients preferences. 32

At this stage in the EBP process, we have in our hands the best available research evidence that is relevant to the clinical question we formulated. We now combine research evidence with our own clinical expertise to answer the question in the context of the clinical environment and with consideration of the patients preferences.

This brings together all the elements of EBP as shown in the EBP diagram:Best available research evidence in EBP steps 2 (Acquire) and 3 (Appraise) the practitioner searches for the highest quality, highest level (most reliable) research evidence relevant to the clinical question at hand.Clinical expertise In this context, clinical expertise is the knowledge and experience of the practitioner, which may have been acquired from education at undergraduate or postgraduate level, reading, observation, clinical experience and other aspects of practice and training. This expertise overlaps to some extent with research evidence, since research often forms the basis of education and clinical practice, but clinical expertise is accumulated from various sources, not only research.Patients preference In EBP, the patient is part of the clinical decision-making process. The practitioner communicates with the patient to understand any circumstances, preferences or concerns that affect the extent to which the patient will be happy with the clinical decision and will comply (or be able to comply) with any recommended treatment. Clinical environment When EBP is applied, this is done in the context of the clinic or practice environment. There may or may not be facilities and attitudes that support EBP. For example, the practice might provide computers with internet access in each room so that practitioners are able to conduct searches of databases such as Cochrane quickly and easily. On the other hand, the practice might not have adopted EBP, and practitioners may not be encouraged to use the best available research evidence as a basis for clinical decision making.

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AuditAssess and adjust: evaluate your performance with this patient / the population and the outcomes of your intervention and adjust management accordingly.

In terms of the patient - practitioner relationship concerning the management of a condition, this would involve requesting the patient to return if problems persist, or to actively make a follow-up date for reviewal of the management planned.

Analysis of clinical decisions (e.g. referral or prescription) in types of patient cases, and this may be retrospective via clinic records, or prospective.

The final step in EBP is to examine whether clinical decision-making has followed the EBP steps and whether patients have followed advice.

Audit is an essential element of clinical practice - and is understood to be the basic practice cycle of presentation, investigation, decision, treatment and review.

More formally, audit involves an analysis of clinical decisions (e.g. referral or prescription) in types of patient cases, and this may be retrospective via clinic records, or prospective. Audit is a time consuming process, but an important one, since it can identify factors that are limiting EBP. The Australian Centre for Evidence-based Clinical Practice produced an online tool (the Auditmaker) to facilitate this process.

The audit process can identify gaps between the best available research evidence and actual practice, and this has been done by many studies

This audit process is intended to ensure that evidence-based practice is critically reviewed periodically, to ensure that it is taking place and to identify any impediments to its implementation.33

Definition & Process of EBP

In summary, in this lecture we have looked at the definition and also the process of EBP. In the PICO activity to do this week, you will yourself consider the first three steps of the process- Ask/Acquire and Appraise. Look on Open Learning PICO activity for the web links to do this task. Then head to the discussion board to chat to your classmates about this task.34

Thank you and Acknowledgement to:Dr Isabelle Jalbert &

Dr Catherine Suttle for content

Many thanks to Drs Jalbert and Suttle for help with content and especially thabnk you to you for listening to this lecture and I loo forward to interacting with you online.35