Ebp rh-july2011g
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Transcript of Ebp rh-july2011g
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: [email protected]