Evidence-based practice
description
Transcript of Evidence-based practice
A marriage made in heavenEvidence-based practice
Sue Jenkins APA Conference 2013
Outline
EBP What it is, what it isn’t and why do we need it?
Physiotherapy evidence
Impact of research on clinical practice
Barriers to the uptake of evidence
My journey into EBP
Strategies for implementing EBP
New moves – Journal of Physiotherapy
EBP – what it is
Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sackett 2000)
EBP – what it isn’t
It is NOT
Cookbook physiotherapy
Mindless application of research findings
Entirely based on RCTs and systematic reviews
Too time-consuming
EBP – why do we need it?
Informed decisions about healthcare in order to make the best use of resources
National Health Reform Agreement (2011) Activity Based Funding
Physiotherapy in Australia
Accreditation of entry-level physiotherapy programs Universities must provide evidence that graduates
can apply an evidence-based approach to their own practice
Australian Standards for Physiotherapy Physiotherapy in Australia uses an evidence-based
clinical reasoning process
Physiotherapy evidence
PEDro
>25,000 randomised trials, systematic reviews and clinical practice guidelines
Absence of evidence ≠ evidence of absence (Altman & Bland 1995)
Physiotherapists’ perceptions of the importance of research
Survey of 355 physiotherapists
171 participants (51% response rate)
Predictors of perceived importance of research Previous research experience Being positive about undertaking further research Postgraduate Degree Working in hospitals
(Grimmer-Somers et al 2007)
Impact of research on clinical practice
Respiratory physiotherapy following cardiac surgery
Cardiac surgery: randomised trials
No effect on important patient outcomes
Addition of DBE or IS to regimen of ambulation + cough (CABG surgery, UK, Jenkins et al 1989)
DBE + cough vs. control (ambulation by nursing staff) (CABG surgery, Australia, Stiller et al 1994)
Removal of DBE from pre-op education + early post-op mobilisation (Cardiac surgery, Australia, Brasher et al 2003)
Did the research influence clinical practice?
Mx of patients post-CABG 19951 20102
Cardiothoracic units (Aus / NZ)
Clinical pathway
35 units 53 units
91% units
DBE or cough routinely used 89% patients 77% patients
IS routinely used 65% patients 40% patients
Factors influencing Rx
Personal experience
Literature
91%
63%
87%
75%
Why not?
17 year lag for uptake of research findings (Morris et al 2011)
(1Tucker et al 1995, 2Filbay et al 2012)
Barriers to the implementation of EBP
Barriers to the implementation
of EBP in healthcare
Awareness
Motivation
PracticalitiesAcceptance and beliefs
Skills
Knowledge
Barriers to EBP in physiotherapy
Unaware of what needs to change
Institution Funding / time Lack of authority /
support Other healthcare
professionals
Published research Volume / time / skills to
appraise Doesn’t ask the right
questions Statistical vs. meaningful Conflicting results Implications unclear
(Fruth et al 2010, Iles & Davidson 2006, Jette et al 2003)
Criticisms of RCTs & systematic reviews
External validity
Single intervention vs. treatment package
Real people are ‘unique’
How the ‘average’ patient might respond or likely outcome for a group of patients
n of 1 trials!
Systematic reviews – strong conclusion often lacking
Recruitment to RCTs%
pa
tient
s re
cru
ited
PAH – pulmonary arterial hypertension, *ongoing trial, (#Calverley et al 2007)
*
#
My journey into EBP
1991 – King’s College London 1992 – Curtin University
Journey cont’d
1992-97 – F/T academic
1997 – sought P/T clinical work
Area with strong evidence (pulmonary rehabilitation)
Patient-centred outcomes
Research opportunities
Team of 3 physios (Nola Cecins, Jackie Frankel)
Approached teaching hospitals – 0.3 FTE appt at Sir Charles Gairdner Hospital
1998 – clinical and research placement (UK)
Pulmonary rehabilitation
Symptomatic patients with chronic respiratory disease Improve physical and psychological condition Promote long-term adherence to health-enhancing
behaviours
Components: assessment, exercise training*, education, behaviour change
Exercise training – LL endurance training
(Nici et al 2006)
Outcome-based program
8 week program – exercise + education
Assessment – validated tools, developed highly standardised protocols (6MWT)
Ex training – developed prescription for high intensity LL endurance training
Education ‘Lectures’ by MDT Evaluated Lorig self-mx program (Cecins & Jenkins 2001)
Informal education sessions
Charlie's Easy Breathers
Evaluation of program
Justify ongoing funding
Outcomes (Jenkins et al 2001)
Exercise capacity HRQoL Patient satisfaction Benchmark with international data Healthcare utilisation
Program costs
Process evaluation
Gradual increase in staff to 0.8 FTE
Charlie's Easy Breathers
Program database
Report on program outcomes
Generate research questions
Output 24 conference abstracts 7 papers Pilot data – research, grant applications
Comparison of program outcomes with international data
Patients with COPD Jenkins & Cecins Puhan 2008*
Number of patients 150 460
Males 68% 71%
Age (yrs) 67±9 69±8
Lung function (%pred) 38±14 39±14
Baseline 6MWD (m) 424±110 361±112
Improvement in 6MWD (> MID) 63% 51%
Improvement in HRQoL (> MID) 69% 60%
mean ± SD, MID – minimal important difference *Data from 9 trials - North America, Europe
Outcomes – healthcare utilisation
Hospitalisations for acute exacerbations of COPD 12 mths pre-rehab vs. 12 mths post-rehab
RCT (200 patients) (Griffiths et al 2000)
Decrease of 4 bed days per patient rehabilitated
Our program (256 patients) (Cecins et al 2008)
46%* decrease in number of patients admitted 62%* decrease in total bed days
*p<0.001
Process evaluation – unmet needs
Process evaluation (Cockram et al 2006)
15% patients unable to attend out-patient program
2002 – supervised home-based program
Benefits of pulmonary rehab last 6-12 mths (Nici et al 2006)
1998 – maintenance classes in non-medical facilities (Community Physiotherapy Services)
Maintained gains in 6MWD and HRQoL, reduction inHCU sustained (Cockram et al 2006, Cecins et al 2013)
Pulmonary rehabilitation and EBP =
A marriage made in heaven
Unlike this one!
Overcoming barriers to the implementation of EBP
“Change is not made without inconvenience, even from worse to better” Richard Hooker 1554-1600
Strategies/drivers for implementing EBP
The expert patient
Clinician-led research
NHMRC TRIP Fellowships
Clinicians
Evidence-based clinical pathways
Clinical guidelines / consensus statements
Support from managers, academics
Mentorship - QI, clinical audits, research
Education University courses PD, EBP sessions Journal clubs Professional
associations
Clinical guidelines – stroke rehabilitation
Adherence with recommended management and outcomes (D/C home, increase ≥22 pts FIM score)
(Australian Guidelines for Stroke Rehabilitation & Recovery, 2005)
National audit – 63% response rate
68 units – 2,119 patient cases
Adherence – 13 to 94%
Improved outcomes when practice adhered to recommendations relating to ADL, balance and home Ax
(Hubbard et al 2012)
FIM – Functional Independence Measure
Journal of Physiotherapy
Clinical trials – prospective registration (2012)
Trial protocols (2013)
Systematic reviews High quality, firm conclusions, important clinical
implications Co-publication of condensed Cochrane Reviews
Commentaries – critically appraised papers, clinical guidelines, clinimetrics
Importance of EBP in the future
More competition for scare healthcare $$$$$$
Need robust evidence to sustain our profession
Physiotherapists as leaders among healthcare professions in translating research into clinical practice
Acknowledgements
Nola Cecins
Jeffrey Tapper & Ian Cooper, Physiotherapy Department, Sir Charles Gairdner Hospital
Research colleagues and students
Patients
Dr Kathy Stiller
Thank you for your attention
Sue JenkinsGradDipPhys, PhD Associate Professor & Pulmonary Rehabilitation PhysiotherapistSchool of Physiotherapy and Exercise ScienceEmail | [email protected] | +61 8 9266 3639
Citations for imagesSlide 4http://www.cancer-clinical-trials.com/p/clinical-trials-in-cartoons.html#.UljzXODcK5
. [accessed 11.10.2013]Slide 10http://www.universityhospital.kramesonline.com.253151.img. [accessed
10.10.2013]Slide 13
http://www.graphics8.nytimes.com/images/2012/08/08/sports/HURDLES2/HURDLES2-article.jpg[accessed 10.10.2013]
Slide 18 http://www.abc.net.au/news/image/4892924-16x9-940x529.jpg. [accessed
10.10.2013] Slide 23 http://www.lungfoundation.com.au/wp-content/uploads/2012/06/COPDPatientGuide2012_chapt_10
. [accessed 10.10.2013] Slide 27http://www.resources2.news.com.au/images/2011/10/12/1226164/643242.jpg.
[accessed 10.10.2013]
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