'From Vision to Reality – Transforming Scotland's Care of Women in Custody'
Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings
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Transcript of Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings
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 [email protected]
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 [email protected]
Jeffrey L. [email protected]
Helen L. [email protected]
Session EvaluationPlease complete and return the
evaluation form to the classroom monitor before leaving this session.
Thank you!