COMMENTARY

Evidence-based speech pathology: Barriers and benefits

ELIZABETH JANE ELLIOTT

University of Sydney and Children’s Hospital at Westmead, Sydney, Australia

Clinicians in my field—Child Health—not infre-

quently face the challenge of trying to change

behaviour, whether in a child with tantrums or sleep

disturbance, bed-wetting or attention deficit. The

challenge of behavioural change may be tackled

using a number of different approaches, including

cognitive behavioural therapy, medications, or re-

assurance. Regardless of the approach, changing

ingrained behaviour is rarely straightforward. Chan-

ging the behaviours and attitudes of clinicians is

equally complex and Sheena Reilly (this issue)

alludes to this in her article on ‘‘The challenges in

making speech pathology practice evidence based’’.

As she points out, a change to evidence-based

practice first requires speech pathologists to acknowl-

edge that anecdote, facts learnt at university,

information gleaned from the popular press, and

‘‘expert’’ opinion no longer suffice to guide clinical

practice. Once this principle is accepted, clinicians

must acquire the tools required to find, evaluate, and

use in their practice, the most up-to-date evidence

available from research (Craig, Irwig, & Stockler,

2001). As identified by Reilly, a failure to base

Speech Pathology practice on good evidence may

deny or delay appropriate treatment, waste ever-

shrinking health resources, and give patients false

hope. Conversely, evidence-based practice will make

speech pathologists more accountable to their

patients, their institution and the law. But even the

most committed clinician, with the evidence at her

fingertips, still faces significant barriers, such as those

outlined below, to implementing change in the

workplace.

The myth of evidence-based practice

Many clinicians claim their practice has always been

evidence-based, but the reality is different.

. Many clinicians are not familiar with the aims and

principles of evidence-based practice. Although

evidence-based medicine is currently part of

the core curriculum in some clinical fields,

many older practising clinicians have had no

formal exposure to the discipline. In a survey

of paediatric dietitians in Australia, 90% said

they strongly believed in the principles and

philosophy of evidence-based medicine (Tho-

mas, Kukuruzovic, Martino, Chauhan, &

Elliott, 2003). However, 73% said either they

did not practice evidence-based nutrition or

they rated themselves as beginners. Only 19%

had had any formal training in evidence-based

practice. Although nearly 30 journals on

speech or language therapy are listed in

PubMed, Reilly identified fewer than 20

articles combining the topics of ‘‘evidence-

based practice’’ and ‘‘speech pathology’’.

There is a clear need for educational opportu-

nities, including literature, specifically

illustrating the rationale for, benefits of, and

means to achieving evidence-based speech

pathology practice. The recently published text

Evidence Based Practice in Speech Pathology will

provide a valuable stimulus for clinicians to

question and justify their use of a range of

speech and language treatments (Reilly, Dou-

glas, & Oates, 2003).

. Variations exist between the quest for and use of

research evidence in clinical practice. Clinicians

frequently fail to identify the need for, or to

seek, information to treat their patients. For

example, General Practitioners estimated they

needed new information to manage their

patients about twice a week. However, when

observed in practice they actually needed

information up to 60 times in a week (Covell,

Uman, & Manning, 1985). Clinical knowledge

deteriorates over time, and in addition older

medical graduates are less likely to have an

evidence-based practice than their younger

colleagues (Moyer & Elliott, 2004). Similarly,

Correspondence: E. J. Elliott, University of Sydney Clinical School, c/o The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, 2145, NSW,

Australia. Tel: 61 2 9845 3448. Fax: 61 2 9845 3389. E-mail: elizabe2@chw.edu.au

Advances in Speech–Language Pathology, Vol. 6, No. 2, June 2004, pp. 127 – 130

ISSN 1441-7049 print/ISSN 1742-9528 online # The Speech Pathology Association of Australia Limited

Published by Taylor & Francis Ltd

DOI: 10.1080/14417040410001708567

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speech pathologists who have been practising

for more than 10 years are less likely to use

research findings to guide their practice than

more recent graduates (Vallino-Napoli &

Reilly, 2004). Despite having access to electro-

nic databases, as many as 18% of speech

pathologists surveyed in Australia had never

used information from a published journal

article in the management of an individual

patient (Vallino-Napoli & Reilly, 2004).

. The necessary evidence is not always available or of

high quality. It has been estimated that between

11 and 82% of treatment decisions in health

care are supported by findings from rando-

mized controlled trials—considered the best

study type to evaluate an intervention (Buchan,

2004). Furthermore, up to 25% of patients

receive treatments that are potentially harmful

or unnecessary (Buchan, Sewell, & Sweet,

2004). In the field of Speech Pathology, as in

many infant specialties, only a limited number

of therapies have been evaluated by rando-

mised controlled trial. We found only 5

completed systematic reviews and 2 protocols

for systematic reviews of interventions of

speech therapies in the Cochrane Database of

Systematic Reviews (Cochrane Library, 2004).

A lack of good evidence forces clinicians to use

the best available evidence (even if inade-

quately proven), and to acknowledge the need

for clinical research to increase the knowledge

base.

. Clinicians often lack the skills needed to find the

evidence they need. It is estimated that clinicians

generally retrieve only one quarter to a half of

the available papers on a topic (Hersh &

Hickham, 1998) and that even skilled librarians

may miss 30% of publications or more

(McKibbon & Walker-Dilks, 1995). Although

speech pathologists have access to the internet,

half of them don’t use the internet to access

electronic literature databases, suggesting they

may lack the confidence to do so (Vallino-

Napoli & Reilly, 2004).

. Clinicians may not have the requisite skills to

evaluate the quality and applicability of study

results to their clinical setting. Critical appraisal

of research requires knowledge of the criteria

used to evaluate different study types, whether

qualitative or quantitative (Guyatt & Rennie,

2001), and an understanding of the ways in

which results are represented. Not surprisingly,

some of the jargon used to report randomized

trials—allocation concealment, blinding, num-

ber needed to treat, and odds ratio—has a

tendency to alienate all but the most recent

graduates (Elliott & Kennedy, 2004). This was

confirmed in a survey of health professionals,

which included speech pathologists (Metcalfe

et al., 2001). Nearly 80% reported difficulty

understanding the statistics used in published

studies. Of interest, nearly 70% complained

that the clinical implications of studies were

rarely stated. This may simply reflect poor

reporting—a problem that is addressed by

some journal editors who request from authors

a list of ‘‘take-home messages.’’ Adoption of

the CONSORT guidelines, which standardize

the reporting of randomized controlled trials,

also makes trial results and methods more

accessible for readers (Moher, Schulz, & Alt-

man, 2001).

. The massive information overload in science

frequently overwhelms the clinician. Medline

currently lists over 12 million references from

more than 4600 medical journals—estimated

at only one third of the biomedical literature—

and as many as 526,430 new studies appear in

Medline every year (Ovid Medline, 2004).

CINAHL, a valuable source of articles on

speech pathology contains 5442 new citations

each year (CINAHL, 2004) and over 400,976

references are listed in the Cochrane Con-

trolled Trials Register (Cochrane Library,

2004). Even in a small specialty no clinician

can possibly read all the relevant literature.

. Even clinicians with the necessary skills rarely have

the time required to keep up to date. Lack of time

is cited as a major barrier to evidence-based

practice by speech pathologists, (Vallino-Na-

poli & Reilly, 2004), dietitians (Thomas et al.,

2003) and doctors (Scott, Heyworth, & Fair-

weather, 2000) alike. This is starkly illustrated

in a 2004 survey of Australian speech pathol-

ogists (Vallino-Napoli & Reilly, 2004). Fewer

than 20% spend 60 min or more each week

reading the relevant clinical literature and

nearly half read the literature for less than 30

min each week.

Overcoming the barriers

A number of recent developments have come part

way to addressing the challenges facing clinicians

striving for an evidence-based practice. These

include the proliferation of desktop PCs with

internet access to electronic literature databases;

educational opportunities (including undergraduate

curricula and web-based resources) for obtaining

the necessary skills; reference texts about evidence-

based speech pathology practice (Reilly et al.,

2003); and check-lists for critical appraisal (Guyatt

& Rennie, 2001). Education needs to be available

not only to undergraduates but to busy clinicians.

Increasingly, sources of pre-evaluated evidence are

becoming available (MacDonald, 2004). These

include sources of summarized or synthesized

evidence such as clinical practice guidelines and

Cochrane systematic reviews (in which attempts are

being made to synthesize both qualitative and

128 E. J. Elliott

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quantitative research) and journals such as Evidence

Based Medicine (http://ebm.bmjjournals.com) and

ACP Journal Club (http://www.acpjc.org). Although

few summary sources are available in the field of

speech pathology, their development is both im-

perative and inevitable. Such evidence sources

provide a valuable short-cut for busy clinicians.

They may also be more effective than teaching

critical appraisal skills for improving clinician

knowledge about the available evidence and for

aiding its translation into clinical practice. This

assumption is supported by data from a study of

General Practitioners who were au fait with

evidence-based practice, regularly searched the

literature and used clinical practice guidelines.

Despite this, they said they poorly understood

evidence-based practice jargon and biostatistics

and were not convinced that learning the steps of

evidence-based medicine was the best way to move

from opinion-based to evidence-based medicine

(McColl, Smith, White, & Field, 1998).

Limitations of evidence

Clinicians sometimes mistakenly equate lack of

evidence with evidence of lack of effect, but the

two are quite different. A lack of evidence to answer

a clinical question indicates the need for research

on that topic. Most speech pathologists value

clinical research (Vallino-Napoli & Reilly, 2004)

and there are many opportunities for speech

pathologists who aspire to, or are established in,

research to address the evidence deficit. This

challenge must be tackled so that often-used speech

pathology treatments can be tested and that the

health dollars and therapist hours are not spent

delivering therapies for which there is no evidence

of benefit.

The quality of evidence available varies. Quality

cannot be judged solely on the basis of study type

and, hence ‘level of evidence’. For example, the best

study type to evaluate a new or existing therapy is a

randomized, placebo-controlled trial, because it is

least likely to be subject to bias. However the best

evidence to support a therapy would come from a

systematic review of all known randomized trials,

particularly if data can be combined by meta-

analysis. Unfortunately, not all randomised trials

are equal and the quality of a systematic review

depends on the quality of the randomized controlled

trials included.

The available evidence may have other limita-

tions. Bias may influence the content of the

published literature (Moyer & Elliott, 2004). For

example, trials with positive results and trials

reported in English are both more likely to be

published, and to have results that are systematically

different from, trials that are not published.

Completed trials with positive results may never

be published, thus biasing the literature. Conver-

sely, the adverse results of some trials may be

purposely suppressed. Furthermore, industry-spon-

sored trials systematically favour the product made

by the sponsoring company. In an effort to identify

studies that may have been biased, most journals

now require authors to declare a conflict of interest

when that exists. Duplicate or multiple publication

of results, publication of studies with inappropriate

study design or statistical analysis, and selective

omission of data may also lead to misinterpretation

of results. In an area where treatments are rapidly

changing it is unlikely that the literature will be up

to date due to inherent delays in the publication

process. In these situations speech pathologists

should consider treating patients not on the results

of published trials, but as participants in trials of

new therapies.

Translating evidence into clinical practice

The application of evidence to clinical decision-

making is the biggest challenge faced by health

professionals and the Medical Journal of Australia

has recently devoted a supplement to this topic

(Medical Journal of Australia, 2004). Gaps between

the availability of evidence and use of that evidence

are well documented and the reasons for this are

complex. It has been proposed that the use or not of

evidence may relate to the complexity of the therapy;

the extent to which it can be trialled and modified; its

advantage relative to current therapies; its compat-

ibility with the individual’s or the institution’s beliefs

and practices; and the ease with which the results of

the therapy can be observed (Sanson-Fisher, 2004).

The way in which evidence is presented to clinicians

is also important. For example, the quality and

complexity of clinical practice guidelines is very

variable and there are few studies to convince

clinicians that guideline use actually improves patient

outcomes.

Social, economic, political and organizational

factors may also determine the extent to which

evidence is used to change clinical practice. Reilly

identified that the availability and quality of

evidence becomes irrelevant if the clinician does

not have the time, resources or organizational

support to implement a tested and proven treat-

ment. Similarly, management change proposed by

an individual will be difficult to implement if the

need for change is not accepted by colleagues on

the clinical team, who may have entrenched views

and practices. Above all, any treatment decision

needs to be made in light of the preferences and

beliefs of the individual patient at hand. All patients

are different and all have the right to refuse or

accept a treatment, having balanced its risks and its

benefits. Although we have to live with some

uncertainty in clinical practice, it is important that

clinicians access and use reliable, updated informa-

tion to guide their clinical practice.

Barriers and benefits 129

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