EVIDENCE BASED PRACTICE

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EVIDENCE BASED PRACTICE

• Amy Baker and Melissa Edwards
• 4th year Occupational Therapy Students
• University of South Australia

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Aims of the Session

• To increase your understanding of Evidence Based
  Practice (EBP), including
• What EBP is
• Why use EBP
• How to be an evidence based practitioner

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What is Evidence Based Practice?

• A process whereby research evidence, clinical
  knowledge and reasoning are used to make
  decisions about interventions that are effective
  for a specific client(s)

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What is EBP?

• A review of the evidence in relation to a
  clinical practice question
• EBP is only a part of the decision making process
• EBP considers clients preferences, beliefs and
  views
• Aims to improve the quality of care and life for
  the client

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Research vs. EBP

• EBP is not about conducting research it is about
  USING RESEARCH
• Research systematic process of gathering and
  synthesising empirical data to generate knowledge
  about a given topic
• EBP the conscientious, explicit and judicious
  use of best current evidence in making decisions
  about care for clients

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Why is EBP important?

• Clinical decisions can be clearly explained and
  justified to clients and their families
• Demonstrate interventions are clinically and cost
  effective to colleagues, managers and
  administration
• Maintaining and improving therapists knowledge
  base and the evidence base of OT for the future

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ANY QUESTIONS?
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How to use EBP

• Overview
• Five Steps
• Identify and formulate a clear review question
• Search the literature for relevant clinical
  articles and evidence
• Critically appraise the evidence
• Implement the evidence within practice
• Evaluate the impact of the evidence

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Step 1 Formulate a review question

• Questions can be in relation to
• The cause of a condition
• Diagnosis and assessments
• Prevention of conditions
• Prognosis of conditions
• Treatment outcomes
• Client concerns
• Economic evaluation

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Clinical vs. Review Questions

• Clinical Question
• A general question relating to a clinical
  practice situation
• Review Question
• Comes from a clinical question
• It is clear and specific to guide the search
• A useful question consists of a problem,
  intervention and outcome and often takes the form
  of
• What is the evidence for the effectiveness of X
  (intervention) for Y (outcome) in a client with Z
  (problem or diagnosis)

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How to Write a Review Question

• Use PICO format
• P The population or problem you are
  interested in (client group, problem)
• I The intervention that you are interested in
• C The comparison or alternative intervention
  (if relevant)
• O The outcome or reason for using the
  intervention

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Example of PICO Question

• What evidence is there for the validity and
  relevance of the Barthel Index vs. the COPM as an
  assessment of occupational performance for older
  adults who have a physical disability?

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Critiquing an EBP Question

• Identify the PICO components of the following
  question
• Are self management strategies more effective
  than medical care alone for improving health
  status, quality of life and function amongst
  adults with coronary heart disease?

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Critiquing an EBP Question
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Activity writing a review question

• Work in groups of 2 or 3, from the following
  scenario
• Identify a clinical question
• Formulate a review question (using PICO)
• You have been running a garden therapy group for
  people with eating disorders, as a part of their
  inpatient program at a mental health hospital.
  The group has been really successful, however,
  you need some extra evidence for its benefits in
  your proposal to have the group continued. You
  decide to conduct an EBP review.

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Step 2 Searching the literature to find the
evidence

• Need to use an organised and systematic approach
• Develop search strategies before you start,
  including
• Databases you will use
• Key terms to search under
• Set limits of your search

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Databases to Use

• Need to consider
• Is your focus medical or broader?
• Is your focus OT specific?
• Do you want literature from a particular country
  or area? (eg. Australia or Asia)
• Is there a specific research method you want to
  focus on? (eg. systematic review)

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Key Terms and Search Limits

• Pull out the key terms from your review question
• Generally the problem, intervention and outcome
• Consider alternative or related terms (eg.
  Occupation and activity)
• Set limits for your search, including
• Language of the article
• Research design
• Date of publication

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Step 3 Critically Analysing the Evidence

• Assess the value and trustworthiness of the
  evidence
• No research is without its flaws, need to ask
• Do the flaws make me question the conclusion?
• 3 broad areas to analyse
• The rigor of the research
• Significance of the results
• Impact upon your OT practice

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Levels of Evidence

• Consider the type of research conducted
  (hierarchical list)
• Systematic reviews, meta analysis
• Randomised controlled trials (RCTs)
• Non-randomised controlled trials
• Case controlled trials
• Cohort studies
• Descriptive studies
• Qualitative studies
• Expert opinion

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Questions for Critiquing Evidence

• Some general questions to ask include
• What is the question?
• What is the purpose of the research?
• Did the research design allow the question to be
  answered?
• What were the results?
• Were the researchers interpretations valid?
• Are the results relevant and useable in practice?
• Useful critical appraisal checklist and
  guidelines are available at
• www-fhs.mcmaster.ca/rehab/ebp

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Step 4 Implementing the evidence

• Examples of strategies to implement evidence into
  practice include
• Apply the results to one or a group of clients
• Reconsider treatment plans/goals
• Develop handouts on topics (with other
  professionals)

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Considerations when implementing evidence

• Who is the right therapist to be implementing the
  evidence?
• What does the evidence say the right thing to
  do is?
• What is the right way to implement the
  intervention?
• What is the right place for the implementation?
• What is the right time to implement?

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Step 5 Evaluating the impact of the evidence

• When evaluating the impact, consider
• The clients outcomes
• Cost effectiveness
• Client satisfaction
• Therapist satisfaction

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Barriers to EBP

• Some barriers to EBP that have been discussed in
  literature include
• Access and availability to information
• Limited time
• Lack of EBP skills
• Confidence in the value of the evidence
• Support from management
• Conflict with client centered philosophy of OT
• HOWEVER, BARRIERS CAN ALWAYS BE OVERCOME

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Becoming an Evidence Based Practitioner

• Strategies include
• Regularly ask clinical reflective questions
• Take time to track down the best evidence to
  support your therapy
• Use the evidence in your therapy
• Evaluate the impact of this evidence on your
  therapy

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Useful Resources

• Databases
• AMED- rehab and therapy for allied health
  professions, accessed through www.silverplatter.co
  m/catalog/amed.htm
• CINAHL- mainly nursing literature but some allied
  health, www.cinahl.com/
• Cochrane Library- RCTs and Systematic Reviews,
  www.cochrane.co.uk/
• OT Seeker- Systematic Reviews and RCTs relating
  to OT, www.otseeker.com/

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Useful Resources

• Websites
• HealthWeb tutorials and guides to searching
  literature- www.healthweb.org/browse.cfm?subjectid
  39
• British medical journals articles relating to
  EBP- http//bmj.bmjjournals.com/collections/
• Canadian Centre for Health Evidence description
  of EBP www.cche.net/usersguides/main.asp

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Useful Resources

• Websites Continued
• OT EBP research group article analysis
  guidelines-
• www-fhs.mcmaster.ca/rehab/ebp
• Joanna Briggs Institute International Research
  Collaboration, centres incl. Thailand and
  Australia www.joannabriggs.edu.au/about/home.php
• For more useful internet resources see
• www.library.unisa.edu.au/resources/subject/ebmed.
  asp

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ANY QUESTIONS?
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References

• Alison Lane- Evidence Based Practice
  Presentation, Pt Pirie
• Mary Russell- Evidence Based Practice
  Presentation, UniSA
• Taylor, MC 2002, Evidence Based Practice for
  Occupational Therapists, Blackwell Science Ltd,
  USA
• Holm MB 2000, The 2000 Elanor Clarke Slagle
  Lecture Our Mandate for the New Millenium
  Evidence-Based Practice, American Journal of
  Occupational Therapy, vol.54, no.6, pp.575-85