The Evidence That Supports the Evidence PEGGY WARD-SMITH

1
The Evidence That Supports the Evidence

• Peggy Ward-Smith, PhD, RN
• UMKC School of Nursing
• The 8th Annual Evidence-Based Practice Nursing
  Symposium

2
Meek Beginnings Archie Cochrane

• 1909-1988 born in Northern Scotland.
• Medical degree from University College London.
• Passion was health studies (pneumoconiosis unit).
  
• WWII served as a medical
• officer at a number of
• prisoner of war camps.

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POW Experience Part I

• In Greece Crete (1941)
• 8000 British POWs
• Daily diet of 400-500 calories
• Initial study used Vitamin C
• Treatment of beri-beri
• Corrected fluid balances
• Wrong hypothesis
• Deaths from shootings
• Doctors are superfluous

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POW Experience Part II

• Transferred to Germany Wittenberg an der Elbe
  (1947)
• 24,000 POWs
• Daily diet of 0-100 calories.
• TB diagnosis routinely made
• Treatments were inconsistent/untested
• Many deaths/many reasons
• I may have harmed many

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Lasting Effects

• Resources will always be limited and thus should
  be used to provide forms of healthcare which have
  been shown in properly designed evaluations to be
  effective (1948).
• It is surely a great criticism of our profession
  that we have no organized a critical summary
  (1979).
• Oxford Database of Perinatal Trials (1980)
• Systematic Reviews of Randomized Controlled
  Trials (RCTs) center at Oxford in 1987
• Center opened in 1992 Cochrane Collection in
  1993

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Cochrane Centers

• Headquartered at Oxford, UK
• 12 Around the World
• US center at Johns Hopkins
• Branch in San Francisco
• Grouped by disease process

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Nursings Beginning

• Florence Nightingale (1820-1910)
• Born in Tuscany
• Educated at St. Thomas Hospital in London (the
  first secular school of nursing).
• Upper-middle class, an education
• was not an expectation and nursing
• was rebellious.
• Her father taught her mathematics,
• which she used to assist the secretary
• of war (Crimean).

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Using These Data

• Used these numbers to track deaths at the
  hospitals.
• Implemented hygiene changes
• Ventilation
• Flushing sewers
• Overcrowding
• Nutrition
• Superintendent at the Institute for the Care of
  Sick Gentlewomen in London (non-paying, her
  father gave her an annual income of
  500pound/year).
• Grateful families made donations which she used
  to set up the Nightingale Training School (1860).
  

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The Joanna Briggs Institute

• Established in 1996 at the University of Adelaide
  (Australia).
• Joanna Briggs was the first matron of Royal
  Adelaide Hospital.
• An international collaborative effort including
  40 countries.
• Free access to evidenced-based information.

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Definition

• "Evidence-based practice (EBP) is an approach to
  health care wherein health professionals use the
  best evidence possible, i.e. the most appropriate
  information available, to make clinical decisions
  for individual patients. EBP values, enhances and
  builds on clinical expertise, knowledge of
  disease mechanisms, and pathophysiology.  It
  involves complex and conscientious
  decision-making based not only on the available
  evidence but also on patient characteristics,
  situations, and preferences.  It recognizes that
  health care is individualized and ever changing
  and involves uncertainties and probabilities.
  Ultimately EBP is the formalization of the care
  process that the best clinicians have practiced
  for generations. 
• McKibbon KA (1998). Evidence based practice.
  Bulletin of the Medical Library Association,
  86 (3) 396-401.

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Purpose of EBP

• Integrate the best research evidence with
  clinical expertise, patient preference and
  circumstances, and awareness of the clinical
  setting and resource constraints.
• Personalize the evidence to fit the specific
  patient and clinical situation.

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The Debate

• Pro
• A solution to improving healthcare in a
  cost-containment environment
• A rationale approach
• Self-directed life-long learning

• Con
• Clinical judgment and patient preference are
  devalued
• Rating is biased
• Advantages are exaggerated

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SHIFT!

• Include all members of a healthcare team.
• This is a major shift.
• Maintaining competency / current / information
  access.

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Classification of Evidence

• Ia Evidence obtained from meta-analysis of
  randomized controlled trials.
• Ib Evidence obtained from at least one randomized
  controlled trial.
• IIa Evidence obtained from at least one
  well-designed controlled study without
  randomization.
• IIb Evidence obtained from at least one other
  type of well-designed quasi-experimental study (a
  situation in which implementation of an
  intervention is without the control of the
  investigators, but an opportunity exists to
  evaluate its effect).
• III Evidence obtained from well-designed
  non-experimental descriptive studies, such as
  comparative studies, correlation studies and case
  studies.
• IV Evidence obtained from expert committee
  reports or opinions and/or clinical experiences
  of respected authorities.

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Classification of Grades of Recommendations

• Grade A - Requires at least one randomized
  controlled trial as part of a body of literature
  of overall good quality and consistency
  addressing specific recommendation. (Evidence
  levels Ia, Ib).
• Grade B - Requires the availability of well
  conducted clinical studies but no randomized
  clinical trials on the topic of recommendation.
  (Evidence levels IIa, IIb, III).
• Grade C - Requires evidence obtained from expert
  committee reports or opinions and/or clinical
  experiences of respected authorities. Indicates
  an absence of directly applicable clinical
  studies of good quality. (Evidence level IV).

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Joanna Briggs Institute

• Feasibility (1-4)
• Meta synthesis, one or more studies, expert
  opinion
• Appropriateness (1-4)
• Meta synthesis, one or more studies, expert
  opinion
• Meaningfulness (1-4)
• Meta synthesis, one or more studies, expert
  opinion
• Effectiveness (1-4)
• RCT or large experimental study,
  quasi-experimental, no randomization, cohort,
  case controlled, observational, expert opinion
• Economic Evidence (1-4)
• Meta synthesis, comparison to alternative
  treatment, expert opinion

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Levels of Evidence Melynk Fineholt-Overholt
                                               
                                                 
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EBP Centers - AHRQ

• Blue Cross and Blue Shield Association,
  Technology Evaluation Center.
• Duke University.
• ECRI Institute.
• Johns Hopkins University.
• McMaster University.
• Minnesota Evidence-based Practice Center.
• Oregon Evidence-based Practice Center.
• RTI InternationalUniversity of North Carolina.
• Southern California.
• TuftsNew England Medical Center.
• University of Alberta.
• University of Connecticut.
• University of Ottawa.
• Vanderbilt University.

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Grading the Evidence

• Rigorous research
• Best evidence
• Personal way of knowing/hunches are minimized.
• If its not published does it exist?

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Critiquing Qualitative Research

• Subjectivity bias
• Multiple outlines/guidelines to follow
  (published)
• Evaluate the rigor not the sample size,
  statistical analyses, and/or generalizability
• Watch the clinical situation, population, and
  outcome

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Critiquing Quantitative Research

• Multiple published outlines/procedures
• Statistical significance
• Power avoidance of a Type II error
• Control, intervention, and data collection time
  (interval)
• Adaptability

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Clinical Significance

• Is the research clinically significant?
• Where the participants like your patient
  population?
• Does the clinical scenario mimic yours?
• Is it feasible / doable?
• Clinical significance is different than
  statistical significance.

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Linking the Clinical Question to the Research
Design
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Formulate a Question?
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Background Information

• References - textbooks
• Practice guidelines
• Review of the literature
• Remember that it takes 3 years for data to be
  published

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Foreground Information

• Patient centered information
• Age
• Gender
• Co-morbidities
• Clinical questions
• Etiology
• Diagnosis
• Prevention
• Harm

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TOOOOO Much Information?

• Limit by healthcare condition
• Prognosis
• Diagnosis
• Prevention
• Limit by clinical question
• Therapy
• Diagnosis
• Etiology/harm
• Prognosis

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Evidence-Based Practice (EBP)

• Combine research evidence with clinical
  expertise.
• Uses an evaluative and qualitative approach.
• Differentiate between high-quality and
  low-quality research findings.

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Implementation Hurdles

• Delay of transferring research findings into
  practice
• Changes in the healthcare system
• Benefit of treatment

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What Does the Evidence Show?

• Prostate cancer screening
• Your 54 year old father/significant
  other/uncle/brother asks about prostate cancer
  screening they are reluctant to have either the
  blood draw or the physical examination.
• There is no family history, physical complaints
  or high risk factors.

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Background

• The most common non-skin cancer in America
• More than 2 million men in the US have it.
• Screening activities allow 90 to be detected
  while localized . an almost 100 5 year cure
  rate.
• (American Cancer Society, 2009)

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History

• In 1996 the American Academy of Family Physicians
  recommended routine screening in men over the age
  of 50 (expert opinion).
• Research by Lefevre (1998) concluded that
  evidence to support routine use of PSA was
  lacking (systematic review).

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Cochrane Review

• In 2001, there were insufficient evidence to
  support or refute routine screening (Wilt, Nari,
  MacDonald Rutks).
• In 2006, additional studies were included, with
  the same result (Ilic, OConnor, Green Wilt).

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US Preventative Services Task Force (USPSTF)

• Insufficient evidence to recommend screening
  among men younger than 75 years of age.
• This activity received a grade of D the
  balances of benefits and harms cannot be
  determined, the evidence is of poor quality,
  conflicting and lacking.
• They recommend that this service be discontinued
  (systematic review and expert opinion).

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Centers for Disease Control

• Does not recommend an age for routine screening
  but reports the results of PSA screening
  activities among men older than 50 years of age
  (2009).
• The CDC affirms that medical experts disagree.
• Increased risk for the disease (African American,
  family history) should be included in
  decision-making.
• In fact, they have specific educational materials
  for African American males (2003).

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The American Cancer Society

• Does not support routine prostate cancer
  screening.
• Recommend discussing it with a healthcare
  provider beginning at age 45.
• IF the man leaves the decision to the healthcare
  provider, they should undergo testing (2009).

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Randomized Controlled Clinical Trials

• New England Journal of Medicine (2009) report
  that screening among 182,000 men (50-74 years of
  age) reduced the death rate from prostate cancer
  20 (Schröder , et al).
• New England Journal of Medicine (2009) reported
  that screening 76,693 men for prostate cancer had
  no impact on the ability to identify localized
  prostate cancer or prevent mortality.

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The American Society of Clinical Oncology
andThe American Urologic Association

• Guideline (2009) suggest that a multi-year regime
  of a 5-a reductase inhibitor medication, such as
  finasteride, be offered to men who routinely
  undergo prostate screening activities.
• This medication reduces the risk of getting this
  disease or delay the diagnosis.
• Early research
• Controversial finding
• May cause a higher grade of disease if it occurs

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EBP?

• The evidence is complex and varying.
• Include demographic information, values, health
  behavior, resource constraints, personal
  preferences .
• Hellenthal and Ellsion (2008) determined that
  referral patterns, accessibility of specialists,
  wait times, belief in complementary or
  alternative treatments, faith and spirituality
  were variables considered by men when making
  treatment choices.
• The experience from men who underwent
  brachytherapy (Ward-Smith, 2003) reveal that
  lifestyle, minimal invasiveness, and recovery
  time influenced their treatment choice.

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The Future

• For prostate cancer
• More will be diagnosed
• Increased age
• Screening activity participation
• Research efforts
• Decision-making process
• Specific demographics
• Insurance / cultural norms

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Who better to guide this journey than nurses?????

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Connecting the Evidence