TIPS FOR TRAINERS: USING EVIDENCEBASED PRACTICE IN THE CLINICAL PRACTICUM

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TIPS FOR TRAINERS USING EVIDENCE-BASED PRACTICE
IN THE CLINICAL PRACTICUM
Barbara B. Walker, Ph.D. Indiana
University BBWalker_at_Indiana.edu Beverly E. Thorn,
Ph.D., ABPP The University of Alabama Bthorn_at_as.ua
.edu

• Council of University Directors of Clinical
  Psychology
• January 18, 2008

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Acknowledgements

• Parts of this presentation are taken from a
  workshop given with Barbara Walker, Ph.D., at the
  Alabama Psychological Association fall meeting,
  Nov. 10, 2007. Although Dr. Walker was not
  physically present at the CUDCP 2008 meeting, she
  was the lead in preparing this talk.
• UA Dept. of Psychology
• IU Dept. of Psychological and Brain Sciences
• Society of Behavioral Medicine / Div. 38 APA
• SBM Evidence-Based Behavioral Medicine Committee
  
• Karina Davidson, Ph.D. Bonnie Spring, Ph.D.
• IU Ruth Lilly Library
• Susan London EBM Librarian Extraordinaire

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• Evaluation
• Clinical interview
• Assessment tools
• Observation

• Case conceptualization
• Diagnosis
• Appropriate treatment?
• Impressions
• Hypotheses

• Clinical decision

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• Evaluation
• Clinical interview
• Assessment tools
• Observation

• Case conceptualization
• Diagnosis
• Appropriate treatment?
• Impressions
• Hypotheses

• Clinical decision

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• Evaluation
• Clinical interview
• Assessment tools
• Observation

BOTHERSOME

• Questions (ours and patients)

• Case conceptualization
• Diagnosis
• Appropriate EST?
• Impressions
• Hypotheses

• Outdated information? Staying up to date

• Overwhelming amount of information

• Better system for teaching

• EBM- other health care professions

• Clinical decision

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What is Evidence Based Practice? (EBP)

• Has its roots in Evidence-based Medicine the
  integration of best research evidence with
  clinical expertise and patient values (Institute
  of Medicine, 2001, pg. 147)
• Includes a framework and a set of tools and
  resources for DOING EBP.

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Psychology introduced EBPP in 2005
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 see American
Psychologist, 2006, p. 273)
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The framework
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Clinical Decision
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The Framework of EBP
Two Components of EBP
Operationalization 5 STEPS

• Convert information needs into questions.
• 2. Search for the best evidence in the
  literature.
• 3. Critically appraise the evidence.
• 4. Integrate with a patients characteristics,
  culture and preferences.
• 5. Evaluate the outcome.

Best research available
CD
Patient characteristics, culture, preferences
Clinical Expertise
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STEPS FOR DOING EBP
Step 1 Formulate a clinical question Step 2
Acquire the evidence Step 3 Appraise the evidence
Best research available
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In EBP

• The evidence ALONE is never enough.

Best research available
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One uses clinical expertise to integrate the
evidence with the patient
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Clinical Decision

• HOW?
• Is there anything about this particular patient
  that would make me question applicability of the
  evidence in this case?

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Clinical Expertise

• Not opinion
• The ability to use clinical skills and past
  experience to accurately assess patient's
• situation
• Values
• Preferences
• risks and benefits of interventions
• AND
• Ones own ability to deliver an intervention

Clinical Expertise
Best research available
CD
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The Framework of EBP
Two Components of EBP
Operationalization 5 STEPS

• Convert information needs into questions.
• 2. Search for the best evidence in the
  literature.
• 3. Critically appraise the evidence.
• 4. Integrate with a patients characteristics,
  culture and preferences.
• 5. Evaluate the outcome.

Best research available
CD
Patient characteristics, culture, preferences
Clinical Expertise
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Psychologys Focus

• EBP is both a framework and a process
• It includes a set of tools and resources for
  clinical decision making
• Until recently, psychology has focused on the
  framework
• Other disciplines (e.g., medicine, nursing,
  social work) have focused on the
  operationalization

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2005
2006
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New for 2008

• Norcross, J.C., Hogan, T. P., Koocher, G. P.
  Clinicians Guide to Evidence-Based Practices
  Mental Health and the Addictions. In press.
• Rubin, Al. (2008). Practitioners Guide to Using
  Research for Evidence-Based Practice. New Jersey
  Wiley Sons.

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Also coming in 2008

• Interactive online learning modules
• Transdisciplinary
• Council for Training in Evidence-Based Behavioral
  Practice (EBBP)
• http//www.ebbp.org

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Clinical decisions using EBP begin and end with
the patient

• We begin by asking specific questions relevant to
  our patient
• We find the evidence
• We evaluate the evidence
• We consider our clinical expertise and patient
  characteristics
• We make clinical decisions in collaboration with
  the patient
• We evaluate the effectiveness of the entire
  process as it was applied to our patient

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The 5-Step EBP Process

• Convert information needs into a clear question.
  (Ask)
• Search for the best evidence in the literature.
  (Acquire)
• Critically appraise the evidence. (Appraise)
• Integrate with a patients needs, preferences,
  circumstances, and values.
• Evaluate the outcome.

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Types of Clinical Questions
By Content
By Format

• Diagnosis
• Therapy
• Harm
• Etiology
• Prognosis
• Cost-effectiveness

• Background
• Foreground

THIS SLIDE COURTESY OF SUE LONDON RUTH LILLY
LIBRARY
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Background Questions

• What are the criteria for diagnosing ?
• What are the known risks associated with
• What is the cost-effectiveness of
• What is the prognosis for
• What treatments have been found to be most
  effective for?

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Foreground Questions

• P Patient Population or Problem
• I Intervention
• C Comparison
• O Outcome

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The 5-Step EBP Process

• Convert information needs into a clear question.
  (Ask)
• Search for the best evidence in the literature.
  (Acquire)
• Critically appraise the evidence. (Appraise)
• Integrate with a patients needs, preferences,
  circumstances, and values.
• Evaluate the outcome.

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Practical Tools and Resources for an
Evidence-Based Practice
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What are we Searching for?

• The Type of Study you Want Depends on the
  Question you are Asking
• Does Treatment A work better than Treatment B for
  Condition X? (RCT or systematic review)
• Etiology Question prospective or cohort studies

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Categories of Studies

• Systematic Reviews (synthesis of all available
  randomized controlled trials, meta-analyses offer
  quantitative estimates of effect sizes)
• Randomized Controlled trials (randomization
  control group is key)
• Cohort studies (prospective ID two groups of
  patients cohorts, one that received exposure
  of interest, one that did not follow these
  cohorts forward for outcome)
• Case Control studies (retrospective- ID patients
  who have outcome of interest case those who
  do not look back to see if they had the
  exposure of interest)
• Case Studies/Case Series (Qualitative -several
  cases, follow long time)
• Case Report (Qualitative one in-depth case)

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Databases that contain all of these TRIP

• Databases of systematic reviews
• Cochrane
• 2. Evidence-based summaries
• Online EB text books
• EB guidelines
• ESTs
• 3. Medline and PsycINFO
• Specific EBP techniques

UpTODate Clinical Evidence

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What if your patient is the one asking the
question (or handing you a printout)?
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Health on the Net Foundation HON CODE SITES
www.hon.ch/
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The 5-Step EBP Process

• Convert information needs into a clear question.
  (Ask)
• Search for the best evidence in the literature.
  (Acquire)
• Critically appraise the evidence. (Appraise)
• Integrate with a patients needs, preferences,
  circumstances, and values.
• Evaluate the outcome.

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Caveats

• All studies have flaws
• You will never find the perfect study
• You want to find the best available evidence
• Knowing there is no good evidence is not the same
  as not knowing if there is evidence

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When Appraising Randomized Controlled Trials

• F Follow-up?
• R Randomization?
• I Intention to treat analysis?
• S Similar baseline characteristics?
• B Appropriate Blinding?
• E Equal treatment of groups?

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One Way to Summarize
Comments In general, what was the quality of the
research and how directly did it address your
question? Clinical bottom line The available
research suggests .
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EBP in practice
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• 43-year-old woman with 1-3 migraine headaches
  per week.
• Otherwise healthy.
• Stress is a significant trigger for her
  headaches,
• Imitrex aborts her headaches most of the time,
  but she dislikes taking it because of the
  side-effects and cost.
• She prefers alternative approaches
• Has heard that acupuncture can help migraines.

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The patient asks

• Should she pursue treatment with us or try an
  alternative approach such as acupuncture?
• What do we think would be the most effective
  treatment for her?

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The 5-step process

• Convert information needs into a clear question.
• Search for the best evidence in the literature.
• Critically appraise the evidence.
• Integrate with a patients needs, preferences,
  circumstances, and values.
• Evaluate the outcome.

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Background Questions

• What are the most effective treatments for
  chronic migraine headache?
• Pharmacological
• Non-pharmacological
• Is acupuncture an effective treatment for
  migraine headache?
• Are there any significant risks associated with
  acupuncture?

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Foreground Questions
In middle aged women with migraine headaches

• P
• I
• C
• O

is there any evidence that acupuncture
compared to sham treatment, biofeedback,
relaxation training, and cognitive-behavioral
therapy
reduces the frequency, intensity, and/or duration
of migraines?
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Where to look

• Background questions ? established information
• EB textbooks
• UpToDate
• Clinical Evidence
• EB guidelines
• ESTs
• Foreground questions ? newer information
• MEDLINE / PsycINFO search

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Background Questions

• What are the most effective treatments for
  chronic migraine headache?
• Pharmacological
• Non-pharmacological
• Is acupuncture an effective treatment for
  migraine headache?
• Are there any significant risks associated with
  acupuncture?

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• www.therapyadvisor.org

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Background Questions

• What are the most effective treatments for
  chronic migraine headache?
• Pharmacological
• Non-pharmacological
• Is acupuncture an effective treatment for
  migraine headache?
• Are there any significant risks associated with
  acupuncture?

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2
1
Search for the treatment in the title and
text e.g. Acup
Search for the disorder in the title e.g.
Headache or migraine or migraine headache
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Combine the two 1 AND 2
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1 and 2
VIEW 43 documents on headache and acupuncture
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List of 43 Evidence-based articles
FILTERS YOU CAN USE- Systematic reviews
(8) E-textbooks (4) Guidelines (4 US 3EU)
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If you click on the icon, it shows you the
conclusions
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4 chapters from e-textbooks great for background
questions
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• Guidelines
• and
• Specialized filters to find articles in Medline
• Therapy
• DX
• Prognosis
• Etiology
• Systematic Reviews

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What did we find?

• Background information
• EB textbooks
• Guidelines and ESTs
• Therapyadvisor.org
• American Academy of Neurology Guideline
• Headache Consortium Guideline
• Systematic reviews
• Acupuncture for idiopathic headache
• Two reviews on Is acupuncture safe?

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• Acupuncture gt sham or no treatment
• ? Compared to other treatments
• Relatively safe
• BUT
• Relaxation, CBT, and BFT
• .have ALL been shown to reduce migraine
  headaches between 40-60.

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Foreground questions

• In middle aged women with migraine, is CBT more
  effective than biofeedback in reducing
  frequency, duration or intensity of migraine
  headaches?
• OrIn middle aged women with migraine, is
  acupuncture more effective than CBT in reducing
  frequency, duration or intensity of migraine
  headaches?

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• Relaxation, BFT,
• CBT A
• Behavioral therapy
• Med B
• Acupuncture some evidence but inconclusive
• More evidence for acupuncture than other
  alternative treatments
• Acupuncture is low risk

Best research evidence
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Patient Characteristics, Values, and Context
Clinical Expertise
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EBP

• Formulate a clear question.
• Search for the best research evidence.
• Critically appraise the evidence
• Integrate with patients needs, preferences,
  circumstances, and values, clinical expertise and
  apply.

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Best research evidence
Prefers alternative treatments Concerned about
cost No co-morbid conditions Similar to pts in
studies Behavioral treatments feasible Insight
into the link between stress and headaches Cost
of acupuncture unknown at time of assessment Not
needle-phobic
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Patient Characteristics, Values, and Context
Clinical Expertise
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Best research evidence
CD

• Assess the patient accurately
• Communicate and form a relationship with the
  patient
• Integrate the research and clinical evidence
• Able to deliver the txs of choice?

Patient Characteristics, Values, and Context
Clinical Expertise
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Step 4 Applying the evidence

• Clinical intervention that involves the patient
• Clinical decision is made jointly

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The Clinical Decision

• Begin treatment with BFT and relaxation training
• Alternative treatment
• Affordable, feasible
• Incorporate CBT
• Monitor outcome
• Reconsider acupuncture therapy