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Title: Evidence-based Practice and Knowledge Translation in the Era of Health Care Reform: Opportunities for Occupational Therapy


1
Evidence-based Practice and Knowledge Translation
in the Era of Health Care Reform Opportunities
for Occupational Therapy
Click to edit Master title style
AOTA Living Life to its Fullest
Kenneth J. Ottenbacher University of Texas
Medical Branch
2
AJOT 1986 (40) p.112-116
3
Center for Evidence-based Medicine
http//www.cebm.net/
4
The Evolution of Evidence-based Practice
Medical Outcomes
Quality Assurance
Evidence-based health care
5
What I would like to talk about
1. What is Evidence-based practice (EBP)?
2. Its impact and does it work?
3. How can we make it better?
4. Opportunities related to Health Care Reform.
6
The desire to connect research findings to
changes in health care practice is not new.
1940-50s
7
But, the evidence has been indirect.
8
The Challenge has been
How to make the connection between research and
practice more obvious and explicit.
Evidence-based Practice
Better Health Care
Research
9
1992 268 2420-2425
10
Original Definition Evidence-based clinical
medicine is the conscientious and judicious use
of current best evidence from clinical care
research in the management of individual
patients.
Evidence Based Medicine Working Group, 1992
11
Evidence-based MedicineHow to Practice and
Teach EBM By Sackett DL, Straus SE, Richardson
WS, Rosenberg W, Haynes RBSecond
Edition.Churchill Livingstone Edinburgh, 2000.
12
Components of EBP
Haynes, et al., 1996
Individual Clinical Experience
Patient Values Expectations
Improved Patient Outcomes
Best Available Evidence
13
Steps in Evidence-based Practice
(Tickle-Degnen, 2000)
14
Steps in Evidence-based Practice
Step 1. Write a question related to a specific
clinical task or problem.
Step 2. Gather current published evidence
that might answer the question.
15
OTseeker
OTseeker is a database that contains abstracts of
systematic reviews and randomized controlled
trials relevant to occupational therapy.
http//www.otseeker.com/
16
Steps in Evidence-based Practice
Step 3. Evaluate the gathered evidence to
determine what is the best evidence for
answering the question.
Levels of Evidence
17
Levels of Evidence
A hierarchy of evidence was developed based on
research design.
Randomized Controlled Trials (RCT) are the gold
standard and provide the best evidence.
18
Randomized Clinical Trial
Random Sampling
Random Assignment
Treatment
Control
Blinding
Pre/post-test outcome measures
19
Hierarchy of Evidence
I II III IV V
A B C D
20
Steps in Evidence-based Practice
Step 4. Interpret the evidence to determine a
possible answer to the question.
Step 5. Communicate with clients and colleagues
about the evidence as intervention decisions are
made.
Step 6. Document clinical decisions and record
assessments, progress and outcomes.
21
  1. Its impact and does it work?

22
The New York Times Magazine Year in Review
identified EBM as one of the five most
influential ideas of the past five years.
The New York Times Magazine
December 23, 2001
23
The British Medical Journal (BMJ) listed
Evidence-based Medicine as one of the 15 most
important developments in medicine in the last
150 years.
January, 2005
24
Evidence-based medicine web sites
13.6
million
1.24
25
  • EBP has contributed to an increase in Randomized
    Clinical Trials

The average number of randomized clinical trials
increased from 5,000 per year during 1980-1990
to 20,000 per year during 1994-2001.
26
National Guideline Clearinghouse
The National Guideline Clearinghouse includes
over 2,500 Clinical Practice Guidelines.
http//www.guideline.gov/
Supported by Agency for Healthcare Research
Quality (AHRQ)
27
So what is the evidence for evidence-based
practice?
Has the increase in research and practice
guidelines improved healthcare decision making
and outcomes?
28
American Academy of Pediatric Guidelines
EBP success Frequency of prone sleeping
decreased from 70 to 20. Sudden infant death
rate reduced 40.
29
Surveys and systematic reviews indicate that
30-45 of patients are not receiving care
according to scientific evidence and that 20-25
of the care provided is not needed or is
potentially harmful.
(2003)
30
McGlynn, et al. examined quality of care scores
based on evidence-based reviews to evaluate
performance on 439 indicators for quality of
care for 30 acute and chronic conditions.

NEJM, 2003
31
They found that less than half of patients
received care based on best evidence currently
available.
The gap between what we know works and what is
actually done is substantial
NEJM, 2003, p. 2644
32
Hand Washing
A large body of research evidence (including
RCTs) demonstrate that hand washing
prevents disease and improves health. Hand
washing is supported by Level A evidence.
33
Hand Washing
Despite Level A evidence, and other
incentives, compliance at the national level
remains poor.
34
The Ideal
Evidence-based Promise
Evidence-based Paradigm
The Reality
Evidence-based Paradox
35
3. How can we make it better?
36
Areas for improvement
  • Levels of Evidence Hierarchy
  • Strategies for Implementation / Application
    (e.g., knowledge translation)
  • The role of theory in EBP

37
Levels of Evidence
The standard hierarchy focuses on research design
(RCT) regardless of the question or context.
38
Concato J., et al. Randomized, controlled
trials, observational studies, and the hierarchy
of research designs. N Eng J Med
20003421887-92.
Examined 99 studies from five major medical
journals. Designs were either RCTs or cohort and
case-control. They found that well-designed
observational studies did not overestimate the
magnitude of treatment effects compared to RCTs.
39
McGlynn, et al. (2003) estimate that
approximately 50 or less of the research
questions in clinical medicine can be addressed
by RCTs.
For the broader area of health care, the
percentage is lt 30.
40
Lee J. Cronbach, Ph.D.
Convincing reasoning about causation may be
possible using many types of design. Once
more we see the limitation of a classification
system that leads to appraisal, in the abstract,
of some types of designs as excellent and others
as defective. (Cronbach, 1983)
41
Where is the wisdom we have lost in
knowledge Where is the knowledge we have lost in
information?
The Rock T.S. Eliot
42
Knowledge Application
  • The process of knowledge translation, transfer
    and application involve system factors and
    behavior change that are complex.

M.C. Escher
43
Changing peoples behavior is difficult. There is
no simple solution.
44
Knowledge to Action Process
Monitor Knowledge Use
Select, Tailor, Implement Interventions
  • KNOWLEDGE CREATION

Evaluate Outcomes
Knowledge Inquiry Knowledge Synthesis Knowledge
Tools / Products
Assess Barriers to Knowledge Use
Sustain Knowledge Use
Adapt Knowledge to Local Context
ACTION CYCLE (Application)
Identify Problem ------------------------------ Id
entify, Review, Select Knowledge
Graham 2006
45
Scholars in occupational therapy have made
important contributions to struggling with the
knowledge translation and application challenge.
Law MacDermid, 2008
46
What is the Role of Theory in Evidence-based
Practice?
Two methods of translating research into practice
  • Empirical method
  • Theoretical method

47
Clinical Practice
Clinical Problem
Theory
3
1
2
Research Studies
48
Patient-Centered Outcomes Research Institute
Arête ??et?, Excellence. The notion of the
fulfillment of purpose or function the act of
living up to one's full potential.
Being the best you can be.
 
49
4. Opportunities related to Health Care Reform
50
Patient Center Outcomes Research Institute
Created by the Affordable Care Act, the Institute
will
  • Identify research priorities and outcome measures
    for Comparative Effectiveness Research
  • Fund research (500 million per year)

51
Patient Center Outcomes Research Institute
www.pcori.org
www.pcori.org


 
52
National Quality Forum
A nonprofit organization with a mission to
improve American healthcare by endorsing national
consensus standards for measuring and publicly
reporting on performance
http//www.qualityforum.org/Home.aspx
 
53
http//www.qualityforum.org/Home.aspx
Patient-Centered Outcomes Research Institute
 
54
Think strategically, Compete collaboratively
Patient-Centered Outcomes Research Institute
have FUN
Competing collaboratively with my daughters
 
55
The End
Patient-Centered Outcomes Research Institute
K. Ottenbacher Division of Rehabilitation
Science UTMB at Galveston kottenba_at_utmb.edu
Old Red at UTMB
PPT slides including references available at
www.shp.utmb.edu/download/AOTA.ppt
 
56
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