Title: Evidence-based Practice and Knowledge Translation in the Era of Health Care Reform: Opportunities for Occupational Therapy
1Evidence-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
2AJOT 1986 (40) p.112-116
3Center for Evidence-based Medicine
http//www.cebm.net/
4The Evolution of Evidence-based Practice
Medical Outcomes
Quality Assurance
Evidence-based health care
5What 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.
6The desire to connect research findings to
changes in health care practice is not new.
1940-50s
7But, the evidence has been indirect.
8The Challenge has been
How to make the connection between research and
practice more obvious and explicit.
Evidence-based Practice
Better Health Care
Research
91992 268 2420-2425
10Original 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
11Evidence-based MedicineHow to Practice and
Teach EBM By Sackett DL, Straus SE, Richardson
WS, Rosenberg W, Haynes RBSecond
Edition.Churchill Livingstone Edinburgh, 2000.
12Components of EBP
Haynes, et al., 1996
Individual Clinical Experience
Patient Values Expectations
Improved Patient Outcomes
Best Available Evidence
13Steps in Evidence-based Practice
(Tickle-Degnen, 2000)
14Steps 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.
15OTseeker
OTseeker is a database that contains abstracts of
systematic reviews and randomized controlled
trials relevant to occupational therapy.
http//www.otseeker.com/
16Steps in Evidence-based Practice
Step 3. Evaluate the gathered evidence to
determine what is the best evidence for
answering the question.
Levels of Evidence
17Levels 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.
18Randomized Clinical Trial
Random Sampling
Random Assignment
Treatment
Control
Blinding
Pre/post-test outcome measures
19Hierarchy of Evidence
I II III IV V
A B C D
20Steps 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- Its impact and does it work?
22The 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
23The 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
24Evidence-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.
26National 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)
27So what is the evidence for evidence-based
practice?
Has the increase in research and practice
guidelines improved healthcare decision making
and outcomes?
28American Academy of Pediatric Guidelines
EBP success Frequency of prone sleeping
decreased from 70 to 20. Sudden infant death
rate reduced 40.
29Surveys 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)
30McGlynn, 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
31They 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
32Hand 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.
33Hand Washing
Despite Level A evidence, and other
incentives, compliance at the national level
remains poor.
34The Ideal
Evidence-based Promise
Evidence-based Paradigm
The Reality
Evidence-based Paradox
353. How can we make it better?
36Areas for improvement
- Levels of Evidence Hierarchy
- Strategies for Implementation / Application
(e.g., knowledge translation)
- The role of theory in EBP
37Levels of Evidence
The standard hierarchy focuses on research design
(RCT) regardless of the question or context.
38Concato 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.
39McGlynn, 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.
40Lee 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)
41Where is the wisdom we have lost in
knowledge Where is the knowledge we have lost in
information?
The Rock T.S. Eliot
42Knowledge Application
- The process of knowledge translation, transfer
and application involve system factors and
behavior change that are complex.
M.C. Escher
43Changing peoples behavior is difficult. There is
no simple solution.
44Knowledge to Action Process
Monitor Knowledge Use
Select, Tailor, Implement Interventions
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
45Scholars in occupational therapy have made
important contributions to struggling with the
knowledge translation and application challenge.
Law MacDermid, 2008
46What is the Role of Theory in Evidence-based
Practice?
Two methods of translating research into practice
47Clinical Practice
Clinical Problem
Theory
3
1
2
Research Studies
48Patient-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.
494. Opportunities related to Health Care Reform
50Patient 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)
51Patient Center Outcomes Research Institute
www.pcori.org
www.pcori.org
52National 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
53http//www.qualityforum.org/Home.aspx
Patient-Centered Outcomes Research Institute
54Think strategically, Compete collaboratively
Patient-Centered Outcomes Research Institute
have FUN
Competing collaboratively with my daughters
55The 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
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