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Evidence Based Practice

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Title: Evidence Based Practice Author: Steven R. Pruett Last modified by: Steven R. Pruett Created Date: 5/9/2005 4:26:18 PM Document presentation format – PowerPoint PPT presentation

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Title: Evidence Based Practice


1
Evidence Based Practice
  • January 10, 2006

2
Definitions
  • Rosenthal and Donald (1996) defined
    evidence-based medicine as a process of turning
    clinical problems into questions and then
    systematically locating, appraising, and using
    contemporaneous research findings as the basis
    for clinical decisions.
  • Sackett, Rosenberg, Gray, Haynes, and Richardson
    (1996) described evidence-based practice as the
    conscientious, explicit, and judicious use of
    current best evidence in making decisions about
    the care of individual patients.

3
Definitions
  • DePalma (2000) further refined the definition of
    evidence-based practice as a complete process
    beginning with knowing what clinical questions to
    ask, how to find the best practice, and how to
    critically appraise the evidence for validity and
    applicability to the particular care situation.
    The best evidence then must be applied by a
    clinician with expertise in considering the
    patient's unique values and needs. The final
    aspect of the process is evaluation of the
    effectiveness of care and the continual
    improvement of the process.
  • Ottenbacher and Mass (1998) indicated that the
    best evidence used to support evidence-based
    practice is derived from a series of research
    studies results in an empirical consensus
    regarding the effectiveness of a treatment
    approach.

4
Evidence-Based Practice
  • Gold standard of best practice in medicine
  • In medicine, with its positivist scientific
    methods tradition, the gold standard for
    scientific evidence is still randomized clinical
    trials and the method of choice for determining
    the cumulative evidence of the effectiveness of a
    treatment is meta-analysis.
  • Randomized clinical trials
  • Meta-analysis

5
Evidence Based Practice
  • Steps for the evidence-based practice of medicine
    by practitioners
  • Formulate a clear clinical question from a
    patient's problem.
  • Search the literature for relevant clinical
    articles.
  • Evaluate (critically appraise) the evidence for
    its validity and usefulness.
  • Implement useful findings in clinical practice.

6
A Hierarchy of Levels of Best Evidence
  • Level 1 evidence is defined as strong evidence
    from at least one systematic review of multiple
    well-designed randomized controlled trials.
  • Level 2 evidence is defined as strong evidence
    from at least one properly designed randomized
    controlled trial of appropriate size.
  • Level 3 evidence is defined as evidence from
    well-designed trials without randomization,
    single group pre-post, cohort, time series, or
    matched case-controlled studies.

7
A Hierarchy of Levels of Best Evidence
  • Level 4 evidence is defined as evidence from
    well-designed non-experimental studies from more
    than one center or research group.
  • Level 5 evidence is defined as opinions of
    respected authorities, based on clinical
    evidence, descriptive studies, or reports of
    expert committees.

8
Related Concepts Empirically Supported Treatment
  • APA Division 12 defined empirically supported
    treatment (EST) as clearly identified
    psychological treatments shown to be efficacious
    in controlled research studies with a delineated
    population.
  • EST should be evaluated in terms of efficacy
    (statistical and clinical significance),
    effectiveness (clinical utility), and efficiency
    (cost-effectiveness).

9
Related Concepts Empirically Supported Treatment
  • Patterned after the FDA guidelines for approval
    of new drugs, the APA Div 12 Task Force on the
    Promotion and Dissemination of Psychological
    Procedures established two criteria for
    establishing the empirical validity of a
    psychotherapeutic approach
  • The approach is superior to a placebo or other
    treatment or
  • The approach is equal to an established
    treatment, in at least two studies established by
    different investigators.

10
Related Concepts Meta-Analysis
  • Meta-analysis is a method used to review research
    literature based on statistical integration and
    analysis of research findings.
  • In treatment effectiveness meta-analysis, the
    dependent variable is the effect size (i.e., the
    outcomes or results of each study selected for
    review transformed into a common metric across
    studies) and the independent variables are study
    characteristics (i.e., participants,
    interventions, and outcome measures).

11
Related Concepts Meta-Analysis
  • Meta-analysis is an effort to review the results
    of a research domain in quantitative terms. The
    intent is to identify what significant
    relationships exist between study features
    (independent variables) and effect sizes
    (dependent variable).
  • Benefits The benefits of meta-analysis include
    its ability to
  • Synthesize the results from many studies
    succinctly and intuitively for nonscientific
    communities,
  • Illustrate the amount and relative impact of
    different programs on different criteria for
    policy decision-making purposes, and
  • Identify the most effective programs and
    highlight gaps or limitations in the literature
    to suggest directions for future research

12
Related Concepts Meta-Analysis
  • A common index of the size of the effect produced
    by each study is the effect size index g, which
    is the standardized difference between the sample
    mean of the treatment group and the sample mean
    of the control group (Wampold, 2001). A positive
    score indicates that the treatment group
    outperformed the control group, and a negative
    score has the reverse meaning. However, the
    effect size index g is a sample statistics. As
    such, it is a biased estimator of the true (i.e.,
    population) effect size.

13
Evidence-Based Practice Implications for
Rehabilitation Counseling
  • Implications for counseling research The need
    for level 1 evidence (empirical supported
    treatment and meta-analysis) related to the
    effectiveness of rehabilitation interventions
    (individual ingredients/components of RC as well
    as RC as interventions)
  • Implications for practitioners For
    practitioners, evidence-based practice is a
    research utilization issue (ability to judge the
    quality of an individual research study and a
    collection of studies, the ability to select the
    best interventions on an individualized basis,
    and the ability to search for research
    information using the Internet and other library
    tools)

14
Problems of RC research
  • A weak theoretical base and poor quality are two
    major criticisms of rehabilitation research.
    These two criticisms are inter-related. Bellini
    and Rumrill (2002) contended that rehabilitation
    counseling operates essentially atheoretically,
    with no general theory to account for a
    significant proportion of the knowledge content
    of rehabilitation counseling. Their observations
    are consistent with many rehabilitation scholars
    (e.g., Arokiasamy, 1993 Cottone, 1987
    Hershenson, 1996).

15
Problems of RC research
  • The view that rehabilitation counseling has a
    deficient theoretical base may also due to our
    failure to adequately distinguish between
    theories and models.
  • According to Bellini and Rumrill (2002), theories
    are more general than models models typically
    operate at an intermediate level of
    conceptualizationModel-generated hypotheses are
    often tied to practical concerns in the role
    performance of rehabilitation counselors and
    delivery of services to persons with
    disabilities. (p.127).

16
Mission of Public Health
  • Mission to fulfill societys interest in
    assuring the conditions in which people can be
    healthy
  • As public health professionals, we strive to
    ensure that people, systems, and communities are
    situated so that we are able to maintain a
    healthy society.
  • Scientific research is one of our primary means
    of accomplishing this mission.

17
Functions of Public Health
  • The public health field is organized in three
    core functions
  • Assessment
  • Policy development
  • Assurance
  • Public health research underlies and cuts across
    all three core functions.

18
Functions of Public Health
  • Assessment
  • Assess the health needs of communities
  • Investigate the occurrence of health effects and
    health hazards
  • Analyze the determinants of health needs
    (personal and societal factors associated with
    the health needs)

19
Functions of Public Health
  • Once we understand the health needs of a
    communities and their determinants we engage in
    policy development
  • Develop plans and policies that help us respond
    to those needs
  • Set priorities among health needs
  • Advocate for public health, build constituencies,
    and identify resources

20
Functions of Public Health
  • Following policy development, we provide
    assurance.
  • Manage the resources available and develop
    organizational structures necessary to address
    health issues
  • Inform and educate the public
  • Develop and implement public health programs
  • Evaluate programs and provide quality assurance

21
Evidence-Based Interventions
  • Evidence-based public health interventions are
    the most visible way that we are responsive
    across all three core public health functions.
  • Public health research focuses on many different
    issues (diseases, behaviors) in many different
    ways (education, advocacy, regulations and laws,
    environmental change, monitoring individual
    health status, communication and media).
  • Public health research and interventions are
    diverse! In order to be effective, however, all
    public health research should be evidence-based.
    This includes SBS.

22
SBS Social Ecological Approach
  • Health is viewed as a function of individuals
    and of the environments in which individuals are
    embedded, including family, social networks,
    organizations, communities, and societies.
    (Stokols, 1996)

23
SBS Social Ecological Approach
  • Focus on the interrelationships among individuals
    and
  • Biological characteristics
  • Psychological characteristics
  • Behavioral characteristics
  • Social environment
  • Cultural environment
  • Physical environment

24
SBS Social Ecological Approach
  • While the social ecological approach to research
    and practice is comprehensive, it is also
    challenging.
  • Instability of individual and ecological
    correlates of health
  • Within each correlate, existence of deep and
    often more complex factors
  • This combination presents a complex web of
    association and causation.
  • Are you sure this is what you want to do with the
    rest of your life? ? This course will hopefully
    help you decide.

25
Public Health Summary
  1. Evidence-based public health research is
    essential and challenging (and exciting)!
  2. A strategic and scientific approach to research
    is the only way to ensure that public health
    interventions are developed and implemented based
    on the needs of communities, their cultural and
    social characteristics, and interventions that
    use state-of-the-art strategies to influence
    behaviors and promote positive health outcomes.
  3. Are you ready to research?
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