Evidence-Based Practice - robinsteed
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Transcript Evidence-Based Practice - robinsteed
Using Evidence to Make Everyday
Decisions
ROBIN STEED, PHD, LOTR
LOTA CONFERENCE
2014
Objectives and Agenda
Part One
• Intro: What? Why?
• Learn the 5 easy steps:
1. Identify the problem
2. Ask a question
3. Find some answers
4. Evaluate the answers
5. Try the best one out
Part Two
Practice EBP Skills
Easy
Checklist
Getting Started
Part One
Introduction to Evidence Based
Practice
WHAT DID YOU SAY?
NOW WHY WOULD I WANT TO DO THAT?
What is EBP?
knowledge
Research
Client
Factors
Clinical
Reasoning
Best Practice
(Sackett ,Straus, Richardson, Rosenberg, & Haynes, 2000).
wisdom
Why? Client education
Why? Client trust
Why? Do no harm!
NSAIDs do not reduce fibromyalgia pain
No evidence to support psychoanalytic (Freudian) treatment
Stretching does not prevent or improve contracture
Sheltered workshops do not increase employment
Cognitive remediation does not improve function
Why? Your own peace of mind
Why? Our clients deserve the BEST!
The Process of
Evidence Based Practice
Yes, you too can be
an evidenced based
practitioner in just 5
easy steps!
Identify the clinical problem
1
I want my clients to:
be more functional
have a higher quality of life
have better outcomes faster
transfer skills to home environment
have maintained gains at follow-up
have better adherence to treatment plan
Types of problems and their questions
1
Assessment/Diagnostic (What is the best assessment to
use to identify performance deficits?)
Intervention efficacy (What is the best treatment?)
Intervention cost-effectiveness (Which treatment gives
me the most return for my money?)
Identify your problem
1
Complete the problem identification worksheet.
Examples:
My clients don’t like constraint induced therapy, would
a modified approach work just as well?
My clients have poor sensory motor skills and have
trouble with handwriting.
We send instructions home with the clients but we
aren’t sure they understand them.
A good problem
1
Ask a PICO question
2
Patient or Problem
Intervention
Comparison Intervention
Outcomes
PICO Examples
2
In children with autism, evidence on vigorous vs. mild
exercise, on stereotyped behaviors?
In clients with schizophrenia, evidence on environmental
supports on ability to transition to community?
In children with hemiplegia, evidence on constraint
induced therapy on motor function?
Work on step two worksheet
Good Questions
2
Within occupational therapy domain
“What” questions, not ‘why’
Just right focus, not too wide, not too narrow
Measurable in some way
Clinically important
Not already answered!
Take a break and relax!
Looking for some answers
3
P: serious or chronic mental illness, psychosis,
schizophrenia, mood disorder, anxiety disorder
I: child care, meal preparation, home management,
shopping, time management, safety, social participation,
education exploration, retirement exploration,
employment seeking
O: employment and education
(Arbesman & Logsdon 2011)
Types of evidence
3
Meta-analysis
Systematic review
Critically appraised papers (CAPs)
Critically appraised topics (CATs)
Individual journal articles
wikipedia
Where do we find the (free) evidence?
3
AOTA Evidence Exchange
Centre for Evidence-based Mental Health
Cochrane Consumer Network
McMaster Occupational Therapy EBR Reviews
National Guideline Clearinghouse™ (NGC)
OT Seeker - The Occupational Therapy Evidence Database
OT Evidence at www.otevidence.info
Everyday Evidence Podcast from AOTA
Centre for Reviews and Dissemination
Where do we find the articles?
3
Pub Med ncbi.nlm.nih.gov/pubmed
Pub Med Central: pubmedcentral.gov
Directory of Open Access Journals: www.doaj.org
NBCOT if registered (ProQuest)
Google Scholar
PubMed Central
3
Open Access:
• Arthritis
• Autism Research
• Journal of Pain
Research
NBCOT
3
ProQuest
RefWorks
AJOT
An easy way to keep
OTJR
track of your articles
OT International
OT Canada, NZ
Google Scholar
3
Critically evaluate the evidence
4
Read the article
Fill out a form
Critical
Review from McMaster’s University
CAP from AOTA
CASP in the UK
Critically evaluate the evidence
4
Study Design
randomization
control for bias
ethical
control group
Sample
size
described
Assessment Properties
Intervention
detailed/replicable
Statistical Analysis
Threats to Validity
internal
external
Make a decision
Given the quality of the
evidence, what are the
implications for clinical
practice?
Implement and evaluate
5
Implement
Evaluate
What is the risk?
Choose outcome
What is the cost?
measures
Keep records of
outcomes and adverse
events
Do a ROI assessment
Do you need special
training?
Getting client consent
Facility support
Take a longer break!
Part Two
Evidence Based Practice Practice
1. Easy Checklist
2. Getting Started
Checklist
Are the results valid?
Subject
selection
Research design
Data analysis & results
Are the results meaningful?
Are the results applicable to my client?
Source: Portney & Watkins (2009)
How were the subjects selected?
1
Random sampling
Random assignment
Convenience
Sample Size?
2
not that great <30> much better
Sample Size?
3
Inclusion: who we let in
Exclusion: of the ones we let in,
who do we kick out
How were participants assigned?
4
Did it result in two equal groups at the start?
Was the design reasonable?
5
• Exercise 2x week
• Constraint Induced Therapy 20 hours/day
• A 4 hour workshop on cultural competence
Was the intervention the reason for results?
6
•
•
•
•
•
•
•
•
•
History
Measurement Instrument
Statistical Regression
Maturation
Unequal Groups
Attrition
Multiple Treatments
Treatment Diffusion
Participant Responses
History
Instrumentation
Statistical Regression
Maturation
Unequal Groups
Mortality/Attrition
Multiple Treatment
Treatment Diffusion
Participant’s Reactions
Artificial environment in effort to control
extraneous variables (can’t generalize to real
world)
Hawthorne effect- subjects aware of being
studied
John Henry effect- subjects get competitive
between groups
Novelty effect- increase motivation because tx is
new
Was everyone blind to treatment?
7
Did the researchers pick the right assessment?
8
• Toglia Categorization Assessment or the Allen
Cognitive Levels to measure change over time.
• Using the O’Connor as a measure of functional
ability
Observation versus self-report
Simulation versus natural setting
Standardized versus made up test
Were the measures valid and reliable?
9
Validity
Reliability
Content
Re-test
Face
Tester
Criterion
Internal Consistency
Concurrent
Pearson’s
Alpha
r
ICC
.7 and above
Cronbach
How many people dropped out of the study?
10
Why?
Percentage
http://www.englishblog.com/2013/10/cartoon-oreos-more-addictive-than-cocaine.html#.UuqugLTkroI
Were the appropriate statistics used?
11
Variables
Levels
Groups
n > 30
n < 30
1
2
1
Paired t test
Wilcoxon
2
Unpaired t (independent t)
Mann-Whitney U
1
One way repeated measures ANOVA
Friedman
2
One way ANOVA
Kruskal Wallis
1
2 way repeated measures ANOVA
2+
Two way ANOVA
3+
2+
Source: Portney & Watkins (2009)
Were the results significant?
12
Increased shoulder ROM 10° = function?
Power- the ability of a study design to find an effect if there
is one, depends on:
Effect size- the amount of impact the independent
variable has on the dependent variable (Cohen’s d)
small= .20 medium= .50
large = .80
Sample size- increases the power to find effect
Source: Portney & Watkins (2009)
Take another break
Are the results meaningful?
13-16
Is the intervention feasible, cost effective?
Is there any risk?
Is this within the scope of OT?
What is the ‘take home’ message?
www.haven.com
www.bioness.com/Healthcare_Professionals/H200_for_Hand_Paralysis.php
Are the results applicable?
17-19
Given the quality of the study, should I apply this to my
practice?
Do I need extra training?
Do I have the resources to replicate intervention?
Are subjects similar to my clients?
Get Real!
LIKE I AM REALLY
GOING TO HAVE TIME
FOR ALL THIS!
Why not? Therapists said . . .
Lack of time (87%)
Large workload/caseload (67%)
Limited searching skills (50%)
Limited critical appraisal skills (44%)
McCluskey (2003)
Expert Solutions
Prioritizing daily tasks
Making plans & goals
Delegating tasks
Setting aside blocks of time
Dividing into manageable chunks
Influences on Success
Readiness for change
Personal and organizational expectations
Presence of deadlines
Availability of support
EBP in just 10 minutes a day!
Join AOTA (Journal Club Toolkit)
Listen to AOTA evidence podcast
Read one or two journal articles a month
Look up the quick summaries on EBP web sites
Sign up for evidence alerts at McMaster’s
Start an EBP file at work
Join/start a journal club
Keep records
EBP Books on Evidence
photos: amazon.com
EBP Books on Implementing EBP
Reasons to Create Evidence
Referrals
Client self-efficacy
Funding for program
Third party payment
Resource allocation
Keep your job !
References
Arbesman, M., & Logsdon, D. (2011). Occupational therapy interventions for employment and
education for adults with serious mental illness: A systematic review. American Journal of
Occupational Therapy, 65, 238-246.
Dunn, (2008). Bringing evidence into everyday practice. Thoroughfare, NJ: Slack
McCluskey, A. (2003), Occupational therapists report a low level of knowledge, skill and
involvement in evidence-based practice. Australian Occupational Therapy Journal, 50, 3–12.
doi: 10.1046/j.1440-1630.2003.00303.x
Page, S. J., Levine, P., & Hill, V. (2007). Mental practice as a gateway to modified constraint
induced movement therapy: A promising combination to improve function. American Journal of
Occupational Therapy, 61(3), 321–327. http://dx.doi.org/10.5014/ajot.61.3.321
Portney, L. & Watkins, M. (2009). Foundations of clinical research (3rd ed.).Upper Saddle River NJ:
Pearson.
Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence
based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone.
Gladstone, D. J., Danells, C. J., & Black, S. E. (2002). The Fugl-Meyer Assessment of Motor
Recovery after Stroke: A Critical Review of Its Measurement Properties. Neurorehabilitation and
Neural Repair, 16(3), 232-240. doi: 10.1177/154596802401105171
Resources at LSUHSC Shreveport
www.robinsteed.pbworks.com