Transcript Sports Epidemiology - National Athletic Trainers' Association

EVIDENCE
IT CAN BE FOR US OR UP AGAINST US
chad starkey, phd, at, fnata
professor
coordinator, division of athletic training
(the) ohio university
athens, oh
A trip down memory lane…
HISTORICAL PERSPECTIVE
The Way We Were (p 1)
Arnheim (1968)
“The first athletic trainers were
hangers-on who ‘rubbed down’ the
athlete. Since they possessed no
technical knowledge the training
techniques usually consisted of a rub,
the application of some type of
counterirritant and poultices. Many of
those early [athletic] trainers were
persons of questionable character.”
(p. 4)
The Way We Were (p 2)
 Apprenticeship
 The “master” would teach the
apprentice “secrets.”
 Information was not shared
 ATs taped in private to keep the
“opposition” from learning their
techniques.
 In today’s terms, all information
was “proprietary”
 There was “corporate espionage”
The Way We Were (p 3)
Legwold (1984)
“A lot of older [athletic] trainers
didn’t want anyone with a formal
education. They said it wouldn’t
work, they wouldn’t do the
menial tasks like clean whirlpools,
sweep up, things like that.”
(p 252)
Then Things Began to Change…
@%#)!)*
 Pinky Newell
 Radical Thought: ATs should
be formally educated
 Bachelor’s degree required
for NATA membership
 Promoted education and
knowledge exchange
between ATs
 What would he think of
where we are today?
2011???
Mid 1980s…
“[Athletic] trainers will continue to use
snake oil, magic, voodoo, or anything
else to get [their] players back on the
field…”
March 1997
“Remember [athletic] trainers ain’t nothing
but tape tearers… And that’s all we’ll ever be.”
For example, what is the sensitivity (true positive) and
specificity (true negative) for the McMurray test for
meniscal pathology when compared with the ‘‘gold
standard’’ of magnetic resonance imaging? If the
consensus among a group of medical and allied
medical professionals, based on review of the scientific
evidence, is that the McMurray test is useful, then it
should be included in our educational programs. If,
however, data demonstrate that this test lacks sufficient
sensitivity and specificity, this practice should
be abandoned and our students’ time spent perfecting
those assessments deemed most valid
First Call for EBP?
Opportunities Missed
 Dehlems’ Bill
 Standardizing education
 Increasing educational standards
 Standardization of state practice acts
 Specialty certificates
 Best practices
 We are walking the walk…
Meeting Health Care Expectations
EVIDENCE IN PRACTICE
What is “Evidence-Based
Practice?”
Evidence-based practitioners incorporate the best
available evidence, their clinical skills, and the
needs of the patient to maximize patient
outcomes. An understanding of evidence-based
practice concepts and their application is essential
to sound clinical decision-making and the critical
examination of athletic training practice.
Athletic Training Education Competencies (ed5), 2011.
5 editions/61 years since profession was founded
5 editions/30 years since formal education began
For You Visual Learners…
Research
Evidence
Situation
Decision
Making
Available
Resources
Clinician
Expertise
Patient
Needs
Patient
Culture
Efficient, effective
patient care
What EBP is Not
 It’s not conducting “research”
 It’s keeping up-to-date
 It’s not a cookbook
 It’s using knowledge
 It’s not about the clinician
 It’s about the patient
 It’s not about stagnation
 It’s about advancement
So Where do we Find Evidence?
 Peer-reviewed journals
 Presentations/Conferences
 Clinician expertise
 Experience ≠ Expertise
 Invest in the following modalities:
 pubmed.com
 pedro.org.au
 scholar.google.com
 Dr. Winterstein
Possible Examples
 Physical therapy
 Occupational therapy
 Nursing
 Speech pathology
 Audiology
 Physicians
(Possible, but they’re soooo cliché)
NASCAR??
BARRIERS TO IMPLEMENTING
EVIDENCE BASED PRACTICE
Barriers | Implementation
 Accountability (or lack thereof)
 Esoteric
 Perceived arrogance
 Time constraints
 What constitutes evidence?
 Students’ clinical experiences
 Coaches’ expectations
Esoteric
MANCOVA
ANOVA
Specificity
Relative
Risk
f
Sensitivity
value
Positive
Likelihood
Ratio
Crossover
Design
Post
hoc
P < .05
Number
Needed
to Treat
Correlation
Coefficient
Odds
Ratio
Honestly
Significant
Difference
Repeated
Measures
Whoa,
dude… This is
so000 cool
Raganomics
What Constitutes Research
Evidence?
 Hallmarks:
 Research must be conducted
on humans
 Control group (and
randomized)
 Control ≠ nothing
 Protocol must be described
 Results published in peer-
reviewed journals
 However clinician expertise
is a valuable element.
Practical View of Evidence
 Physics
 Does the physical principles produce the effect?
 Physiology
 Does the effect alter healing/metabolism?
 Efficiency
 Efficient use of the clinician’s and patient’s time?
 Outcomes
 Does the sum of the above equal positive patient
benefits?
Volume and Time
 Ivan Toffler: Future Shock
 Information Overload
 JAT+JSR+ AJSM = 524 articles in 2010
 44 articles/month to keep up on
pertinent literature
 Clinically
 Initially may take away from patient
care time (or “leisure time”)
 Should be seen in a return on
efficiency of care
Despite the Contradiction
and Confusion…
 Conflicting
 Think diet plans…
 Consensus is still in flux
 Shortage of evidence
causes sudden change
 Lack of profession-
specific evidence
 Validation of
“borrowed evidence”
When “Evidence” Goes Bad…
Not a Rare Event
Plausable
• Does the premise sound plausible?
• Can disease be spread that way?
“Validated”
• Supported by an “authority”?
• FOX, CNN reported it, so…
Action
• Actions are implemented
• Media hysteria about the risks
Are ATs Vulnerable to Hype?
 Pressure to return athletes




to play – Not insurance co.
Desperation may override
logic
Anecdotal claims over
research-based findings
Millions of $$$$ spent on
devices whose efficacy are
not proven
Untold hours wasted using
these devices
Clinical Education
Program Expansion (chad.0)
 Not “Soapboxing” but….
 The large number of programs:
 Dilutes student pool
 Dilutes educator pool
 Dilutes pool of researchers
 Dilutes state and federal funding
 More difficult to obtain cohesion
The Other End of the Telescope
 Many are still rooted in an athletic
rather than healthcare model
 RTP & wins were the outcome measure
 Coaches’ expectations dictate care
 Laissez-faire attitude from
“other” professions
 We lived in our own realm
 Move to the mainstream of
healthcare
 Placed us under the microscope
INTEGRATING EVIDENCE
We Are No Longer “Unique”
How Important is Evidence?
 OUR FUTURE DEPENDS ON IT!
 Better, more efficient patient care
 Improved working conditions (work load)
 Improved salaries
 RESPECT
 Continued retention of our “best and
brightest”
Most Prominent Evidence
 Diagnostics – Most straight forward
 Efficacy of clinical diagnostic tests
 Clinical decision rules
 Interventions – Most easily misinterpreted
 Efficacy is situational
 Pathology
 Patient demographics
 Clinical prediction rules
 But a piece is missing…
The Missing Piece…
 Outcomes Data
 Professional efficacy
 Reimbursement
 Licensure
 Obtaining
 Revising
 Job development
 Job retention
 Salaries
 Cost-effectiveness
We can say that we are the experts (but only we will listen)
Missing element in VISIONQUEST
Professional Benefits
 Evidence Supporting
AT:
 Educational standards
 Research conducted
 Evidence Lacking:
 Patient outcomes
 Cost effectiveness
 Profession-specific data
CMS is more than just a reimbursement issue!
Higher Clinical Practice
Standard
 Improved patient care
 Better use of time
 Our patients are getting more
savvy.
 They have access to evidence too
 Some correct
 Some incorrect
We must all be in this together (or we won’t be “we” anymore)
ACTIONABLE ITEMS
Education
 Contemporary research serves as basis
 Instructors should:
 Develop content expertise
 Revise lecture notes regularly
 Textbooks only serve as the foundation…
 There is NO reason to teach 100s of special
tests
 (See Board of Certification slide)
 There must be congruence with clinical
education
NATA
 “Best Practices” document
 Position Statements
 Scientific basis
 Clinically written
 Updated when need arises
 Web archive of relevant research-based
information
 Continue to promote the professional
development and consumption of research
 Teach educators and clinicians about EBP
Journal of Athletic Training
NATA+JAT+JSR+Thinktank =
 Evidence blasts (evBlast?)
 Concise, nongeeked-out research blurbs with
an emphasis on clinical application.
Use the Ingersoll Test First when Ruling Out Slap Lesions
The Ingersoll test has been identified as the clinical test that best rules out
the presence of possible SLAP lesions. If this test is negative the chances
are good that the patient does not have tear of the long head of the biceps
tendon at its insertion on the superior glenoid labrum.
This could (should) also be reprinted in the NATA News & website.
Board of Certification, Inc.
 Certification Examination
 Two sources does not a good test question
make (poetic, huh?)
 Examination questions should be:
 Decision-making driven
 Evidence-based
 Inform us of the exact
skills tested on the
exam!
 Basis of education/
testing
NATA News
 Most widely read AT
publication
 Tone? Focus?
 Perfect opportunity to have
research synopsis
 Done to an extent now
 Increased emphasis
Researchers
 PROFESSION-SPECIFIC EVIDENCE
 NATA Foundation fosters research
 Support the Foundation!
 All types of research are important
 Priority should be given to research that supports
the NATA’s strategic needs
 (Again) encourage the development of:
 Multi-centered research projects
 Researcher/clinician research partnerships
Opportunities
 Hard times present opportunities
 Athletic trainers are ideal:
 Capitated healthcare service costs
 Point of first medical
contact in underserved
areas
 Early intervention
prevents long-term
costs
LET’S RETHINK THE ORIGINAL
PREMISE
Tomorrow’s (26 February 2012)
State of Affairs
 “[Athletic] trainers will continue to use
snake oil, magic, voodoo, or anything else to
get [their] players back on the field…”
 “Athletic trainers will use science, research, sound
decision-making, and their clinical expertise to
return [their] patients back to their desired lifestyle
and level of activity.”
OPPORTUNITY
LET’S NOT WASTE IT!
(Please wake up now)
THANK YOU