Sports Epidemiology - National Athletic Trainers' Association
Download
Report
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