Transcript Evidence based decision making in pediatric physical therapy

Evidence based decision making in
pediatric physical therapy
Pediatric physical therapy
o Infants ( under age2 years)
o Children ( from 2-12 years)
o adolescents ( from 13-16 or 18 years)
 Why Pediatric physical therapy is a specialized
entity ?
o Physical/ psychological/emotional differences
o Family participation and Family Dynamics
o Huge population (24% of 307,006,550 in USA) and 37% of
164,741,924 in PK
EBP VS. Non-Standard treatment
 Non-standard treatment
• not verified through the scientific study
• not published or included in peer-reviewed
journals
 90% treatment methods in physical therapy
are taken from professional education,
continuing education, and experience.
Turner and Whitfield, PTs use of EBP. Physiotherapy Research International, 2(1), 1997
What is evidence based practice?
Paradigm Shift in 1992
 “the conscientious, explicit and judicious use of current best
evidence in making decisions about the care of individual
patients”
(Sackett et al, 1996)
 Barriers for achieving EBP
Steps in achieving EBP
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Formulating a Question
Finding Evidence
Appraisal of evidence
Translation of evidence to practice
Evaluation of evidence
“ the responsibility to deliver evidence based treatment rests with all
members of profession not only with researchers”
Finding Evidence
 Peer-reviewed journals: Primary source of evidence
o sources;
1) Hard Copy libraries catalog
2) Electronic databases ( e.g. MEDLINE, ERIC, PsycINFO, PEDro,
Cochrane, Hooked on evidence)
Expert Consensus/ expert opinions
o Secondary source of evidence ( e.g. practice guideline,
clinical pathway) e.g. C-Spine rule, Ottawa Ankle rule
o Appraisal of guidelines to research and evaluation (AGREE)
 Textbooks & personal experiences are also
secondary sources of evidence
Appraisal of evidence
 All available evidence is not Diamond or Gold
Important steps in appraisal ( primary source)
o Find out a relevant research that you think can
answer your question ( journal article/systematic
review, etc.)
o Appraise Research design: Quantitative Vs Qualitative
 Quantitative Research- Experimental Vs non-experimental
 Experimental research- true vs. quasi-experimental or
experimental research with no control group
 Internal Vs. External validity
 Efficacy (RCT) Vs. Effectiveness (non-experimental)
Hierarchical Evidence Based Practice
Levels of Evidence
1+
High quality meta-analysis (based on double blind)
High quality RCT (double blind)
1
Good meta-analysis (based on single blind RCTs)
Good RCT (single blind)
2+
Poor quality meta-analysis (based on open studies)
Poor RCT (open studies)
2
Cohort study
3
Outcomes, relationship, retrospective studies
4
Case report, expert opinion
Five-level system of evidence
Used for experimental design ( for single
research)
• Level I & II for randomized control trial (RCT)
• Level III & IV for Quasi-experimental design ( when
there is no randomization)
• Level V for quasi-experimental design ( when there is
no control group)
Grades of Recommendation for
systematic reviews

A systematic review is a comprehensive survey of a topic in which all of
the primary studies relevant to topic have been systematically identified,
appraised and then summarized.
• Grade A recommendation is for at least one level I
study
• Grade B recommendation is for at least one level II
study
• Grade C recommendation is for level III, IV or V
studies
 Meta-analysis(studies that used inferential statistics)
Translation of evidence to practice
 “Evidence alone does not make decision, people do”
 “why in health care transfer of evidence is
practice is slow”?
Patient/client & their family perspectives
o Family dynamics
o Informed choices ( family voices, kid power)
o Cultural differences
o Financial resources
Clinical Reasoning and Decision
Making
Medical Model
Social model
• Person has a disease
• Treat the disease
• How are we going to cope
with disease?
• Accepting person means:
we have change our
practice, and it will cost
more.
• Finally these persons are
excluded
• Person has an impairment
• What are the barriers?
• What are solutions to
overcome barriers
• Diversity and cultural
differences are accepted
• Finally these persons are
included
Frameworks for Decision making
Frameworks helps in clinical decision making (
diagnosis, intervention, prognosis, etc)
1. Nagi Model presented by Saad Nagi in 1965
2. International Classification of Impairments,
disabilities, and Handicaps (ICIDH) published
by WHO in 1980
3. International classification of Functioning,
disability (ICF) and Health by WHO in 2001.
Nagi Model
 Active Pathology: Interruption or interference of
normal processes and efforts of the organism to
regain normal state.
 Impairment: Anatomical, physiological, mental, or
emotional abnormalities or loss.
 Functional limitation: Limitation in performance at
the level of the whole organism or person
 Disability: Limitation in performance of socially
defined roles and tasks within a sociocultural &
physical environment
ICIDH
 Disease: Intrinsic pathology or disorder
 Impairment: Loss or abnormality of psychological,
physiological, or anatomical structure or function at
organ level
 Disability: Restriction or lack of ability to perform an
activity in a normal manner
 Handicap: Disadvantage resulting from impairment
or disability that limits or prevents fulfillments of a
normal role in community ( Depending age, sex,
cultural factors)
ICF
 Body Functions and Structures: Changes in body
functions (physiological) or structures (anatomical).
Change may be positive or negative( impairment)
 Activities: Functioning at an individual level
 Participation: Functioning at a societal level
 Activities and participation can be viewed in terms
of capacity and performance
 Disability occurs when activities are limited or
participation in societal roles is restricted.
 Example: child with Hemiplegia
Patient/client Management Model
(adapted from the APTA Guide to PT practice)
Examination
Physical therapists are educated and clinically trained
to perform a number of tests and measures that can
assess an impairment/problem
 History ( General information & core interview)
 General Information: Age, Gender, Race/ethnicity,
Past medical/surgical history, clinical tests
 Core Interview: History of present illness, pain &
symptom assessment, medical treatment, current
level of fitness, review of systems
 How to incorporate evidence in examination??
Patient/client Management Model
cont..
Evaluation
Diagnosis
Physical therapists can utilize
data collected during
examination procedures to
assess impairment that
may reflect current
pathology, and functional
limitation, as well as the
propensity for future injury
which may impact quality of
life, and mortality
 Physical therapists can
utilize data collected during
examination procedures to
provide a physical therapy
diagnosis including
impairments, and functional
limitations
 Examples of PT diagnosis:
 Muscle weakness, muscle
Imbalance, lack of
coordination
Patient/client Management Model
cont..
Prognosis
Interventions
 Based on the outcomes
measured during the
examination process, the PT
can make statements
regarding potential benefits
to be derived from
interventions that target
impaired measurements, as
well as resultant or
potential pathology, and
functional limitation.
 Physical therapists may
provide
• coordination,
communication, and
documentation
• patient/client education
• direct intervention
outcomes
What will be final outcomes?
• Minimize functional limitations
• Health promotion and wellness
• Optimization of patient/client satisfaction
• Prevention of disability
Evaluation of
intervention/outcomes
Case report ( non-experimental)
Single subject design (experimental)
 ABA or withdrawal design
• A number of observations with no treatment (the A or baseline sessions)
are followed by a number of observations with treatment (B).
• If the treatment is successful, there should be improvement on the
Dependent variable in the B sessions.
• To show that the improvement is the effect of the Independent variable
and not maturation or history, another no-treatment or A session is given.
ABA or Withdrawal Design
A
B
A
Baseline Phase
0
Treatment Phase
Withdrawal phase
0
0
0
0
0
0
0
0
0
0
0
0
0
Physiotherapy program evaluation
• Overall monitoring of program effectiveness
• Evaluation of record keeping
• Monitoring of therapist adherence to program
policies
• Monitoring of therapist interaction with client, other
health care provider, and third party payers
• Evaluation of client satisfaction and long-term
outcomes
Monitoring services within a
database
• Multiple users
• Proper organization and storage of data
• Can easily be retrieved, updated and
reorganized
• Requirement of Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) & Commission on Accreditation of
Rehabilitation Facilities ( CARF)
Formal Program
Evaluation
• Mostly evaluated by a separate evaluating
body
• Summative VS Formative evaluation
Framework for program evaluation
o Does the method of service delivery represents the best educational
practices?
oIs the intervention being implemented accurately and consistently?
oIs an attempt being made to verify the effectiveness of intervention
objectively?
oDoes the program carefully monitor patient progress and demonstrate a
sensitivity to points in which changes in services need to be made?
oDoes a system exist for determining the adequacy of patient progress
and service delivery?
oIs the program accomplishing its goals and objectives?
oDoes the service delivery system meet the needs and values of the
community and clients it serves?
Circular versus Hierarchical EBP
• Hierarchical model based on
pharmacology model of
therapy
• Applied to other complex
interventions
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–
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Surgery
Physiotherapy
Occupational Therapy
Complementary or
Alternative Medicin
Circular EBP
• Multiplicity of methods
• Used in a complimentary fashion
• Each research method has strengths and
weaknesses
• Achieve a result – replicate with other
methods
Circle of Methods
• Experimental methods
that test specifically for
efficacy (upper half of
the circle) have to be
complemented by
observational, nonexperimental methods
(lower half of the circle)
that are more
descriptive in nature
and describe real-life
effects and applicability.
Questions
&
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