Transcript Evidence Based Practice

Evidence Based Practice
January 10, 2006
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.
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.
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
Evidence Based Practice
 Steps
for the evidence-based practice of medicine by
practitioners:
1.
2.
3.
4.
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.
A Hierarchy of Levels of Best
Evidence
 Level
1 evidence is defined as strong evidence from
at least one systematic review of multiple welldesigned 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 welldesigned trials without randomization, single group
pre-post, cohort, time series, or matched casecontrolled studies.
A Hierarchy of Levels of Best
Evidence
 Level
4 evidence is defined as evidence from welldesigned 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.
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).
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.
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).
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
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.
Rehabilitation Philosophy
Intrinsic worth of
persons with disabilities
People with disabilities are capable of change
Persons’ with disabilities can contribute to
society
Rehabilitation counselors are committed to the
successful completion of the rehabilitation
process
Biopsychosocial model
RC Scope of Practice Statement
(according to the CRCC)
 Rehabilitation
counseling is a systematic process which
assists persons with physical, mental, developmental,
cognitive, and emotional disabilities achieve their
personal, career, and independent living goals in the
most integrated setting possible through the application
of the counseling process. The counseling process
involves communication, goal setting, and beneficial
growth or change through self-advocacy, psychological,
vocational, social, and behavioral interventions.
Scope of Practice: RC Specific
Techniques & Modalities
 Assessment
& appraisal
 Diagnosis & treatment planning
 Career (vocational) counseling
 Individual & group counseling
treatment interventions focusing
on adjustment to medical &
psychosocial impact of disability
 Case management, referral &
service coordination
 Program evaluation & research
 Interventions
to remove
environmental, employment and
attitudinal barriers
 Consultation services among
multiple parties and regulatory
systems
 Job analysis, job development
and placement services, including
assistance with employment and
job accommodation, and
 The provision of consultation
about and access to rehabilitation
technology.
Evidence-Based Practice: Implications
for Rehabilitation Counseling
1.
2.
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)
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).
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
conceptualization…Model-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).
Mission of Public Health

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Mission: “to fulfill society’s 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.
Functions of Public Health

The public health field is organized in
three core functions:
1.
2.
3.

Assessment
Policy development
Assurance
Public health research underlies and
cuts across all three core functions.
Functions of Public Health
1.
Assessment
a.
b.
c.
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)
Functions of Public Health
2.
Once we understand the health needs of a
communities and their determinants … we
engage in policy development
a.
b.
c.
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
Functions of Public Health
3.
Following policy development, we provide
assurance.
a.
b.
c.
d.
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
Evidence-Based Interventions

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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 evidencebased. This includes SBS.
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)
SBS: Social Ecological Approach

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Focus on the interrelationships among
individuals and:
Biological characteristics
Psychological characteristics
Behavioral characteristics
Social environment
Cultural environment
Physical environment
SBS: Social Ecological Approach
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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.
Public Health: Summary
1.
2.
3.
Evidence-based public health research is
essential and challenging (and exciting)!
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.
Are you ready to research?