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Bringing the Evidence into Hi-Def:
`Nita Ferree, MAIS, AHIP, University of Florida, Health Science Center Libraries, Gainesville, FL.
Consuelo Maun Kreider, MHS, OTR/L, University of Florida,
College of Public Health and Health Professions, Occupational Therapy Program, Gainesville, FL.
Presented at AOTA April 16, 2011
Philadelphia, PA
Background on EBP
Traditionally, patients have been treated based on:
What has always worked
What experts in the field say
What is published in textbooks
2
However…
“It takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice.”
Crossing the Quality Chasm: A New Health System for the 21st Century. Washington. D.C. National Academy Press. 2001. http://courses.washington.edu/pharm560/CRPC/resource_articles/IOM_1_Crossing.pdf
Westfall, J. M., Mold, J., & Fagnan, L. (2007). Practice-based research - "Blue Highways" on the NIH roadmap. JAMA, 297(4), p. 403.
= 17 years of practice
3
But Physicians are Still Using…
1. Textbooks
2. Humans (other people)
3. Personal libraries
4. Electronic resources
5. Internet
Davies, K., The information-seeking behaviour of doctors: a review of the
evidence. Health Info Libr J, 2007. 24(2):78-94.
4
…and so Are OTs
Evidence Based Practice: Where do Occupational Therapists Turn for
Answers to Clinical Questions? Online Survey, 2010
Internet , 26%
Other People, 21%
CE, 20%
Journals, 18%
Textbooks, 12%
Library, 2% Other, 1%
Information Sources N=243 named 412 sources
Information Sources
Internet - 106
Other People - 85
CE - 81
Journals - 75
Textbooks - 50
Library - 10
Other - 5
5
Barriers to OT EBP
• TIME -> Large, busy caseloads 1, 2
• ACCESS -> Many resources cost money1
• KNOWLEDGE -> Where to search1, 2 -> How to search1, 2 -> How to interpret, appraise the literature/evidence1,2
The science is intimidating! 2
1. Mount, J. , Kern, S. Delicana, J., Levitiski, B., Michlik, E. & Tran, T. (2006). Environmental supports and barriers to physical and occupational therapists using evidence based practice in a neurological rehabilitation setting. Journal of Neurological Physical Therapy, 30(4), 210. 2. McCluskey, A., & Lovarini, M. (2005). Providing education on evidence-based practice improved knowledge but did not change behaviour: a before and after study. BMC Medical Education, 5:40, doi:10.1186/1472-6920-5-40 Retrieved February 20, 2011 from http://www.biomedcentral.com/1472-6920/5/40
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Other Very REAL Barriers
Many years refining specific interventions
Incompatibility of proposed changes
Private practices may lose clients if they do not provide therapy that the clients expect
McCluskey, A. & Cusick, A. (2002). Strategies for introducing evidence-based practice and changing clinician behaviour: A manager’s toolbox. Australian Occupational Therapy Journal, 49, 63-70.
EBP ain’t child’s play!
7
Definition of Evidence-Based Practice
“The integration of best [current] research evidence
with our clinical expertise
and our patient’s unique values and
circumstances.”
Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2d ed. Edinburgh:
Churchill Livingstone, 2000.
Image: Centre for Evidence Based Medicine http://www.cebm.net/index.aspx?0=4390 8
SO WHAT SHOULD WE BE DOING?
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The Very First Thing to Do is…
…make a librarian your new BFF.
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The Process: Four Steps of Evidence
Based Practice
Step 1: Ask an answerable question
Step 2: Identify the best type of research study to
answer the question.
Step 3: Determine the best resource(s) or
database(s) to search.
Step 4: Evaluate the evidence based upon the
patients’ preferences and your
clinical expertise. 11
ASK AN ANSWERABLE QUESTION
Step 1
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P I C O Your question should include this information:
P Patient or Problem
Describe the relevant characteristics of the patient.
I Intervention
Which intervention are you considering?
C Comparison
Is there an alternative to compare with the intervention?
O Outcome
What do you hope to accomplish or affect?
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Examples of PICO
P Patient or Problem In elderly males or females I Intervention Will Tai Chi C Comparison Yoga O Outcome Improve balance?
P Patient or Problem In patients who have suffered a stroke
I Intervention And received constraint induced movement therapy
C Comparison [none] O Outcome Are functional gains sustained after
one year?
P Patient or Problem In children with Attention Deficit Disorder
I Intervention Does dietary sugar
C Comparison [None]
O Outcome Affect function?
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IDENTIFY THE BEST TYPE OF RESEARCH
STUDY TO ANSWER THE QUESTION
Step 2
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What Type of Study Is Best? If your question is one of… Suggested Best Type of Study
Treatment Therapy Intervention
• Meta-analysis if available, or Systematic/Narrative Reviews
• RTCs
• Cohort Studies
• Case Studies/Series
• Expert Opinion
Population Description
Prognosis
Etiology
• Meta-analysis if available, or Systematic/Narrative Reviews
• Cohort Studies
• Case Control Studies
• Case Study/Series
• Expert Opinion
Instrumentation Evaluation (diagnosis)
• Meta-analysis, if available or Systematic/Narrative Reviews • Psychometric Studies • Expert Opinion
Adapted from:
Miller PJ, Jones-Harris AR. The evidence-based hierarchy: is it time for change? A suggested alternative. Journal of Manipulative and Physiological Therapeutics. 2005 Jul-Aug;28(6):453-7. 16
Identify the Best Type of Research Study
Evidence-Based Levels of Evidence
Adapted from: Evidence Based Nursing: Evidence Based Practice in the Health Sciences.
“Levels of Evidence”. http://ebp.lib.uic.edu/nursing/?q=node/12
Meta-Analysis
Systematic Reviews
Randomized Controlled Trials
Cohort Studies
Case-Control Studies
Case Reports, Case Series
Editorials, Expert Opinion
17
DETERMINE THE BEST RESOURCES
TO SEARCH (FOR FREE)
Step 3
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Meta-Analysis
Systematic Reviews
Randomized Controlled Trials
Cohort Studies
Case-Control Studies
Case Series, Case Reports
Editorials, Expert Opinion
MEDLINE (PubMed) TRIP
Google, Google Scholar
Hierarchy of Resources
Guidelines Clinical Tools (i.e. UpToDate) Critically Appraised Topics
(i.e. OTCATS, OTSeeker, BestBETs) Textbooks
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Finding the highest level of evidence
Meta-Analysis
PubMed TRIP
Systematic Reviews PubMed TRIP
OTSeeker
Randomized Controlled Trials PubMed
TRIP OTSeeker
Meta-Analysis is a subset of
Systematic Reviews
20
Free Resources…
• PubMed http://pubmed.gov
• Google Scholar http://scholar.google.com
• Google.com – search: “Netting the Evidence”
• TRIP http://www.tripdatabase.com
• OTSeeker http://otseeker.com
• OTCATS http://otcats.com
• BestBETS http://bestbets.org
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SEARCHING THE FREE RESOURCES
PICO Example
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The Clinical Question
• Should my patient go home?
• Or should my recommendation be for assisted living or an adult child’s home?
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Should my patient go home? Vs. going to assisted living or an adult
child’s home?
• RESTATEMENT # 1: In elderly clients with cognitive decline, what OT interventions will contribute to safety with independent living
• P = In elderly patients w/ cognitive decline
• I = What OT interventions will contribute to…
• C = (none)
• O = Safety with independent living
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Should my patient go home? Vs. going to assisted living or an adult
child’s home?
• RESTATEMENT #2: What factors will contribute to safety at home for elders with cognitive decline/impairment?
• P = In elderly patients w/ cognitive decline
• I = (none)
• C = (none)
• O = Safety with independent living
25
• RESTATEMENT #2: What factors will contribute to safety at home for elders with cognitive decline/impairment?
• P = In elderly patients w/ cognitive decline
• I = (none)
• C = (none)
• O = Safety with independent living
• RESTATEMENT # 1: In elderly clients with cognitive decline, what OT interventions will contribute to safety with independent living
• P = In elderly patients w/ cognitive decline
• I = What OT interventions will contribute to…
• C = (none)
• O = Safety with independent living 26
RESTATEMENT #1: In elderly clients with cognitive decline, what OT interventions will contribute to safety with independent living? P = In elderly patients w/ cognitive decline
I = What OT interventions will contribute to… C = (none) O = Safety with independent living
• Best types of research: – Meta-analysis, systematic reviews, RTCs…
• Potential Sources: – PubMed?, OT Seeker? OT Cats?
TRIP?...
• Potential search terms: – Occupational therapy, cognitive decline, safe
ADLs, aging, independent living, aging in place
27
RESTATEMENT #2: What factors will contribute
to safety at home for elders with cognitive
decline/impairment?
P = In elderly patients w/ cognitive decline
I = (none)
C = (none)
O = Safety with independent living
• Best types of research: – Overviews, basic or descriptive research, population
studies, qualitative studies
• Potential Sources: – PubMed?, OT Seeker? OT Cats? TRIP?... – Social sciences (ssrn.com; apa.org), ERIC…
• Potential search terms: – Cognitive decline, safe ADLs, aging, independent
living, aging in place 28
Every OT’s Quandary
• OT vs. PT – Permission granted by Erin O'Brien D:\VLC\vlc.exe
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What are your clinical questions?
• RESTATING in PICO format
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PubMed http://pubmed.gov
Limits: Narrow search by date, language, article type, and availability of full-text articles etc.
Search using keywords
Advanced Search: Search builder and History
My NCBI: -> Store and rerun searches -> Email updates -> Customize filters
Single Citation Matcher: Verify or locate hard-to-find
citations
MeSH Database: Search Medical Subject Headings
Clinical Queries: Limits to specific clinical questions
32
A Quick PubMed Search
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Clinical Queries
Take note of search number
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• Google scholar
• Netting the Evidence Filter
40
Google http://google.com
the Netting the Evidence filter
“Netting the Evidence”
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AOTA’S EVIDENCE BASED PRACTICE & RESEARCH LINK
http://aota.org/educate/research
57
AOTA’s Evidence-Based Practice & Research http://aota.org/educate/research
58
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A peek at an AOTA CAT
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USING PUBMED’S SINGLE CITATION MATCHER
What about when you’re only looking for one specific article?
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OTHER RESOURCES So many resources, so little time
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Other Resources for other Types of Questions
• Education
-> ERIC http://www.eric.ed.gov
• Anthropology/Sociology
-> Social Science Research Network http://www.ssrn.com/
• Psychology -> APA Databases http://www.apa.org/pubs/databases/index.aspx
• Engineering, Technology -> US Government Science Portal http://www.science.gov
73
EVALUATE THE EVIDENCE
Step 4
• Source (Journal)
• Research type
• Article
• Methods section 75
Journal Status
Peer- Reviewed, Refereed or Juried?
Practice Journal?
Evaluating the Source
76
What is a “journal impact factor”?
• Impact factor is the average number of citations received per paper published in a specific journal during the two preceding years. It is used to compare different journals within a certain field.
77
OT Journals Ranked by SCImago
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Authors Rankings Online survey of 1st or corresponding authors of peer reviewed articles in 18
Occupational Therapy journals. They were asked to rate the journals based on 11 quality indicators. Total Sample: 554 Completed Survey: 184
Reprinted with permission from the Australian Occupational Therapy Journal, Vol. 54, Roger, S.et.al., “Quality and impact of occupational therapy journals: Authors’ perspectives, 174-184, copyright © 2007, John Wiley & Sons, Inc.
80
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• Some research terms
• Some understanding of…
–Research design
– Scientific method
–Research continuum
Evaluating the Research Type
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Terms you need to know
• Case studies & case series: unique clinical observations/ treatments
• Cross-sectional studies: snap shot descriptive
• Case-control studies: comparing characteristics of people who have a diagnosis to those who don’t
(aka Jargon)
83
• Prospective cohort studies: follow same group over time
• Outcomes studies: results following an intervention
• Randomized controlled trials: controlled experiments
• Systematic reviews & meta-analyses: summative analyses of existing research
84
Even more jargon... From the Methods Section
• Parallel group comparison: each group gets a different intervention
• Paired (or matched) comparison: each group member is matched to someone specific in the other group
• Within subject design: looks at changes made within each subject following the tx
85
• Single blind: Subjects are blinded
• Double blind: Subjects + Investigators
• Crossover: each subject gets the intervention + the control conditions
• Factorial design: effect of 2 or more variables on the outcome
86
Revisiting the Hierarchy
87
AOTA’s Evidence-Based Literature Review
Project Levels of Evidence
I. SR; MA; RCT
II. 2-group non-randomized
III. 1-group non-randomized
IV. Single-subject; descriptive; case series; case report
V. Editorials, Expert Opinion
Gutman, S. A. (2008). State of the journal. American Journal of Occupational
Therapy, 62(6), 619-22
…if question is
answered by an
intervention study
88
But, what about the rest of our clinical questions?
• Basic Research
How will my client’s cultural beliefs affect willingness to follow through on the home activities I recommend?
• Instrument
Can I use the LOTCA to assess cognitive functioning for a child with autism?
• Efficacy What is the best way to give a
home exercise program for a child who has two homes/joint custody and attends an afterschool care program?
Real Life Clinical Questions Aren’t as Simple as “Is intervention X better than intervention Y for client Z?…”
89
Stages of Scientific Method in Clinical Research
1. Observation & description
2. Hypothesis explaining clinical implications
3. Hypothesis to predict outcomes
4. Clinical experiment
5. Summaries of clinical research
90
Reading the Article
• Identify the research design
• Where the design fits in the Hierarchy or the Continuum of research
• Research type consumed
• How research can be incorporated into practice
• Understand meaning of results
92
Evaluating the Article
1. What specific clinical question did it address? – Why was study done? What clinical questions?
2. What type of study? a) Primary or secondary?
b) Types of primary: experiments, clinical trials, surveys
3. What type of research? – Intervention, instrument development/testing,
prognosis, causation 93
Evaluating the Methods section
1. Does this new research add to what is already known? In what way(s)?
2. Who was it about?
3. Did the design match the question asked?
4. Was bias minimized or avoided?
5. Was the study large enough (or long enough) to make the results credible?
94
PUTTING IT ALL TOGETHER
95
EBP
• An APPROACH to practice – Clinician is aware of the evidence
– It’s strength
– How it bears on her/his clinical practice
• A PROCESS – Development of evidence-based knowledge
– Attitude
• Awareness
• Creativity
• Judgment
• Consultation
96
3 legs of EBP
1. Clinical expertise
2. Client & family
3. Science
Baily, B. J., Johnson, J. T., & Newlands, S.D. (2006). Head and Neck Surgery – Otolaryngology, 4th ed. Philadelphia, PA: Lippincott, Williams, & Wilkins (pg 37) 97
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Questions for thought…
• Is EBP different from what you thought it was? How is it different?
• How are you already practicing EBP?
• How can you contribute to the evidence?
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Giving Back… Contributing to the Evidence
• OT CATS http://otcats.com/template/index.html
• BestBETs http://bestbets.org/links/BET-CA-worksheets.php
• AOTA Clearinghouse – coming in July
101
Thank you!
• Nita Ferree
– Research librarian
– nferree@ufl.edu
• Consuelo Kreider
– ckreider@ufl.edu
Links to free evidence:
• http://ot.phhp.ufl.edu/fieldwork/educators/
• UF OT fieldwork educators
102
Special thanks: Emily Pugh
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