EVIDENCE EVIDENCE- -BASED HEALTH CARE BASED HEALTH CARE BASED - - PowerPoint PPT Presentation

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EVIDENCE EVIDENCE EVIDENCE EVIDENCE-

• BASED HEALTH CARE

BASED HEALTH CARE BASED HEALTH CARE BASED HEALTH CARE

AND OTHER MYTHS OF A MODERN AGE AND OTHER MYTHS OF A MODERN AGE AND OTHER MYTHS OF A MODERN AGE AND OTHER MYTHS OF A MODERN AGE…

…

Peggy Mancuso, PhD, CNM, RN Peggy Mancuso, PhD, CNM, RN

. .

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An Overview of EBM An Overview of EBM

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Evidence Evidence-

• Based Health Care

Based Health Care

Definition Definition

• Conscientious, explicit, judicious use

Conscientious, explicit, judicious use

• Current best evidence

Current best evidence

• To make decisions about health care

To make decisions about health care

• Application of working knowledge to treatment:

Application of working knowledge to treatment:

• Medical informatics

Medical informatics

• Clinical epidemiology

Clinical epidemiology

• Integration of:

Integration of:

• Clinical expertise

Clinical expertise

• Best external evidence

Best external evidence

• Patient and society values

Patient and society values

• Patient expectations

Patient expectations

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Ways to Classify the Evidence Ways to Classify the Evidence Type of Review Type of Review – – or Individual Study

• r Individual Study

1. 1.

Systems Systems

2. 2.

Synopses Synopses

3. 3.

Syntheses Syntheses

4. 4.

Studies Studies

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Hierarchy of Evidence Hierarchy of Evidence Classification of Intervention Studies Classification of Intervention Studies

Expert opinion without explicit critical appraisal or Expert opinion without explicit critical appraisal or based on physiology or bench research based on physiology or bench research

5 5

Case series (poor cohort or case Case series (poor cohort or case-

• control)

control)

4 4

Individual case Individual case-

• control

control

3b 3b

Systematic review with homogeneity of case Systematic review with homogeneity of case-

• control

control

3a 3a

Individual cohort study or Individual cohort study or ↓ ↓ quality RCT quality RCT

2a 2a

All or none All or none

1c 1c

Individual RCT with narrow confidence interval Individual RCT with narrow confidence interval

1b 1b

Systematic review with homogeneity of RCTs Systematic review with homogeneity of RCTs

1a 1a

Therapy/prevention/etiology/harm Therapy/prevention/etiology/harm

Evidence Evidence Level Level

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The Most Basic of Statistics The Most Basic of Statistics

• Validity

Validity

• Accuracy of measure

Accuracy of measure

• Measure what we intends?

Measure what we intends?

• Reliability

Reliability

• Repeatability of measure

Repeatability of measure

• P

P-

• value (probability)

value (probability)

• Not as good as we think

Not as good as we think

• Number needed to treat

Number needed to treat

• Number needed to harm

Number needed to harm

Source: Stroudwater Associates - MacKinney

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Two Different Approaches to Two Different Approaches to Evidence Evidence-

• Based Practice

Based Practice

• Clinical practice guidelines

Clinical practice guidelines

• “Top

“Top-

• down” approach

down” approach

• Tell clinicians how to practice

Tell clinicians how to practice

• Favored by health care systems

Favored by health care systems

• Evidence

Evidence-

• based medicine

based medicine

• “Bottom

“Bottom-

• up” approach

up” approach

• Teach clinicians how to find answers

Teach clinicians how to find answers

• Favored by medical educators

Favored by medical educators

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Basic 5 Basic 5-

• Step Process of Evidence

Step Process of Evidence-

• Based Practice

Based Practice

1. 1.

Formulate the question Formulate the question

2. 2.

Search for answers Search for answers

3. 3.

Appraise the evidence Appraise the evidence

4. 4.

Apply the results Apply the results

5. 5.

Assess the outcome Assess the outcome

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Methods of Evidence Methods of Evidence-

• Based Practice

Based Practice

• Formulate the question

Formulate the question

• Patients or problem of interest

Patients or problem of interest

• Intervention

Intervention

• Control or alternative treatment

Control or alternative treatment

• Outcome of interest

Outcome of interest

• Search for answers

Search for answers

• Appraise the evidence

Appraise the evidence

• Apply the results

Apply the results

• Assess the outcome

Assess the outcome

Mark A. Goedecker, MD Mark A. Goedecker, MD

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Example of 4 Example of 4-

• Part Question (PICO)

Part Question (PICO)

• Patients or problem of interest

Patients or problem of interest

• In patients who have become pregnant through ART

In patients who have become pregnant through ART

• Intervention

Intervention

• Does the addition of progesterone during first trimester

Does the addition of progesterone during first trimester

• Control or alternative treatment

Control or alternative treatment

• When compared to usual care alone

When compared to usual care alone

• Outcome of interest

Outcome of interest

• Increase percentage of pregnancies that progress to term

Increase percentage of pregnancies that progress to term birth of healthy newborns? birth of healthy newborns?

Mark A. Goedecker, MD Mark A. Goedecker, MD

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Methods of Evidence Methods of Evidence-

• Based Practice

Based Practice

• Formulate the question

Formulate the question

• Search for answers

Search for answers

• What type of study best answers the question?

What type of study best answers the question?

• Where can I quickly find the evidence?

Where can I quickly find the evidence?

• Appraise the evidence

Appraise the evidence

• Apply the results

Apply the results

• Assess the outcome

Assess the outcome

Mark A. Goedecker, MD Mark A. Goedecker, MD

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Systems Synopses Syntheses Studies Examples Examples

Computerized Computerized decision support decision support Evidence-based Evidence-based journal abstracts journal abstracts Cochrane reviews Cochrane reviews Original journal Original journal articles articles Page 34 Page 34

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Searching for Answers Searching for Answers → → Examples Examples

The “4S” Approach The “4S” Approach

• Systems

Systems (comprehensive resources) (comprehensive resources)

• Good Clinical Decision Support for Electronic

Good Clinical Decision Support for Electronic Medical Records Medical Records

• Clinical Evidence (

Clinical Evidence (www.clinicalevidence.com www.clinicalevidence.com) )

• British Medical Group

British Medical Group

• UptoDate (

UptoDate (www.uptodate.com www.uptodate.com) (updated quarterly) ) (updated quarterly)

• E

E-

• textbook

textbook

• Collection of evidence

Collection of evidence-

• based guidelines

based guidelines

• Some incorporated within electronic medical record

Some incorporated within electronic medical record

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Searching for Answers: Searching for Answers:

The “4S” Approach The “4S” Approach

• Syntheses

Syntheses (systematic reviews) (systematic reviews)

• Cochrane Database (OVID)

Cochrane Database (OVID) ( (www.cochranelibrary.com www.cochranelibrary.com) )

• DARE (

DARE (http://agatha.york.ac.uk/darehp.htm http://agatha.york.ac.uk/darehp.htm) )

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Searching for Answers: Searching for Answers:

The “4S” Approach The “4S” Approach

• Studies

Studies (original research) (original research)

• OVID

OVID

• PubMed

PubMed

• http://www4.ncbi.nlm.nih.gov/entrez/query.fcgi

http://www4.ncbi.nlm.nih.gov/entrez/query.fcgi

• Clinical queries screen has built

Clinical queries screen has built-

• in filters

in filters

• Type of question

Type of question

• Sensitivity versus specificity

Sensitivity versus specificity

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Alternatives to the “4S” Search Approach Alternatives to the “4S” Search Approach – – or help to find the studies

• r help to find the studies
• TRIP database (

TRIP database (www.tripdatabase.com www.tripdatabase.com) )

• Searches Cochrane, DARE, collections of systematic reviews

Searches Cochrane, DARE, collections of systematic reviews and guidelines, and some on and guidelines, and some on-

• line journals

line journals

• Links to PubMed clinical queries

Links to PubMed clinical queries

• SUMSearch (

SUMSearch (http://sumsearch.uthsca.edu http://sumsearch.uthsca.edu) )

• Searches MEDLINE, DARE, National Guidelines

Searches MEDLINE, DARE, National Guidelines Clearinghouse Clearinghouse

• Takes longer than TRIP

Takes longer than TRIP

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Methods of Evidence Methods of Evidence-

• Based

Based Practice Practice

• Formulate the question

Formulate the question

• Search for answers

Search for answers

• Appraise the evidence

Appraise the evidence

• Critical appraisal worksheets

Critical appraisal worksheets

• Apply the results

Apply the results

• Assess the outcome

Assess the outcome

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Appraising the Evidence Appraising the Evidence -

• RCT

RCT

• Is the study valid?

Is the study valid?

• Was it a randomized controlled trial?

Was it a randomized controlled trial?

• Was the randomization list concealed?

Was the randomization list concealed?

• Were subjects and clinicians blinded?

Were subjects and clinicians blinded?

• Were all subjects accounted for?

Were all subjects accounted for?

• Was intention

Was intention-

• to

to-

• treat analysis used?

treat analysis used?

• Despite randomization, were the groups similar?

Despite randomization, were the groups similar?

• Aside from the experimental treatment, were the

Aside from the experimental treatment, were the groups treated equally? groups treated equally?

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Appraising the Evidence Appraising the Evidence -

• RCT

RCT

• Are the results important?

Are the results important?

• How large is the treatment effect?

How large is the treatment effect?

• How precise are the results?

How precise are the results?

• Can I apply the results to my patient?

Can I apply the results to my patient?

• Is my patient too different from those in the study?

Is my patient too different from those in the study?

• Is the treatment consistent with my patient’s values

Is the treatment consistent with my patient’s values and preferences? and preferences?

• Is the treatment feasible in my setting?

Is the treatment feasible in my setting?

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Methods of Evidence Methods of Evidence-

• Based

Based Practice Practice

• Formulate the question

Formulate the question

• Search for answers

Search for answers

• Appraise the evidence

Appraise the evidence

• Apply the results

Apply the results

• Assess the outcome

Assess the outcome

• Patient response to treatment

Patient response to treatment

• Clinician’s performance

Clinician’s performance

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Sections of the Evidence Sections of the Evidence-

• Based Paper

Based Paper APA Guidelines APA Guidelines

1. 1.

Title Page Title Page

2. 2.

Table of Contents Table of Contents

3. 3.

Introduction Introduction

4. 4.

Purpose Purpose

5. 5.

Justification Justification

6. 6.

Definition of Terms Definition of Terms

7. 7.

Methodology Methodology

8. 8.

Review of Literature Review of Literature

9. 9.

Conclusions Conclusions

10. 10.

References References

• Use appropriate APA

Use appropriate APA headings for these sections headings for these sections

• The Review of Literature

The Review of Literature may need subheadings may need subheadings

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Introduction Introduction

(¼ to 1 page) (¼ to 1 page)

• Brief set of statements that introduces the reader

Brief set of statements that introduces the reader

• Approximately 1

Approximately 1-

• 2 paragraphs, ¼ to 1 page

2 paragraphs, ¼ to 1 page

• Leads logically to the statement of the question

Leads logically to the statement of the question

May include demographic/statistics that supports the

importance of the problem

CDC is a good source for this kind of data

• Evaluation Criteria

Evaluation Criteria

• Provides the foundation for the EBP question being

Provides the foundation for the EBP question being explored. explored.

• Leads to the statement of the question

Leads to the statement of the question

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Example of Introduction Example of Introduction

Condition x affects ___ percentage of the citizens of the Condition x affects ___ percentage of the citizens of the United States (CDC, 2008). The burden of condition x United States (CDC, 2008). The burden of condition x includes _______, _______, and ______ (_____, includes _______, _______, and ______ (_____, _____, ______). Approximately $$$$ is spent annually _____, ______). Approximately $$$$ is spent annually

• n prescriptions and complimentary therapies for
• n prescriptions and complimentary therapies for

condition x (________). This paper will explore condition x (________). This paper will explore ________ related to (prevention, assessment, diagnosis, ________ related to (prevention, assessment, diagnosis, treatment) of condition X. By determining the current treatment) of condition X. By determining the current best evidence regarding (prevention, assessment, best evidence regarding (prevention, assessment, diagnosis, treatment) of condition x, ____________will diagnosis, treatment) of condition x, ____________will be (enhanced, promoted, relieved, etc.) be (enhanced, promoted, relieved, etc.)

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Purpose Purpose

(¼ to ½ page) (¼ to ½ page)

• Establishes thrust and goal of the literature

Establishes thrust and goal of the literature review review

• Includes a researchable clinical question (PICO)

Includes a researchable clinical question (PICO)

• Related to Clinical Concept or future Capstone

Related to Clinical Concept or future Capstone Project Project

• Evaluation Criteria

Evaluation Criteria

• Stated clearly and concisely

Stated clearly and concisely

• Includes intervention and population being studied

Includes intervention and population being studied

• Is of importance to advanced practice nursing

Is of importance to advanced practice nursing

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Example of Purpose Example of Purpose

“ “The purpose of this evidence The purpose of this evidence-

• based inquiry is to

based inquiry is to evaluate the current, best evidence evaluate the current, best evidence-

• based

based literature related to ____________. The clinical literature related to ____________. The clinical problem that will guide this review is: (PICO problem that will guide this review is: (PICO problem)” (one paragraph) problem)” (one paragraph)

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Justification Justification

(1/2 to 2 pages) (1/2 to 2 pages)

• Why this question/purpose is important

Why this question/purpose is important

• Logical, documented argument

Logical, documented argument

• Claims, reasons, some evidence

Claims, reasons, some evidence

• May expand on introduction

May expand on introduction

• Question can be answered through scientific inquiry

Question can be answered through scientific inquiry

• Sufficient research available to guide clinical practice

Sufficient research available to guide clinical practice

• Evaluation Criteria

Evaluation Criteria

• Background information provides project foundation

Background information provides project foundation

• Sufficient evidence from the literature presented

Sufficient evidence from the literature presented

• Substantiates that question is worthy of study

Substantiates that question is worthy of study

• Developed in a logical manner

Developed in a logical manner

• Documentation well cited

Documentation well cited

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Definition of Terms Definition of Terms

(¼ to 1 page) (¼ to 1 page)

• Listing of conceptual or operational definitions

Listing of conceptual or operational definitions

• Need citation for definition if one exists

Need citation for definition if one exists

• Evaluation

Evaluation

• All essential definitions included

All essential definitions included

• Appropriately referenced

Appropriately referenced

• Use a lead

Use a lead-

• in sentence like, “For the purposes of

in sentence like, “For the purposes of this project, the following terms were defined:” this project, the following terms were defined:”

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Methodology Methodology

(1/4 to 1 page) (1/4 to 1 page)

• Methods used

Methods used

• Details of how ROL was accomplished

Details of how ROL was accomplished

• Resources used

Resources used

• Search terms

Search terms

• Start from the top of the pyramid and work your way down

Start from the top of the pyramid and work your way down

• Evaluation

Evaluation

• Methods clearly stated

Methods clearly stated

• Appropriate to the project

Appropriate to the project

• Steps follow a natural and logical progression

Steps follow a natural and logical progression

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Review of Literature Review of Literature

(4 to 8 pages) (4 to 8 pages)

• Related to researchable clinical question

Related to researchable clinical question

• Includes relevant research

Includes relevant research

• Intervention

Intervention

• Population

Population

• Recent research studies and articles from refereed

Recent research studies and articles from refereed sources sources

• Organized with headings and subheadings

Organized with headings and subheadings

• For each source

For each source

• Summarize evidence

Summarize evidence

• Rate the strength of evidence

Rate the strength of evidence

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Review of Literature Review of Literature

(4 to 8 pages) (4 to 8 pages)

• Evaluation

Evaluation

• Adequate in scope

Adequate in scope

• Sources are scientifically based

Sources are scientifically based

• Rationale for rating strength of sources

Rationale for rating strength of sources

• Logically organized

Logically organized

• Appropriately referenced

Appropriately referenced

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Conclusions Conclusions (½ to 2 pages) (½ to 2 pages)

• Integrative summary of evidence

Integrative summary of evidence

• Evaluation of:

Evaluation of:

• Quality of literature

Quality of literature

• Basis for foundation for clinical decisions

Basis for foundation for clinical decisions

• Consistency of study designs/uniformity of findings

Consistency of study designs/uniformity of findings

• Conclusions related to what the evidence suggests

Conclusions related to what the evidence suggests

• Implications of findings for practice/education

Implications of findings for practice/education

• Areas of future research needed

Areas of future research needed

• Evaluation

Evaluation

• Conclusions logically and clearly stated

Conclusions logically and clearly stated

• Sufficient discussion

Sufficient discussion

• Implications for practice/education clearly stated

Implications for practice/education clearly stated

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References References

• All references

All references

• APA Manual (5

APA Manual (5th

th Edition)

Edition)