Overview Asking focused answerable questions Evidence Based - - PDF document

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Evidence Based Practice: Skills Boot Camp

Joanne DeSanto Iennaco PhD, PMHNP‐BC

Overview

• Asking focused answerable questions
• Conducting efficient searches
• Analyzing study methods
• Determining how to implement evidence

Evidence Based Practice:

• “The conscientious, explicit and judicious use
• f current best evidence in making decisions

about the care of individual patients.”

(Sackett, DL, Rosenberg, WMC, Gray, JAM, Haynes, RB, Richardson, WS. Evidence based medicine: what it is and h i i ’ BMJ (1996) 312 71 2 ) what it isn’t. BMJ (1996) 312:71‐2.)

Evidence Based Practice is : ‘The integration of best research evidence with clinical expertise and patient values.”

Sackett DL Straus SE Richardson WS Rosenberg W Haynes RB (2000) Evidence based medicine:How to practice and teach EBM (p 1) Sackett, DL, Straus, SE, Richardson, WS, Rosenberg, W., Haynes, RB. (2000). Evidence‐based medicine:How to practice and teach EBM. (p.1).

• What is the ‘best research evidence’?
• What is ‘clinical expertise’?
• What do we mean by ‘patient values’?

Steps in Evidence Based Practice

• 1. Identify a question (PICO)
• 2. Find the best evidence to answer question
• 3. Critically appraise the evidence for validity,

impact and applicability impact and applicability

• 4. Integrate evidence with clinical expertise

and patient values/wishes

• 5. Evaluate process (prior steps) to improve

next time

Asking a Focused Question…

PICO

• P = The Patient or Population

“Who will be the focus?” EX: In (patient, problem, risk factor) does…

• I = Intervention or Clinical Action

“What is the Exposure or the Treatment of interest?” EX: does Treatment A compared to …

• C = Comparison

EX: Compared to Treatment B Reduce…

• O = Outcome

EX: Reduce Outcome of interest

APNA 27th Annual Conference Session 1031: October 9, 2013 Iennaco

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Prioritizing: Deciding on a Question

• Disease/Condition:

– Patient: Severity, Duration, Cost – Societal: Prevalence, Severity, Costs

• Intervention:

– Potential for meeting unmet needs, Lowering cost

• Practice Change:

– How would it benefit practice? Preferences? Timing? – Motivation to change

• Feasibility:

– Information/data availability – Cost

• Other:

– Interest – Innovation – Social or Ethical implications

Refining the Question

• State of the science may dictate
• Too few studies… go up!
• Too many studies…

move down! …move down!

• Specificity important

– What age group? – What dose? – What setting? (inpt, outpt, cty) – What about outcome?

Does SGA treatment increase risk of metabolic s/e?

• Does age of patient

matter? ‐ All patients

• Does diagnosis of pt

matter?

• Does setting matter?
• All SGA’s or just some?
• Compare to FGA’s?

What about mood stabilizers? Placebo?

• All metabolic s/e? BMI?

Wt gain? Lipids?

Why will asking these questions help us?

In adolescents, does aripiprazole vs risperidone treatment lower risk of wt gain and increased BMI?

Asking a Focused Question…

PICO

• P = The Patient or Population

“Who will be the focus?” EX: In (patient, problem, risk factor) does…

• I = Intervention or Clinical Action

“What is the Exposure or the Treatment of interest?”

• P: In youth
• Is this all ages?
• Does setting matter?
• Does diagnosis matter?
• I: Does SGA treatment
• Any SGA or all?

EX: does Treatment A compared to …

• C = Comparison

EX: Compared to Treatment B Reduce…

• O = Outcome

EX: Reduce Outcome of interest

• Any SGA or all?
• C: (vs. ……..
• First generation?
• Mood stabilizers?
• Placebo?
• O: Increase risk of

metabolic s/e and weight gain?

Now try it with your question…

Searching the Literature

What is the usefulness of an evidence based review if we don’t find all the evidence out there? Will we ever find ‘ALL’ the evidence? What if the evidence overwhelms us?

Searching the Literature

• Defining a Search Strategy

– Database Choices – References/Bibliographies – Hand searching Hand searching – Contacting authors/researchers – Conferences/Associations – Abstracts

• Dates to search
• Savvy searching…

What is the usefulness of an evidence based review if we don’t find all the evidence out there?

APNA 27th Annual Conference Session 1031: October 9, 2013 Iennaco

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Searching the Literature

• Defining a Search Strategy
• Database Choices
• Medline, PubMed, CINAHL,

PsychInfo, Social sci, web of sci

• Vs. TRIP? Cochrane?
• Vs. Google scholar?
• Dates to search
• When does date matter?
• Savvy searching…

Save or print what you did!

• References/Bibliographies
• Hand searching
• Contacting

authors/researchers

• Conferences/Associations
• Abstracts

What is the usefulness of an evidence based review if we don’t find all the evidence out there?

Search strategy terms…

Topic1 Topic2 Topic3 Topic4 Topic5 Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym

And And And And

• r
• r
• r
• r
• r

y y y y y y y y y y Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym Synonym

Thoughts about Searching…

• ‘Google it’… key terms…
• Combining terms…
• Be careful of early ‘AND’ use
• Like terms – ‘OR’
• Focus with ‘AND’
• Step by step…

For future…

• How would you study the question…
• Why that design vs. others…

Search Results…

# ▲ Searches Results Search Type Actions 1 exp Depression/ dt, th [Drug Therapy, Therapy] 16881 Advanced 2 ketamine.mp. or exp Ketamine/ 11664 Advanced 3 1 and 2 32 Advanced Display

Blocking NMDA receptor at rest: a possible alleviation of depression. Lu W. Zhongguo Yao Li Xue Bao/ Acta Pharmacologica S

• inica. 32(9):1087-8, 2011 S

ep. [Journal Article] UI: 21804573 [Journal Article] UI: 21804573 Involvement of AMPA receptor in both the rapid and sustained antidepressant­like effects of ketamine in animal models of depression. Koike H. Iijima M. Chaki S. Behavioural Brain Research. 224(1):107‐11, 2011 Oct 10. [Journal Article] UI: 21669235 NMDA receptor blockade at rest triggers rapid behavioural antidepressant responses. Autry AE. Adachi M. Nosyreva E. Na ES. Los MF. Cheng PF. Kavalali ET. Monteggia LM. Nature. 475(7354):91‐5, 2011 Jul 7. [Journal Article. Research Support, N.I.H., Extramural. Research Support, Non‐U.S. Gov't] UI: 21677641 Be prudent of ketamine in treating resistant depression in patients with cancer. Yang C. Zhou ZQ. Yang JJ. Journal of Palliative Medicine. 14(5):537, 2011 May. [Letter] UI: 21592028 Ketamine plus imipramine treatment induces antidepressant­like behavior and increases CREB and BDNF protein levels and PKA and PKC phosphorylation in rat brain. Reus GZ. Stringari RB. Ribeiro KF. Ferraro AK. Vitto MF. Cesconetto P. Souza CT. Quevedo J. Behavioural Brain Research. 221(1):166‐71, 2011 Aug 1. [Journal Article. Research Support, Non‐U.S. Gov't] UI: 21397634

Kinds of Evidence?

• Empirical research (hierarchy)
• Professional literature
• Effectiveness data
• Clinical intervention & Observation
• Clinical intervention & Observation
• Patient response to intervention
• Clinical expertise

– Judgement – Adaptation to needs

Comparing Searches…

• Medline
• PubMed

41 exp Depression/ dt, t h [Drug Therapy, Therapy] 16931 42 ketamine.mp. or exp Ketamine/ 11695 43 41 and 42 32

Blocking NMDA receptor at rest: a possible #3 Search #1 AND #2 740 #2 Search ketamine 12254 #1 Search depression 267907

• 1. New drug targets in depression: inflammatory, cell‐mediated

g p p alleviation of depression. Lu W. Zhongguo Yao Li Xue Bao/Acta Pharmacologica

• Sinica. 32(9):1087­8, 2011 Sep.

[Journal Article] UI: 21804573 NMDA receptor blockade at rest triggers rapid behavioural antidepressant responses. Autry AE. Adachi M. Nosyreva E. Na ES. Los MF. Cheng PF. Kavalali ET. Monteggia LM.

• Nature. 475(7354):91­5, 2011 Jul 7.

[Journal Article. Research Support, N.I.H., Extramural. Research Support, Non­U.S. Gov't] UI: 21677641

immune, oxidative and nitrosative stress, mitochondrial, antioxidant and neuroprogressive pathways. And new drug candidates‐Nrf2 activators and GSK‐3 inhibitors. Maes M, Inflammopharmacology. 2012 Jan 24. [Epub ahead of print] PMID: 22271002

• 2. Neuromodulators for pain management in rheumatoid arthritis.

Richards BL, Cochrane Database Syst Rev. 2012 Jan 18;1:CD008921. PMID: 22258992

• 3. Minimum infusion rate and hemodynamic effects of propofol,

propofol‐lidocaine and propofol‐lidocaine‐ketamine in dogs. Mannarino R, Vet Anaesth Analg. 2012 Jan 17. doi: 10.1111/j.1467‐ 2995.2011.00679.x. [Epub ahead of print] PMID: 22248386

• 4. The effect of sub‐anesthetic and anesthetic ketamine on water

maze memory acquisition, consolidation and retrieval. Moosavi M, Eur J Pharmacol. 2011 Dec 23. [Epub ahead of print] PMID: 22209880 5.Ketamine as a novel antidepressant: from synapse to behavior. Murrough JW. Clin Pharmacol Ther. 2012 Feb;91(2):303‐9. doi: 10.1038/clpt.2011.244. Epub 2011 Dec 28. PMID: 22205190

APNA 27th Annual Conference Session 1031: October 9, 2013 Iennaco

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Comparing…

• Google scholar

Results 1 ‐ 10 of about 46,300. (0.16 sec)

depression and ketamine

The effects of pentobarbital, fentanyl‐droperidol, ketamine‐xylazine and ketamine‐diazepam on arterial blood pH, blood gases, mean arterial blood pressure and heart … SK Wixson, WJ White, HC Hughes Jr… ‐ Laboratory animal …, 1987 ‐ ncbi.nlm.nih.gov ... Results showed marked acidosis, hypercarbia and hypoxia with high doses of Innovar‐Vet, moderate respiratory depression with all dosages of pentobarbital and minimal respiratory depression with ketamine‐xylazine and ketamine‐

• TRIP

(depression AND Ketamine) Psychiatry2

• 1. A Single Subanesthetic Dose of Ketamine Relieves Depression‐like

Behaviors Induced by Neuropathic Pain in Rats

• 2. Ketamine lifts mood quickly in bipolar disorderHEALTH NEWS

REVIEW 18 Aug 2010

• 3. Adverse events associated with ketamine for procedural sedation in
• adultsDARE. 2008
• 4. A randomized controlled trial of ketamine/propofol versus propofol

alone for emergency department procedural sedationEVIDENCEUPDATES 2011 respiratory depression with ketamine xylazine and ketamine

• diazepam. ...

Cited by 69 ‐ Related articles ‐ Yale Links ‐ All 2 versions Effects of ketamine and althesin anesthesia on baroreceptor‐heart rate reflex and hemodynamics of intact and pontine rabbits Yale Fulltext DW Blake… ‐ Journal of the autonomic nervous system, 1982 ‐ Elsevier ... Althesin produced much lessvagal depression than ketamine in the intact rabbit but in pontine rabbits the depression was greatly

• enhanced. ... This was only 10% less

than the depression produced by ketamine (Fig. 1, Table II). Cited by 28 ‐ Related articles ‐ All 3 versions EVIDENCE171 All Secondary Evidence39 Evidence Based Synopses1 Systematic Reviews11 Guidelines Canada2 UK14 USA11 Clinical Q&A0 Core primary research3 Extended primary research51 eTextbooks68 Patient Decision Aids0 Patient Information4 More3 News3

Assessment & Reporting of Results:

• Cochrane Reviews: Treatment of Inhalant Abuse
• CONSORT statement: Quality of RCT’s
• PRISMA statement: Reporting of systematic reviews

and meta‐analyses d l f

• STROBE statement: guidelines for reporting
• bservational studies
• TREND statement: reporting quality of nonrandom

behavioral and public health interventions

• https://classesv2.yale.edu/portal/site/nurs851_s13/pa

ge/a9a2596e‐053e‐41b3‐a5d8‐577dbbb02188

What results will be used?

• Review by title

– Exclude those unrelated to your question

• Review by abstract

– Determine those applicable to your question

• Review parts of article

– Verify they should be included

• Review full article

– Extract data to answer your question

Maintain records of what you have done!

Flow Diagram

Inclusion criteria

Help you to focus results for review:

• Specific to your question
• Are there specific types of studies you

i ? require?

• Is a particular population involved?
• Within a particular time period?

You should have a list of criteria that help you decide when you review results

Exclusion Criteria

Remove articles unrelated to your review

• What articles can be safely excluded?

– Off topic articles Li i – Literature reviews – Opinion pieces, editorials

• Use criteria set to determine what to remove

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Data Extraction

Author (yr), country Sample or Patient Group Setting Study type Exposure/ intervention Outcomes studied Key results (include quantitative effect estimates) Study strengths & weaknesses Comments Example: Iennaco (2010) US N=7566 Heavy industrial workers 6 yr period Manufacturing plant (11 locations) Retrospective cohort study Effects of high demand, low control based on JCQ completed by plant managers Depression diagnosis from health claims data High demand significantly increases risk of depression dx OR: 1.39 (95% CI: 1.04‐1.86) Low control not significant OR: 0.78 (95% CI: 0.56‐1.08) Strengths: Large longitudinal study; uses objectively ascertained demand & control Limitations: Health claims data used; expect this is underestimate of depr cases

Study Results Marienfeld et al. (2012) N=20 68.9% of psychiatrists asked for BZDs for “drug seeking reasons” 74.6% do not prescribe BZDs to pts with a history of SUD Ciraulo et al. (1997) N=26 ETOH subjects scored higher on subjective drug liking report scales than control subjects did for Xanax and Valium Shelton et al. (1993) N=78 Pts with drug history are 3X more likely to misuse xanax Bruce et al. (2003) N=443 Pts with comorbid panic and depressive disorder are 3.5 times more likely to use an SSRI

Quality Criteria

Define what studies are best – develop rating system

• By study type
• Sample
• Methods
• Measures
• Analytic method
• Outcome measurement

Allows you to decide which results matter most to your question

Study Designs

(the hierarchy) Cross‐Sectional study, RCT, case control study, case series retrospective cohort, case study, prospective cohort

Can you put them in order?

• ‘Best’ evidence:
• ‘Worst’ evidence:

What design is even better than the ‘best’ in this list?

Study Designs

(the hierarchy)

• Systematic Review of RCT’s (meta‐analysis)
• RCT’s
• Prospective Studies
• Retrospective Studies
• Retrospective Studies
• Cross‐sectional surveys
• Case Series
• Case Reports

& Appropriate Analytic Methods…

Study Designs… & their r/t TIME…

• Cross‐sectional (of individuals) : ‘snapshot’
• Ecologic (of group vs individual)

1950 1970 1990 2010 Future follow‐up

• Ecologic (of group vs. individual)
• Case‐Control (retrospective, id disease/look back at exposure)
• Cohort (retrospective or prospective, identify exposure groups

follow for disease development (free of disease at start))

• RCT
• Systematic Review
• Meta‐analysis

Which way does the hierarchy go here?

Is an Association Causal?

[3 possibilities: random error; bias; or confounding ]

and Study Designs…

• Selection of participants
• Confounding factors

Confounding factors

• Bias = systematic error in a study

– Observer – Selection – Prevalence – Recall – Information

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Selection of Participants

• Criteria should be clear and objective
• Relationship of sample selected to population (ability

to generalize?)

• State of health/disease or other factors in

i i participants

• Matching (unable to use matched variables in

analysis)

• Exposed vs. Unexposed / Treatment vs. Control
• Specific methods based on design…

Confounding…

• A real association
• To be a confounder the factor must be:

Exposur e Disease C C

– Associated with the exposure – Associated with the outcome or disease – Not intermediate in causal pathway (do not adjust if intermediate (mediator / moderator?)

• to deal with confounding:

– Stratify by confounder – Adjust for confounder – Restrict to single exposure category (ex: non‐smoker) – Matching cases =controls on confounder (analysis must account for matching to be done correctly)

Bias…

• Presence of systematic error in a study  provides

mistaken estimate of association between exposure and disease

• 2 types of bias:

– Selection Bias

• From selecting participants
• From factors influencing participation

– Information Bias

• Recall bias
• Reporting bias
• Interviewer bias

Selection Bias…

• Participants aren’t representative of target

population (actually r/t generalizability)

• Those following thru/participating different than

non‐participants

• Cases and controls are similar (no systematic

Cases and controls are similar (no systematic differences, from same source population)

• Randomized allocation to tx and comparison group
• Later problems…

– Drop outs/loss to follow up (minimize)

Information Bias…

• Misclassification…may be:

– Non‐differential – amt of misclass independent in groups compared  mask or decrease in size of result/estimate / – Differential – amt of misclass not independent in groups compared  increase/dilution/spurious result/estimate Misclassification of Exposure: Recall bias: error in recall of past exposure Interviewer bias: expos info collected differently in cases and controls

Misclassification of Disease or Outcome: Misclassification of Disease or Outcome: Observer bias: observer knows exposure status is more thorough in cases vs. controls Respondent bias: info about outcome is not objective (use

• bj forms when possible)

Detection bias: those exposed are under greater surveillance so greater likelihood of being diagnosed

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Statistical Analysis = Tools

• Descriptive statistics
• Types of data, summarizing (mean, median)
• Variability & distributions
• Hypothesis testing & statistical inference
• Null hypothesis, Type I & II error, p‐values
• Null hypothesis, Type I & II error, p values
• Estimation
• Standard errors, Confidence Intervals
• Statistical Tests
• Type of data & methods
• Correlation & Regression
• Pearson’s r, Rsquare, linear regression, logistic regression

Study Evaluation Worksheet

• Sample:

– Representative? – Chosen in similar ways? If RCT randomly? – Similar groups in important ways (other than exposure or treatment; Randomized)

• Methods:

– Were measurement of exposures or provision of interventions similarly managed in all groups? – Was timing of exposure or intervention appropriate? Was blinding used? – Was measurement appropriate? – Were scales used validated?

• Outcome Assessment:

– How were outcomes assessed? – Were assessors blind to exposure or intervention group? – Was follow up period appropriate length?

• Analysis:

– Were appropriate tests used to evaluate outcomes? Adequate power? Effect Size? – Were results significant? ITT analysis?

• Evaluation of Evidence:

– Is there any evidence supporting causation –(dose‐response; exposure preceded outcome; biologic explanation; consistent results) – Are conclusions supported by data or evidence? – How does this sample compare to your patient or population of interest? – Would your patient or setting be open to this intervention? – Are there alternatives available?

Implementing the Evidence… Implementation: An Overview

• Carry out search, identification of literature, evidence
• Describe evidence
• Evaluate/synthesize evidence
• Identify ‘answers’ to the PICO question
• Identify plan for implementation in the setting… specific to:

P l ti Ch t i ti

• Population Characteristics
• Patient (& Family, Community) needs & abilities
• Clinician needs & expertise
• Organizational resources & limitations; (elicit organiz support)
• Larger system requirements

Real World may re‐engage at this point for re‐assessment,, identification of plan & implementation Instilling confidence in ability to independently intervene Identify evaluation plan… how will we know this worked?

Assessment…

What is the problem or concern? Why is it a problem now? Who is the problem affecting? What are they (patient, families, clinicians) experiencing? How are consultee and others affected? How are consultee and others affected? Involves data collection: from clinicians, patients, family… organization… community Systems knowledge; group operating in larger system… Involves assessment of knowledge important to problem

Preplanning

• What are the current practices?
• How do outcomes from best practices compare with
• utcomes from treatment as usual (TAU)?

D th t t ti t h li t/ it d ?

• Does the new target practice match client/community needs?
• Could the new target practice be realistically accommodated?
• If so, what elements of the program need to change?
• What data can you collect to establish a baseline?

From: p. 9 of Center for Substance Abuse Treatment. Implementing Change in Substance Abuse Treatment Programs. Technical Assistance Publication Series 31. HHS Publication No. (SMA) 09­4377. Rockville, MD: SubstanceAbuse and Mental Health Services Administration, 2009.

APNA 27th Annual Conference Session 1031: October 9, 2013 Iennaco

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• Who should be involved in planning?
• Stakeholders: staff, leaders, clients, external
• Identify the goal before you identify the plan
• What outcomes are important?
• How will they be measured?
• Administrative level? (approval, supervisory change)

ff ?

• Staff training?
• Roadblocks?
• Financial, funding
• Staff concerns?
• Map the Route to change
• Timeline? Who will carry out change?

Identification of Needs…

• Agree on formulation of problem
• Joint understanding of PICO question
• Limits of current review identified/understood
• Approach to understanding problem identified
• Approach to understanding problem identified
• Search strategy
• Collection of information from system, organization,

community

• Collection of secondary data r/t patient care

Planning for Intervention

• Forum for problem solving
• Elicit support for plan from team involved
• Identification of Assessment/Formulation
• Seek input and feedback from others
• Engage in problem solving w/participants…

Wh t ld lik t h ?

• What would you like to see happen?
• What solutions have you tried…
• Provide information already gained r/t problem
• Identify tools used in study of problem
• Discuss current evidence
• How do findings fit with clinical wisdom of participants?

Identify Plan to carry out intervention & evaluate results

Working within multiple organizational levels…

• Alliance with administration
• Alliance with clinicians, staff, other groups of import

to problem

• Perceptions of consultant
• Threatening
• Threatening
• Extension of administration
• ‘Take over’ vs… foster independent problem solving
• Giving feedback vs. criticizing
• Working with each level… vs. dictating
• Will not know all the answers…

From ‘best practice’ to practice…

• Diffusion – share information about best practice
• Implementation – put best practice in place
• Fidelity – degree practice adheres to best

i practice

• Reinvention – how best practice modified to fit

setting

Who is involved

• Purveyor –individual or group that initiates or

monitors change

• Change agents – individuals promote change,

influence colleagues influence colleagues

• Organizational change – altering culture,

customs, values, practices

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Diffusing Innovation: Rogers

• Knowledge of best practice
• Persuasion of its value
• Decision to adopt innovation
• Implementation of the practice
• Confirmation to continue or reject practice

Roles individuals play: Roles individuals play:

• Innovators – risk takers
• Early adapters – leaders
• Early majority – deliberate decision makers
• Late majority – traditionalists, skeptics
• Laggards – fearful of change, unaware of trends

NIATx: essential ingredients for process improvement

• Understand and involve the customer

– Who is customer?

• Fix key problems

i f l d – gain support of leaders

• Pick a powerful change leader

– need authority, respect, time to devote

• Get fresh ideas from outside system/field
• Rapid‐cycle testing to establish effectiveness

NIATx:

Five phases of this model

• Walk through to understand customer needs
• Pick a change goal
• Identify a simple data point to determine if

goal reached

• Select and rapidly test changes one at a time
• Sustain the gain

Principles to Implement Change

• No single way to implement change
• Preconceptions, rigidity about how not useful
• Vigilance, corrections may be needed
• Individualize to fit culture, readiness of organization
• Change is not linear
• May need to back track, evaluate and adjust plan
• Change is ongoing
• Requires planning, coordination, cooperation, evaluation,

follow up

• Ultimate goal: create change sustainable over time
• Institutionalization = part of everyday practice

Implementation

• Realistic Goals
• Celebrate small steps
• Keep your eye on the goal
• Evaluate, re‐evaluate
• Monitor progress
• Fidelity?

Responses to change

• Seekers – readily adopt, likely to embrace
• Receptive clinicians – likely to change if from

reliable source

• Traditionalists – rely on authoritative sources,

f k ll h focus on experience, skill, authority

• Respond to rewards, penalties, reinforcement
• Pragmatists – want the bottom line
• Remove obstacles, need strong incentives to

change

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Evaluation

• What are outcomes?
• What should be measured?
• How should it be measured?
• Fidelity to best practice
• Costs
• Efficiency
• Who will evaluate?
• Collecting data, analyzing data, reporting data
• Where’s the $$$!

Sustainability

• Maintenance
• Reinforcement
• Fidelity
• Evaluate/monitor outcome
• Extension
• Extension
• May need to make changes; improvements
• Adaptation
• Vision
• Support
• Monitor trends

Problems with Models…

• Is change process linear?
• What realities are involved –

– Financial effects/systems; Regulatory; Cultural

• What is needed to successfully change?
• What is needed to successfully change?

Ex: evidence based treatment method – Education – Training – Supervision – Competency

A Few Trusted Resources: http://journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalCollectionID=1 AJN series of 12 articles on EBP in nursing Ajetunmobi, Olajide. (2002). Making Sense of Critical Appraisal. Oxford University Press: New York. ISBN: 9780340808122 (new edition is coming out soon!) Straus, Sharon, Glasziou, Paul, Richardson, W. Scott, Haynes, R. Brian.(2011) Evidence‐ based Medicine.4th edition. Edinburgh: Churchill Livingstone. ISBN: 9780702031274 9780702031274 Guyatt, (2008). User’s Guide to Medical Literature (2nd ed.). McG ISBN: 9780071590341 Goodheart, C.D., Kazdin, A.E., & Sternberg, R.J. (2006). Evidence‐Based Psychotherapy: Where Practice and Research Meet. Washington D.C.: American Psychological

• Association. ISBN 9781591474036

Greenhalgh, Trisha. (2010). How to Read a Paper, 4th edition. BMJ Books: London. (may be available online) http://web.ebscohost.com/ehost/ebookviewer/ebook/nlebk_325257_AN?sid=565 5a1c5‐3d50‐4b79‐8957‐fd51aea7ea19@sessionmgr114&vid=1

CAPs

Critically Appraised Papers(CAP’s) Outline for Preparing CAP’s CAP’s are a short, concise summary of one study, DO NOT EXCEED 1½ ‐2pages!

• Clinical Question: (in PICO format, include patient/population, intervention/exposure,

comparison gp, outcome)

• Search Strategy: (identify key words/terms used, databases/sources, number and kind of

lt ) results)

• Study Design: (briefly identify the design of the study reviewed)
• Sample & Setting: (include where the study took place (outpatient clinic, hospital, community),

and the ‘N’ and particular inclusion/exclusion criteria of import)

• Study Aims/Objectives: (identify aims or objectives of study as author states)
• Strengths/Limitations: (Consider study design, methods/analysis, measurement issues, bias,

confounding, sampling/selection, blinding, etc; see individual worksheets or chapters in text for guides to reviewing articles by study type)

CAPs continued

• Study Results:(Report estimates from study related to your clinical question, Identify author’s

major conclusions, Can conclusion be drawn based on this evidence?)

• Conclusions:(organize by questions below)

Identify: – Are the results Valid? (Why or Why Not?) – Are the results Important? (Why or Why Not?) – Are the results applicable to the patient/question? (Why or Why Not?)(see individual Are the results applicable to the patient/question? (Why or Why Not?)(see individual worksheets or chapters in text for guides to reviewing articles by study type)

• Take Home Message:(The answer to your clinical question based on results from this study (i.e.

what will you do now as a practitioner?), this is your overall conclusion based on a synthesis of your review/critical appraisal of major result/estimate. The ‘Take Home Message’ should only be 1 sentence!)

• Reference: (provide APA format reference, also turn in a hard copy of the article reviewed)

APNA 27th Annual Conference Session 1031: October 9, 2013 Iennaco