what is e3bp? how do you integrate the findings from caps/cats into everyday clinical practice?...

What is E3BP? How do you integrate the findings from

CAPs/CATs into everyday clinical practice?

Elise Baker, Ph.D.

The University of Sydney

NSW SPEECH PATHOLOGY EBP NETWORK EBP EXTRAVAGANZA, 9th December 2009Sydney Children’s Hospital, Randwick, Lecturer Theatre

Outline

What is EBP?

Is EBP really a regular part of clinical practice?

What is E3BP?

Guidelines for conducting E3BP

What is evidence-based practice (EBP)?

From: http://www.asha.org/members/ebp/default 10/23/08

Current best evidenceCurrent best evidence

Client’s valuesClient’s valuesClinical expertiseClinical expertise

However, EBP “has not become a regular part of clinical

practice”.Brackenbury, Burroughs and Hewitt (2008, p. 78)

Why? Lack of time to search for, read and critique

published evidence relevant to every clinical decision

Too much information Aphasia therapy – 220,000 hits Dysphagia treatment – 3,290 000 Voice therapy – 2,760 000 Phonology therapy – 1,050 000

Too little information - how many systematic reviews have you come across in your search for evidence?

Why?

Need time and resources to develop efficient searching skills

Even then….Brackenbury et al. , (2008) reported that “it is doubtful that most SLPs can afford to take 3 to 7 (or more) to provide evidence for each of the clinical decisions that must be made” (p. 85).

Why?

Have found, read, critiqued the research ... the findings may not be easily applied to clinical practice

O’Conner and Pettigrew (2009) reported that half their participants did not feel that research results were generalizable to their own setting.

Why?

EBP has been thought of as simply using research to justify an intervention approach.

Sense that ….“until EBP came along, clinicians were basing their clinical decisions on something other than evidence, which is simply not true” (Dollaghan, 2007, p. 1)

Why? How many clients/patients in the past week

have you...

Searched for and answered a clinical question (or known the answer to a clinical question based on work you have done on a CAP or CAT?)

Provided the client / patient with the information necessary to make an informed choice

Outline

What is EBP?

Is EBP really a regular part of clinical practice? No….not completely.

What is E3BP?

Guidelines for conducting E3BP

What is E3BP?

“the conscientious, explicit, and judicious integration of

1. best available external evidence from systematic research,

2. best available evidence internal to clinical practice, and

3. best available evidence concerning the preferences of a fully informed patient”

(Dollaghan, 2007, p. 2)

What is E3BP?

Best external evidenceBest external evidence

Best internal evidence(from client factors & preferences)Best internal evidence(from client factors & preferences)

Best internal evidence(from clinical practice)Best internal evidence(from clinical practice)

External published evidenceTo date, our CAPS seem to focus primarily on

the level of identified evidence

To facilitate the integration of difference sources of evidence we need to:

Consider the validity of the evidenceand... Consider the importance of the evidence

Effect size Precision Practical significance

(Based on Dollaghan, 2007)

Yeah but..... I can’t exactly replicate that in my service

Gap between what is possible and what is practical

Internal evidence from clinical practice

Internal evidence about what is possible in your clinical practice

However....determining what is possible in clinical practice is a challenging task, as, “our strong preferences for what we

already believe to be true makes us poor judges of whether it is actually

true” (Dollaghan, 2007, p. 3).

Internal evidence from clinical practice

It is perhaps, best derived from the systematic and regular collection and

analysis of clinical case-based outcome data.

How are you currently doing this?

Could you compare your outcomes with another colleague?

Internal “client” evidence:client factors, values and preferences Client factors

ICF / ICF-CY frameworks (integrated impairment and socially-based perspective)structure, functionactivity and participation environmental factors and Personal

factors – that could act as barriers or facilitators

Client values and preferences

Consider – Is there any

externalpublished evidence

on client factors?

Consider – Is there any

externalpublished evidence

on client factors?

Outline

What is EBP?

Is EBP really a regular part of clinical practice? No….not really.

What is E3BP?

How to conduct E3BP

How can individual clinicians incorporate EBP in a meaningful and

realistic manner?

(Brackenbury, Burroughs, & Hewitt, 2008)

7-Step process for engaging in E3BP (Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)

STEP 1. Pose a “PICO” question (Patient, Intervention, Comparison, Outcome)“In children with a phonological impairment and no

other concomitant conditions, does the Hodson (2007) cycles approach lead to significantly greater gains in percent consonants correct as compared with the Williams (2010) multiple opposition approach?”

STEP 1. Pose a “PICO” question (Patient, Intervention, Comparison, Outcome)“In children with a phonological impairment and no

other concomitant conditions, does the Hodson (2007) cycles approach lead to significantly greater gains in percent consonants correct as compared with the Williams (2010) multiple opposition approach?”

STEP 2. Search for external evidenceUse electronic databases – SpeechBITE; HighWire

Press via ASHA membership, ERIC, Medline, Cochrane….

STEP 2. Search for external evidenceUse electronic databases – SpeechBITE; HighWire

Press via ASHA membership, ERIC, Medline, Cochrane….

(Based on Baker & McLeod, 2008)

7-Step process for engaging in E3BP

(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)

STEP 3. Evaluate the external evidence

Consider the validity and importance of the evidence

STEP 3. Evaluate the external evidence

Consider the validity and importance of the evidence

(Based on Baker & McLeod, 2008)

STEP 4. Evaluate the internal client evidence

Use the ICF and/or ICF-CY framework

Consider your client / patient’s activity and

participation

Consider the family beliefs and cultural values,

financial resources, and informed preferences

STEP 4. Evaluate the internal client evidence

Use the ICF and/or ICF-CY framework

Consider your client / patient’s activity and

participation

Consider the family beliefs and cultural values,

financial resources, and informed preferencesInternational Classification of Functioning Disability and Health – Children and Youth (WHO, 2007)

7-Step process for engaging in E3BP

(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)

(Based on Baker & McLeod, 2008)

STEP 5. Evaluate your internal clinical evidence

Think about what you currently do and why

Think about the efficiency of your intervention

How do your outcomes compare with the research?

How do your outcomes compare with your colleagues or other similar departments?

STEP 5. Evaluate your internal clinical evidence

Think about what you currently do and why

Think about the efficiency of your intervention

How do your outcomes compare with the research?

How do your outcomes compare with your colleagues or other similar departments?

7-Step process for engaging in E3BP

(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)

(Based on Baker & McLeod, 2008)

Remember….

“our strong preference for what we already believe to be true makes us poor judges of whether it is actually

true…

…E3BP requires honest doubt about a clinical issue, awareness of one’s own biases, a respect for other positions, a willingness to let strong evidence alter

what is already known, and constant mindfulness of ethical responsibilities to patients”

(Dollaghan, 2007, p. 3).

“our strong preference for what we already believe to be true makes us poor judges of whether it is actually

true…

…E3BP requires honest doubt about a clinical issue, awareness of one’s own biases, a respect for other positions, a willingness to let strong evidence alter

what is already known, and constant mindfulness of ethical responsibilities to patients”

(Dollaghan, 2007, p. 3).

(Based on Baker & McLeod, 2008)

STEP 6. Make a decision by integrating your three sources of evidence

STEP 6. Make a decision by integrating your three sources of evidence

STEP 7. Evaluate the outcome of your decision

Did it work? What is efficient?

(This adds to your own internal clinical evidence)

STEP 7. Evaluate the outcome of your decision

Did it work? What is efficient?

(This adds to your own internal clinical evidence) (Based on Baker & McLeod, 2008)

7-Step process for engaging in E3BP

(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)

Where to from here?

E3BP and the NSW EBP Network

Implications – Focus of current CAP is on external evidence Could we develop “CAPs” for internal clinical and

client evidence? How might they be used within clinical groups?

QUESTIONS AND DISCUSSION

Elise: e.baker@usyd.edu.au