Evidence Based Practice

Why is knowledge translation important?

Evidence that research is not being translated into clinical practice ¤ 20-25% of patients get care that is not needed or potentially harmful ¤ 30-40% of patients do not get treatments of proven effectiveness Schuster, McGlynn, Brook. Milbank Quarterly 2005, 83(4):843-895 **Traditional methods of KT have not been effective (publication of journal articles and conference presentations) example of length of knowledge translation shown between scurvy and citrus on ships 17 yrs to translate evidence from discovery into health care practice (Balas & Boren, 2000) But, only 14% of it is believed to enter day-to day clinical practice

Other barriers...

Information overload -130 trials and 52 systematic reviews published a day (2015 Cochrane Colloquium, presentation from Glasziou) -Shortage of coherent, consistent scientific evidence - A reason in support of guidelines Difficulties in applying evidence to the care of individual patients Resource barriers to the practice of high-quality care The need to develop new skills in a climate of limited resources

Definition of evidence based practice

Integrating individual clinical expertise with the best available external clinical evidence from systematic research ...evidence based OT practice uses research evidence together w clinical knowledge and reasoning to make decisions about interventions that are effective for specific clients

Ensuring research makes it into clinical practice?

Knowledge translation, research utilization, research-to-practice gaps, evidence-to-practice gaps, research transfer, knowledge transfer, dissemination, knowledge mobilization, knowledge transfer and exchange ¤ > 100 terms ¨ Achieving EBP requires KT

Example of evidence based practice gap in wheelchair example?

Measure the gap between desired practice and current practice for wheelchair assessment in spinal cord injury rehabilitation Methodology - data collection We extracted data on: • location of documentation (where?) - New assessment form (in place for a year, based on best practices) - Old assessment form - documentation on the chart progress notes • Level of completion for 69 items (what?) - completion - non completion - Partial Results: where assessment was located: new form-69% old form-5% various mix including progress note-3% no documentation-23% (maybe left on desk?) big problem Other big problem is that... no assessment had all items completed only 8% had 90% or higher of items completed 60% assessments had fewer than 80% items completed

Why EBP?

Our clients expect it - clients expect interventions that are effective, provided by competent therapists, and appropriate to their needs and preferences -We have a responsibility to ensure best practice - Financial accountability

Crossing the quality chasm

book written which showed measure of the difference between what should be evidence based practice and what is actually being delivered so the gap was huge

Potential barriers to KT

-Structural (e.g. financial disincentives) -Organisational (e.g. inappropriate skill mix, lack of facilities or equipment) -Peer group (e.g. local standards of care not in line with desired practice) - Individual (e.g. knowledge, attitudes, skills) -Client (e.g. knowledge, attitudes, skills) -Professional - client interaction (e.g. problems with information processing)

2 valleys of death in research

1. Basic biomedical research -valley death here Valley 1- learned a bunch of knowledge and then loss of translation of knowledge on the way so work in research should translate into interventions but it does not 2. clinical science and knowledge Valey death 2 here next we have our interventions which is for particular diagnosis (so clinical sicent/knowledge) so again produce amazing knowledge then its not used in practice 3. health decision making and clinical practice

Levels of evidence

1. systematic reviews 2. single experimental design RTCs 3. quasi experimental studies 4. non experimental 5.case reports/program evaluation/lit reviews 6. opinion of respected authorities

Evidence to practice gaps in rehab

Strong evidence in stroke care Numerous best practice guidelines (Lindsay et al., 2008) Treatment of unilateral neglect (Menon-Nair et al., 2007) - 80% recognized unilateral neglect as a problem in a vignette -27% rate of desired assessment use -16% were classified as taking a best practice approach Actual vs best practices for families post-stroke (Rochette et al., 2007) -Hypothetical cases, survey -One-third of the sample identified a family-related problem - Only 12/1755 (<1%) would use a standardized assessment of family functioning OT practice related to the treatment of participation post-stroke (Korner-Bitensky et al., 2008) -telephone, vignette based -60.2% identified a problem relating to leisure or social - Desired assessment use was 1% - Desired intervention use was 15% Physiotherapy treatment of typical LBP - 68% reported treatments with strong to moderate evidence - 90-96% using treatments with limited or no evidence

What do we know about changing rehab practice?

Systematic review on strategies to move stroke evidence into rehabilitation practice - OT/PT - Limited evidence, n=12 Active, as opposed to passive were more likely to be effective Systematic review on KT strategies in allied health (PT,OT, SLP, Dietetics, Pharmacy) - N=32 - PT=11, OT=6, Dietetics=3, SLP=2 - Educational meetings most prominent - Need higher quality in studies for advancing our science of KT

EPOC-the state of the science

The Cochrane Effective Practice and Organisation of Care (EPOC) group supports reviews of interventions to improve healthcare systems and healthcare delivery Over 7,000 randomized and quasi-experimental studies 80 systematic reviews of professional, organizational, financial, and regulatory interventions

Barriers to EBP in Rehab

The utility of research for clinical practice Critical appraisal skills -52-57% of PT's felt they could critically appraise evidence -Lack of confidence in the ability to use research and a limited skill base for understanding research Time - 8% report protected time for EBP activities Poor access to resources, doing searches Organizational support

What to do?

Use steps involved in evidence-based practice ¤ 1. Convert information needs into answerable questions ¤ 2. Track down the best evidence with which to answer these questions ¤ 3. Critically appraise the evidence for its validity and importance ¤ 4. Integrate this appraisal with clinical expertise and patient values to apply the results in clinical practice ¤ 5. Evaluate performance -Know and use any clinical practice guidelines in your area - Measure the outcomes of your care - Do not assume you are delivering evidence based care - Consider using audit and feedback to improve practices

Things to remember about best practice

What is best practice today evolves into standard practice in future standard practice today was once best practice of past when someone continues their standard practice across too long of a time we say that practice is out of date and would not stand up to standard practice scrutiny

When does EBP occur?

when 1. best research evidence 2. clinical practice 3. patient values and preferences come together

What can we do with this example?

• It's audit and feedback - one of the most effective KT intervenKons • Use it to facilitate practice improvement • Can facilitate a discussion for the areas completed well, and the areas not • Facilitate discussion on changes to the new form • Not performance appraisal • Create action plans based on the discussion and re-do chart review in 1 year