4/11/2016

Evidence Based Practice

• Synthesis of
– Patient goals
– Therapist expertise
– Research foundation
Efficient and Effective EBP Search
Strategies to Enhance your
Practice
Beth Cloud, PhD, PT
Jena Ogston, PhD, PT
Peter Rundquist, PhD, PT

Objectives Overarching Goal

1. Describe the benefits and limitations of different
research study designs and levels of evidence • “…decreasing practice variation and
2. Identify 5 commonly used search engines
and/or websites that link to a clinical question standardizing care around best practice
that is relevant to the participants clinical patterns to maximize clinical outcomes
practice and cost effectiveness… (Cleland et al,
3. Demonstrate efficient search skills in various
search engines and websites including, but not 2008, p. 476)”
limited to PICO, rehabmeasures.org, pubmed
Clinical Queries, and ptnow.org.
4. Based on a clinical question, identify the form
of research and conduct an efficient search

What it is Barriers to EBP

• Documenting and testing elements of clinical • Gaps in knowledge
practice through rigorous and objective analysis
and scientific inquiry. • Patients improve despite evidence to the
(Portney and Watkins, 2000 p. 3)

• … the judicious use of current best evidence in contrary

making decisions about the care of individual • Productivity standards
patients
(Sackett, 1996) • Reliance on clinical expertise
• Evidence-based medicine (EBM) is the • Resource availability
integration of best research evidence with clinical
expertise and patient values. • Time consuming
(Sackett, 2001, p. 1)

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APTA 2020: Qualitative vs. Quantitative

http://www.apta.org/vision2020/ Research
Quantitative Qualitative
Evidence‐based practice is access to, and application and 
integration of evidence to guide clinical decision making to  • Experimental • Naturalistic Inquiry
provide best practice for the patient/client. Evidence‐based  • Positivist • Post-positivist
practice includes the integration of best available research, 
clinical expertise, and patient/client values and  • Empirical • Constructivist
circumstances related to patient/client management, 
practice management, and health care policy decision 
making. Aims of evidence‐based practice include enhancing 
patient/client management and reducing unwarranted 
variation in the provision of physical therapy services.

New Vision (adopted 2013) Qualitative vs. Quantitative

Research
• Transforming society by optimizing movement to Method Quantitative Qualitative
improve the human experience
Theory A priori: Deductive Ground-up: Inductive

Number and selection of Groups, random Small number, purposive

• Principles: quality commits the profession to subjects

establish and adopt best practice standards. Measurement tools Instruments Human

Type of data Numerical Language (Descriptive)

• Value: includes accountability in demonstrating Manipulation Present Absent

that services are safe, effective, patient- Control Maximized Minimized

centered, timely, efficient and equitable

Research Methods Study Classifications – Qualitative

• Qualitative:
• Generally applied to descriptive or exploratory
• Subjective, narrative, measurement is based on “open-
ended” questions, interviews and observations
• Quantitative:
• Descriptive, exploratory (correlative), experimental
• Numerical data under standardized conditions
• Phenomenology – evaluates narratives of
individuals to determine meaning; gives a better
understanding of what is associated with a
specific clinical phenomenon
• Grounded Theory – development of a theory
after analyzing qualitative data
• Ethnography – focused on understanding how
culture affects attitudes, beliefs, and behaviors

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Levels of Evidence
Study Classifications – Quantitative
• Intervention Studies
– Randomized controlled trials
– Quasi-experimental research designs
• Prognostic
– Cohort studies
– Case control studies
• Diagnostic Accuracy

Levels of Evidence Study Classifications – Intervention

1a. Systematic Review with homogeneous RCTs Randomized Quasi-experimental
1b. Individual Randomized Controlled Trial controlled trials designs
2a. Systematic Review with homogeneous cohort studies • Participants randomized • Lacks control/
to intervention group randomization
2b. Individual Cohort Study or low quality RCT (< 80%
return) • May apply masking (of • Possible designs
participants and/or – Repeated measures (within
2c. Outcomes research investigators) subject)
3a. SR with homogeneous case control studies – Non-randomized groups
(between subject)
3b. Individual case control study – Case study or case series
4. Case series and poor quality case control study (single subject or multiple
cases)
5. Expert opinion Sackett et al 2000

Definitions Study Classifications – Prognostic

• SR – literature summary utilizing specific Cohort studies Case-control studies
methodology to review individual articles • Following individuals
over time • Evaluating previous
• RCT – randomized into experimental and control exposure or effect of a
• May consist of groups
group that differ by some quality/characteristic
• Cohort Study – experimental and control cohorts quality or exposure • Groups will consist of
• Outcome is individuals with or
• Outcomes Research – population based disease/condition of
interest without the disease/
• Case control – retrospective cohort condition of interest
• Case series – report on outcomes; no control Heart Stroke Heart CASE
disease disease S
Stroke
Sackett et al 2000 No heart No No heart CONTRO
disease stroke disease LS
No
stroke

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Study Classifications –
Diagnostic Accuracy
• Sensitivity
– % of cases who tested
positive among those that
have the disease
Interpreting the Literature
• SNOut • Reliability
– If Sensitivity is very • Validity
high a Negative test
will rule the disorder
• Responsiveness
Out
• few false negatives

Study Classifications –
Diagnostic Accuracy
• Specificity
– % of cases who tested
negative among those that
do not have the disease
Reliability
• SPIn • The consistency of an instrument in
– If Specificity is very measuring what it is designed to measure
high, a Positive test – Intra and Inter-Rater
will rule the disorder In
– Test-Retest
• few false positives
– Relative
– Absolute

Mixed Method Validity

• Combination • Are the authors’ conclusions
– Believable
– Sequential Explanatory: qualitative after – Useful
quantitative
• Adds depth (explanation and interpretation)

– Sequential Exploratory: quantitative after

qualitative
• Adds breadth (generalization)

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Validity Overarching Considerations

• Internal
– How did the investigator lessen intervening
variables that could confound the results?
• External
– Who does this research apply to?
• Construct
– Operational definitions
• Statistical conclusion
– Is there truth in measurement and inference?
• When reading and/or planning studies,
find measures that have good reliability,
responsiveness, and validity
• Evaluate and/or design studies that have
well constructed design and control
elements to allow for the detection of
meaningful difference
• Make sure the outcome measures validly
represent the concept being studied

Reliability versus Validity Additional Definitions Resource

• rehabmeasures.org
– Statistics review

Responsiveness Search Engines, Resources

• Ability of an instrument to detect change General Rehab Specific
when it has occurred • PubMed: • PEDro:
http://www.ncbi.nlm.nih.gov/pubmed/ http://www.pedro.org.au/
– Minimal Detectable Change • Scopus: • PTNow:
http://www.scopus.com/ http://www.ptnow.org
– Minimal Clinically Important Difference
• Cochrane Library: • Rehabilitation Measures
http://www.cochranelibrary.com/ Database:
• Trip: http://www.rehabmeasures.org
https://www.tripdatabase.com/
• Google/Google Scholar:
https://scholar.google.com/

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Search Strategies Studies of Intervention – Example

In individuals who have had a stroke, how does the use of functional electrical stimulation compare to an ankle
Medical Subject Headings Boolean Operators foot orthosis in terms of resultant gait speed?

(MeSH) Terms: • Assist with focusing the MEDLINE/PubMed PICO Trip PICO PubMed Clinical Queries

https://www.nlm.nih.gov/mesh/
scope of a search
• Purpose: “provide a
• Basic Boolean operators
hierarchically-organized
terminology for indexing – AND
and cataloging of – OR
biomedical information” – NOT
• Search for MeSH terms: • Search engines may
https://www.nlm.nih.gov/mesh/MBr automatically use or
owser.html
facilitate use of these

Studies of Intervention – PICO Clinical Practice Guidelines

Patient/Problem, Medical Stroke • Systematically developed statements
Condition Functional Electrical designed to facilitate evidence-based
Stimulation
Intervention decision making for the management of
Ankle Foot Orthosis
Compare to (optional, alternative specific health conditions. CPGs
Gait Speed
intervention) incorporate evidence from research and
Outcome (optional) clinical expertise.
Sample Clinical Question: In individuals who have had a stroke, how does
the use of functional electrical stimulation compare to an ankle foot orthosis
in terms of resultant gait speed?

Intervention Search Engines Clinical Practice Guidelines (CPGs)

• PICO templates
– MEDLINE/PubMed - “Guidelines are systematically developed
http://pubmedhh.nlm.nih.gov/nlmd/pico/piconew.php statements to assist practitioner decisions
– Trip - https://www.tripdatabase.com/#pico about appropriate health care for specific
clinical circumstances.”
• PubMed Clinical Queries - (Scalzitti, 2001)
http://www.ncbi.nlm.nih.gov/pubmed/clinical

• Consider systematic reviews, clinical prediction rules, clinical

practice guidelines as other sources for intervention information

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Purpose of CPGs
1. Make evidence based practice efficient
and realistic
2. Make the best available research
evidence directly applicable to clinical
practice
3. Integrate research evidence with
knowledge from clinical experts
4. Consider research evidence with
consideration for patient perspectives

Systematic Reviews vs. Clinical

Resources for CPG’s
Guidelines
• National Guideline • TRIP Database
• Focus is on a single • Broad clinical focus Clearinghouse (NGC) http://www.tripdatab
topic • Developed by a http://guidelines.gov ase.com
• Developed by a few diverse group and • Joanna Briggs Institute • http://guidelines.gov/
researchers/authors numerous researchers www.joannabriggs.ed • http://www.pedro.fhs.
• Based on best • Based on best u.au/ usyd.edu.au/ (PEDro)
evidence evidence, expert • ICSI - Institute for
opinion, and patient Clinical Improvement
input (Click on the
"Guidelines and More"
link at the top)
http://www.icsi.org/

Examples of CPG’s in PT Limitations of CPG’s

1. Neck & low back pain guidelines (Childs •Very general
JD et al., 2008) •May be lacking as research is either lacking
2. Torticollis: (Burch et al., 2009) and/or low quality or rigor
3. Development of DVT’s (Riddle et al., • Ptnow.org: Agree II tool
2005)
4. Ankle and knee fractures (Steill et al.,
1992; Stiell et al., 1995)

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Types of CPR’s Other ways to locate scientific

I. Diagnostic: probability that a patient has a
particular condition
II. Prognostic: likely outcome of patients with a
specific condition
III. Interventions: which patients are likely to
respond to a type or set of intervention(s)
evidence…
1. Use a single article & work backwards
2. Become a regular reader of selected
journals
3. Push technology (e.g. RSS feed)
4. Review Journals: ex: Clinics in Sports
Medicine

Types of CPR’s: Examples PTNow.org

I. Diagnostic: Ottowa ankle rules
• One stop shop for APTA members
II. Prognostic: Dionne et al. (2005) predictors – Article search
on return to work in patients with LBP – Rehab Reference Center
– Clinical Summaries
III. Interventions: Hicks et al. (2005) stabilization – Tests
exercises in persons with nonradicular LBP
– CPGs
– Cochrane reviews

Creation of CPR’s EBP “toolkit” resources

1. Create the CPR
-identify factors with predictive value •Pick 2: Pubmed, CINAHL, Pedro,
•Outcome measures: rehabmeasures.org
2. Validation
-reproduction in various populations •One stop shop: ptnow.org
3. Conduct Impact Analysis
-evaluate clinical decision making (cost
difference?)

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What is in your toolkit?

2 push resources:

2 pull resources: