Evidence Based Practice

1. Evidence Based Practice January 10, 2006

2. Definitions • Rosenthal and Donald (1996) defined evidence-based medicine as a process of turning clinical problems into questions and thensystematically locating, appraising, and using contemporaneousresearch findings as the basis for clinical decisions. • Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) described evidence-based practice as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

3. Definitions • DePalma (2000) further refined the definition of evidence-based practice as a complete process beginning with knowing what clinical questions to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation. The best evidence then must be applied by a clinician with expertise in considering the patient's unique values and needs. The final aspect of the process is evaluation of the effectiveness of care and the continual improvement of the process. • Ottenbacher and Mass (1998) indicated that the “best evidence” used to support evidence-based practice is derived from a series of research studies results in an empirical consensus regarding the effectiveness of a treatment approach.

4. Evidence-Based Practice • Gold standard of best practice in medicine • In medicine, with its positivist scientific methods tradition, the “gold standard” for scientific evidence is still randomized clinical trials and the method of choice for determining the cumulative evidence of the effectiveness of a treatment is meta-analysis. • Randomized clinical trials • Meta-analysis

5. Evidence Based Practice • Steps for the evidence-based practice of medicine by practitioners: • Formulate a clear clinical question from a patient's problem. • Search the literature for relevant clinical articles. • Evaluate (critically appraise) the evidence for its validity and usefulness. • Implement useful findings in clinical practice.

6. A Hierarchy of Levels of Best Evidence • Level 1 evidence is defined as strong evidence from at least one systematic review of multiple well-designed randomized controlled trials. • Level 2 evidence is defined as strong evidence from at least one properly designed randomized controlled trial of appropriate size. • Level 3 evidence is defined as evidence from well-designed trials without randomization, single group pre-post, cohort, time series, or matched case-controlled studies.

7. A Hierarchy of Levels of Best Evidence • Level 4 evidence is defined as evidence from well-designed non-experimental studies from more than one center or research group. • Level 5 evidence is defined as opinions of respected authorities, based on clinical evidence, descriptive studies, or reports of expert committees.

8. Related Concepts – Empirically Supported Treatment • APA Division 12 defined empirically supported treatment (EST) as clearly identified psychological treatments shown to be efficacious in controlled research studies with a delineated population. • EST should be evaluated in terms of efficacy (statistical and clinical significance), effectiveness (clinical utility), and efficiency (cost-effectiveness).

9. Related Concepts – Empirically Supported Treatment • Patterned after the FDA guidelines for approval of new drugs, the APA Div 12 Task Force on the Promotion and Dissemination of Psychological Procedures established two criteria for establishing the empirical validity of a psychotherapeutic approach: • The approach is superior to a placebo or other treatment or • The approach is equal to an established treatment, in at least two studies established by different investigators.

10. Related Concepts – Meta-Analysis • Meta-analysis is a method used to review research literature based on statistical integration and analysis of research findings. • In treatment effectiveness meta-analysis, the dependent variable is the effect size (i.e., the outcomes or results of each study selected for review transformed into a common metric across studies) and the independent variables are study characteristics (i.e., participants, interventions, and outcome measures).

11. Related Concepts – Meta-Analysis • Meta-analysis is an effort to review the results of a research domain in quantitative terms. The intent is to identify what significant relationships exist between study features (independent variables) and effect sizes (dependent variable). • Benefits: The benefits of meta-analysis include its ability to: • Synthesize the results from many studies succinctly and intuitively for nonscientific communities, • Illustrate the amount and relative impact of different programs on different criteria for policy decision-making purposes, and • Identify the most effective programs and highlight gaps or limitations in the literature to suggest directions for future research

12. Related Concepts – Meta-Analysis • A common index of the size of the effect produced by each study is the effect size index g, which is the standardized difference between the sample mean of the treatment group and the sample mean of the control group (Wampold, 2001). A positive score indicates that the treatment group outperformed the control group, and a negative score has the reverse meaning. However, the effect size index g is a sample statistics. As such, it is a biased estimator of the true (i.e., population) effect size.

13. Evidence-Based Practice: Implications for Rehabilitation Counseling • Implications for counseling research – The need for level 1 evidence (empirical supported treatment and meta-analysis) related to the effectiveness of rehabilitation interventions (individual ingredients/components of RC as well as RC as interventions) • Implications for practitioners – For practitioners, evidence-based practice is a research utilization issue (ability to judge the quality of an individual research study and a collection of studies, the ability to select the best interventions on an individualized basis, and the ability to search for research information using the Internet and other library tools)

14. Problems of RC research • A weak theoretical base and poor quality are two major criticisms of rehabilitation research. These two criticisms are inter-related. Bellini and Rumrill (2002) contended that rehabilitation counseling operates essentially atheoretically, with no general theory to account for a significant proportion of the knowledge content of rehabilitation counseling. Their observations are consistent with many rehabilitation scholars (e.g., Arokiasamy, 1993; Cottone, 1987; Hershenson, 1996).

15. Problems of RC research • The view that rehabilitation counseling has a deficient theoretical base may also due to our failure to adequately distinguish between theories and models. • According to Bellini and Rumrill (2002), theories are more general than models: “…models typically operate at an intermediate level of conceptualization…Model-generated hypotheses are often tied to practical concerns in the role performance of rehabilitation counselors and delivery of services to persons with disabilities.” (p.127).

16. Mission of Public Health • Mission: “to fulfill society’s interest in assuring the conditions in which people can be healthy” • As public health professionals, we strive to ensure that people, systems, and communities are situated so that we are able to maintain a healthy society. • Scientific research is one of our primary means of accomplishing this mission.

17. Functions of Public Health • The public health field is organized in three core functions: • Assessment • Policy development • Assurance • Public health research underlies and cuts across all three core functions.

18. Functions of Public Health • Assessment • Assess the health needs of communities • Investigate the occurrence of health effects and health hazards • Analyze the determinants of health needs (personal and societal factors associated with the health needs)

19. Functions of Public Health • Once we understand the health needs of a communities and their determinants … we engage in policy development • Develop plans and policies that help us respond to those needs • Set priorities among health needs • Advocate for public health, build constituencies, and identify resources

20. Functions of Public Health • Following policy development, we provide assurance. • Manage the resources available and develop organizational structures necessary to address health issues • Inform and educate the public • Develop and implement public health programs • Evaluate programs and provide quality assurance

21. Evidence-Based Interventions • Evidence-based public health interventions are the most visible way that we are responsive across all three core public health functions. • Public health research focuses on many different issues (diseases, behaviors) in many different ways (education, advocacy, regulations and laws, environmental change, monitoring individual health status, communication and media). • Public health research and interventions are diverse! In order to be effective, however, all public health research should be evidence-based. This includes SBS.

22. SBS: Social Ecological Approach • “Health is viewed as a function of individuals and of the environments in which individuals are embedded, including family, social networks, organizations, communities, and societies.” (Stokols, 1996)

23. SBS: Social Ecological Approach • Focus on the interrelationships among individuals and: • Biological characteristics • Psychological characteristics • Behavioral characteristics • Social environment • Cultural environment • Physical environment

24. SBS: Social Ecological Approach • While the social ecological approach to research and practice is comprehensive, it is also challenging. • Instability of individual and ecological correlates of health • Within each correlate, existence of deep and often more complex factors • This combination presents a complex web of association and causation. • Are you sure this is what you want to do with the rest of your life?  This course will hopefully help you decide.

25. Public Health: Summary • Evidence-based public health research is essential and challenging (and exciting)! • A strategic and scientific approach to research is the only way to ensure that public health interventions are developed and implemented based on the needs of communities, their cultural and social characteristics, and interventions that use state-of-the-art strategies to influence behaviors and promote positive health outcomes. • Are you ready to research?