Title: The Evidence That Supports the Evidence PEGGY WARD-SMITH
1The Evidence That Supports the Evidence
- Peggy Ward-Smith, PhD, RN
- UMKC School of Nursing
- The 8th Annual Evidence-Based Practice Nursing
Symposium
2Meek Beginnings Archie Cochrane
- 1909-1988 born in Northern Scotland.
- Medical degree from University College London.
- Passion was health studies (pneumoconiosis unit).
- WWII served as a medical
- officer at a number of
- prisoner of war camps.
3POW Experience Part I
- In Greece Crete (1941)
- 8000 British POWs
- Daily diet of 400-500 calories
- Initial study used Vitamin C
- Treatment of beri-beri
- Corrected fluid balances
- Wrong hypothesis
- Deaths from shootings
- Doctors are superfluous
4POW Experience Part II
- Transferred to Germany Wittenberg an der Elbe
(1947) - 24,000 POWs
- Daily diet of 0-100 calories.
- TB diagnosis routinely made
- Treatments were inconsistent/untested
- Many deaths/many reasons
- I may have harmed many
5Lasting Effects
- Resources will always be limited and thus should
be used to provide forms of healthcare which have
been shown in properly designed evaluations to be
effective (1948). - It is surely a great criticism of our profession
that we have no organized a critical summary
(1979). - Oxford Database of Perinatal Trials (1980)
- Systematic Reviews of Randomized Controlled
Trials (RCTs) center at Oxford in 1987 - Center opened in 1992 Cochrane Collection in
1993
6Cochrane Centers
- Headquartered at Oxford, UK
- 12 Around the World
- US center at Johns Hopkins
- Branch in San Francisco
- Grouped by disease process
7Nursings Beginning
- Florence Nightingale (1820-1910)
- Born in Tuscany
- Educated at St. Thomas Hospital in London (the
first secular school of nursing). - Upper-middle class, an education
- was not an expectation and nursing
- was rebellious.
- Her father taught her mathematics,
- which she used to assist the secretary
- of war (Crimean).
8Using These Data
- Used these numbers to track deaths at the
hospitals. - Implemented hygiene changes
- Ventilation
- Flushing sewers
- Overcrowding
- Nutrition
- Superintendent at the Institute for the Care of
Sick Gentlewomen in London (non-paying, her
father gave her an annual income of
500pound/year). - Grateful families made donations which she used
to set up the Nightingale Training School (1860).
9The Joanna Briggs Institute
- Established in 1996 at the University of Adelaide
(Australia). - Joanna Briggs was the first matron of Royal
Adelaide Hospital. - An international collaborative effort including
40 countries. - Free access to evidenced-based information.
10Definition
- "Evidence-based practice (EBP) is an approach to
health care wherein health professionals use the
best evidence possible, i.e. the most appropriate
information available, to make clinical decisions
for individual patients. EBP values, enhances and
builds on clinical expertise, knowledge of
disease mechanisms, and pathophysiology. It
involves complex and conscientious
decision-making based not only on the available
evidence but also on patient characteristics,
situations, and preferences. It recognizes that
health care is individualized and ever changing
and involves uncertainties and probabilities.
Ultimately EBP is the formalization of the care
process that the best clinicians have practiced
for generations. - McKibbon KA (1998). Evidence based practice.
Bulletin of the Medical Library Association,
86 (3) 396-401.
11Purpose of EBP
- Integrate the best research evidence with
clinical expertise, patient preference and
circumstances, and awareness of the clinical
setting and resource constraints. - Personalize the evidence to fit the specific
patient and clinical situation.
12The Debate
- Pro
- A solution to improving healthcare in a
cost-containment environment - A rationale approach
- Self-directed life-long learning
- Con
- Clinical judgment and patient preference are
devalued - Rating is biased
- Advantages are exaggerated
13SHIFT!
- Include all members of a healthcare team.
- This is a major shift.
- Maintaining competency / current / information
access.
14Classification of Evidence
- Ia Evidence obtained from meta-analysis of
randomized controlled trials. - Ib Evidence obtained from at least one randomized
controlled trial. - IIa Evidence obtained from at least one
well-designed controlled study without
randomization. - IIb Evidence obtained from at least one other
type of well-designed quasi-experimental study (a
situation in which implementation of an
intervention is without the control of the
investigators, but an opportunity exists to
evaluate its effect). - III Evidence obtained from well-designed
non-experimental descriptive studies, such as
comparative studies, correlation studies and case
studies. - IV Evidence obtained from expert committee
reports or opinions and/or clinical experiences
of respected authorities.
15Classification of Grades of Recommendations
- Grade A - Requires at least one randomized
controlled trial as part of a body of literature
of overall good quality and consistency
addressing specific recommendation. (Evidence
levels Ia, Ib). - Grade B - Requires the availability of well
conducted clinical studies but no randomized
clinical trials on the topic of recommendation.
(Evidence levels IIa, IIb, III). - Grade C - Requires evidence obtained from expert
committee reports or opinions and/or clinical
experiences of respected authorities. Indicates
an absence of directly applicable clinical
studies of good quality. (Evidence level IV).
16Joanna Briggs Institute
- Feasibility (1-4)
- Meta synthesis, one or more studies, expert
opinion - Appropriateness (1-4)
- Meta synthesis, one or more studies, expert
opinion - Meaningfulness (1-4)
- Meta synthesis, one or more studies, expert
opinion - Effectiveness (1-4)
- RCT or large experimental study,
quasi-experimental, no randomization, cohort,
case controlled, observational, expert opinion - Economic Evidence (1-4)
- Meta synthesis, comparison to alternative
treatment, expert opinion
17Levels of Evidence Melynk Fineholt-Overholt
18 EBP Centers - AHRQ
- Blue Cross and Blue Shield Association,
Technology Evaluation Center. - Duke University.
- ECRI Institute.
- Johns Hopkins University.
- McMaster University.
- Minnesota Evidence-based Practice Center.
- Oregon Evidence-based Practice Center.
- RTI InternationalUniversity of North Carolina.
- Southern California.
- TuftsNew England Medical Center.
- University of Alberta.
- University of Connecticut.
- University of Ottawa.
- Vanderbilt University.
19Grading the Evidence
- Rigorous research
- Best evidence
- Personal way of knowing/hunches are minimized.
- If its not published does it exist?
20Critiquing Qualitative Research
- Subjectivity bias
- Multiple outlines/guidelines to follow
(published) - Evaluate the rigor not the sample size,
statistical analyses, and/or generalizability - Watch the clinical situation, population, and
outcome
21Critiquing Quantitative Research
- Multiple published outlines/procedures
- Statistical significance
- Power avoidance of a Type II error
- Control, intervention, and data collection time
(interval) - Adaptability
22Clinical Significance
- Is the research clinically significant?
- Where the participants like your patient
population? - Does the clinical scenario mimic yours?
- Is it feasible / doable?
- Clinical significance is different than
statistical significance.
23Linking the Clinical Question to the Research
Design
24Formulate a Question?
25Background Information
- References - textbooks
- Practice guidelines
- Review of the literature
- Remember that it takes 3 years for data to be
published
26Foreground Information
- Patient centered information
- Age
- Gender
- Co-morbidities
- Clinical questions
- Etiology
- Diagnosis
- Prevention
- Harm
-
27TOOOOO Much Information?
- Limit by healthcare condition
- Prognosis
- Diagnosis
- Prevention
- Limit by clinical question
- Therapy
- Diagnosis
- Etiology/harm
- Prognosis
28Evidence-Based Practice (EBP)
- Combine research evidence with clinical
expertise. - Uses an evaluative and qualitative approach.
- Differentiate between high-quality and
low-quality research findings.
29Implementation Hurdles
- Delay of transferring research findings into
practice - Changes in the healthcare system
- Benefit of treatment
-
30What Does the Evidence Show?
- Prostate cancer screening
- Your 54 year old father/significant
other/uncle/brother asks about prostate cancer
screening they are reluctant to have either the
blood draw or the physical examination. - There is no family history, physical complaints
or high risk factors.
31Background
- The most common non-skin cancer in America
- More than 2 million men in the US have it.
- Screening activities allow 90 to be detected
while localized . an almost 100 5 year cure
rate. - (American Cancer Society, 2009)
32History
- In 1996 the American Academy of Family Physicians
recommended routine screening in men over the age
of 50 (expert opinion). - Research by Lefevre (1998) concluded that
evidence to support routine use of PSA was
lacking (systematic review).
33Cochrane Review
- In 2001, there were insufficient evidence to
support or refute routine screening (Wilt, Nari,
MacDonald Rutks). - In 2006, additional studies were included, with
the same result (Ilic, OConnor, Green Wilt).
34US Preventative Services Task Force (USPSTF)
- Insufficient evidence to recommend screening
among men younger than 75 years of age. - This activity received a grade of D the
balances of benefits and harms cannot be
determined, the evidence is of poor quality,
conflicting and lacking. - They recommend that this service be discontinued
(systematic review and expert opinion).
35Centers for Disease Control
- Does not recommend an age for routine screening
but reports the results of PSA screening
activities among men older than 50 years of age
(2009). - The CDC affirms that medical experts disagree.
- Increased risk for the disease (African American,
family history) should be included in
decision-making. - In fact, they have specific educational materials
for African American males (2003).
36The American Cancer Society
- Does not support routine prostate cancer
screening. - Recommend discussing it with a healthcare
provider beginning at age 45. - IF the man leaves the decision to the healthcare
provider, they should undergo testing (2009).
37Randomized Controlled Clinical Trials
- New England Journal of Medicine (2009) report
that screening among 182,000 men (50-74 years of
age) reduced the death rate from prostate cancer
20 (Schröder , et al). - New England Journal of Medicine (2009) reported
that screening 76,693 men for prostate cancer had
no impact on the ability to identify localized
prostate cancer or prevent mortality.
38The American Society of Clinical Oncology
andThe American Urologic Association
- Guideline (2009) suggest that a multi-year regime
of a 5-a reductase inhibitor medication, such as
finasteride, be offered to men who routinely
undergo prostate screening activities. - This medication reduces the risk of getting this
disease or delay the diagnosis. - Early research
- Controversial finding
- May cause a higher grade of disease if it occurs
39EBP?
- The evidence is complex and varying.
- Include demographic information, values, health
behavior, resource constraints, personal
preferences . - Hellenthal and Ellsion (2008) determined that
referral patterns, accessibility of specialists,
wait times, belief in complementary or
alternative treatments, faith and spirituality
were variables considered by men when making
treatment choices. - The experience from men who underwent
brachytherapy (Ward-Smith, 2003) reveal that
lifestyle, minimal invasiveness, and recovery
time influenced their treatment choice.
40The Future
- For prostate cancer
- More will be diagnosed
- Increased age
- Screening activity participation
- Research efforts
- Decision-making process
- Specific demographics
- Insurance / cultural norms
41Who better to guide this journey than nurses?????
42Connecting the Evidence