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The Evidence That Supports the Evidence PEGGY WARD-SMITH

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The Evidence That Supports the Evidence PEGGY WARD-SMITH, PHD, RN UMKC SCHOOL OF NURSING THE 8TH ANNUAL EVIDENCE-BASED PRACTICE NURSING SYMPOSIUM – PowerPoint PPT presentation

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Title: The Evidence That Supports the Evidence PEGGY WARD-SMITH


1
The Evidence That Supports the Evidence
  • Peggy Ward-Smith, PhD, RN
  • UMKC School of Nursing
  • The 8th Annual Evidence-Based Practice Nursing
    Symposium

2
Meek 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.

3
POW 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

4
POW 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

5
Lasting 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

6
Cochrane Centers
  • Headquartered at Oxford, UK
  • 12 Around the World
  • US center at Johns Hopkins
  • Branch in San Francisco
  • Grouped by disease process

7
Nursings 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).

8
Using 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).

9
The 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.

10
Definition
  • "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.

11
Purpose 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.

12
The 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

13
SHIFT!
  • Include all members of a healthcare team.
  • This is a major shift.
  • Maintaining competency / current / information
    access.

14
Classification 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.

15
Classification 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).

16
Joanna 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

17
Levels 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.

19
Grading the Evidence
  • Rigorous research
  • Best evidence
  • Personal way of knowing/hunches are minimized.
  • If its not published does it exist?

20
Critiquing 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

21
Critiquing Quantitative Research
  • Multiple published outlines/procedures
  • Statistical significance
  • Power avoidance of a Type II error
  • Control, intervention, and data collection time
    (interval)
  • Adaptability

22
Clinical 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.

23
Linking the Clinical Question to the Research
Design
24
Formulate a Question?
25
Background Information
  • References - textbooks
  • Practice guidelines
  • Review of the literature
  • Remember that it takes 3 years for data to be
    published

26
Foreground Information
  • Patient centered information
  • Age
  • Gender
  • Co-morbidities
  • Clinical questions
  • Etiology
  • Diagnosis
  • Prevention
  • Harm

27
TOOOOO Much Information?
  • Limit by healthcare condition
  • Prognosis
  • Diagnosis
  • Prevention
  • Limit by clinical question
  • Therapy
  • Diagnosis
  • Etiology/harm
  • Prognosis

28
Evidence-Based Practice (EBP)
  • Combine research evidence with clinical
    expertise.
  • Uses an evaluative and qualitative approach.
  • Differentiate between high-quality and
    low-quality research findings.

29
Implementation Hurdles
  • Delay of transferring research findings into
    practice
  • Changes in the healthcare system
  • Benefit of treatment

30
What 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.

31
Background
  • 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)

32
History
  • 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).

33
Cochrane 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).

34
US 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).

35
Centers 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).

36
The 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).

37
Randomized 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.

38
The 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

39
EBP?
  • 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.

40
The Future
  • For prostate cancer
  • More will be diagnosed
  • Increased age
  • Screening activity participation
  • Research efforts
  • Decision-making process
  • Specific demographics
  • Insurance / cultural norms

41
Who better to guide this journey than nurses?????

42
Connecting the Evidence
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