Integrating Evidence into Practice

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Integrating Evidence into Practice

• OT 653
• Fall 2003

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Reminder How to Do An Evidence-Based Review

• Ask a good Clinical Question that addresses a
  particular
• Situation
• Intervention, and
• Outcome
• Question may or may not include a comparison.

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Research the Clinical Question

• Do a literature search on your clinical question
• Fill out a Critical Review Form for each article
  about your question
• Rate the evidence available using Holms System
• Organize your findings in a meaningful way for
  easy use.

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Decide Whether or not to Apply Findings with Your
Particular Client

• Remember
• Evidence-Based
• Practice (EBP) is
• comprised of
• Clients Input
• Clinical Expertise
• Evidence

Evidence
EBP
Clinical Expertise
Client Input
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Integrating Evidence in Practice - 3 Structured
Ways

• Clinical Practice Guidelines (CPGs)
• Algorithms
• Clinical Pathways

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Clinical Practice Guidelines (CPGs)

• What are Clinical Practice Guidelines (CPGs)?
• Systematically developed statements that assist
  practitioner and patient decisions about
  appropriate health care for specific clinical
  circumstances (Law, 2002, p.196).
• Based on
• Expert opinion/consensus
• Evidence-based practice grounded in research
• CPGs typically
• are currently in existence mostly for physician
  interventions
• offer recommendations for care
• are prescriptive in nature
• help the practitioner determine appropriateness
  of interventions.

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http//www.ccs.ca/society/conferences/archives/200
1/2001coneng-03.asp
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Algorithms and Decision Trees

• What are Algorithms?
• Written guidelines to stepwise evaluation and
  management strategies that require observations
  to be made, decisions to be considered, and
  actions to be taken.
• Algorithms - may be part of a Protocol.
• Algorithms are CPGs in Decision Tree format.
• What is a Decision Tree?
• A flow chart that provides structure to the
  decision making process.

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What is a Protocol?

• A Protocol is
• A written statement or plan that defines the
  management of broad patient/client problems or
  issues and may include decision trees,
  algorithms, flowcharts, and research plans.

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Example of a Decision Tree

• Will the answer to this question change my plan
  of care?
• Yes No
• Collect Do I need this information
  for another source?
• No
  Yes
• Dont Collect
  Collect
• Will the service provider
  collect this information as
• part of his or her
  assessment?
• No
  Yes
• Collect
  Dont Collect

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http//jama.ama-assn.org/cgi/content/abstract/249/
5/627
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http//www.clinical-informatics.com/decisiontools.
htm
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Clinical Pathways

• What is a Clinical Pathway?
• A multidisciplinary tool that makes explicit the
  usual patient/client problem and activities that
  must occur to facilitate the achievement of
  expected patient/client outcomes in a defined
  length of time.
• Based upon evidence gathered from CPG process

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Barriers to Implementation and Uptake of CPGs

• Developing CPGs is time consuming and labor
  intensive
• Inadequate information and reporting systems
• Dissemination of information, evaluation, and
  feedback on CPGs is an intensive process
  typically not supported by most institutions
• Practitioners suspicious of CPGs (conflicting
  info on topics fearful about purpose of CPGs
  legal issues)
• Guidelines too complicated, time consuming,
  impractical
• No system for monitoring
• Concern over decreased individualized care.

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http//www.aapmr.org/hpl/clinpath.htm
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Factors for Ensuring Successful Implementation of
CPGs

• Choose a simple rather than complex clinical
  problem to address with CPGs
• Include practitioners in the development of the
  CPG
• Write the CPG document in clear simple language
  and format
• Offer financial incentives to those who develop
  CPGs
• Demonstrate cost-effectiveness of CPGs
• CPGs must have strong evidence base.

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Evaluation of CPGs

• CPGs must become integral part of practice
• Require adequate funding for entire process,
  including evaluation
• should ultimately affect practice and policy
• shift of focus from development of CPGs to
  changing behavior and outcomes.
• CPG evaluation tools
• AGREE Instrument
• Appraisal Instrument for Clinical Guidelines,
  Version 1
• Practice Guideline Evaluation and Adaptation Cycle

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http//www.agreecollaboration.org/
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Practice Guideline Evaluation and Adaptation Cycle

• 1. Conduct a systematic search for practice
  guidelines
• 2. Select a validated guideline appraisal
  instrument
• 3. Assess quality of how guidelines were
  developed and quality of recommendations
• 4. Assess clinical content
• 5. Develop local protocol based upon adaptation
  and adoption of existing guideline
  recommendations
• 6. Return to step 1 for continual review and
  revision of guideline

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Framework for Clinical Pathways

• Based upon the CareMap Concept -
• uses Case Mixed Groups or DRGs (Diagnostic
  Related Groups)
• Commercial Systems
• viewed by many as cookie cutter medicine
  generic exludes client input cost-cutting
  mechanisms for administrators
• Interventions on 1 axis
• (consulations and referral, assessments and
  observations, tests, treatments, measurements and
  diagnostics nutrition, medication, activity, and
  mobility safety patient/client, and family
  education/teaching discharge planning),
• Time on the other axis

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Choosing Case Types for Pathway Development

• Greatest Success when doing a systematic review
  of groups with
• high volume
• high cost
• high risk
• high practice variability
• potential for improvement
• predictable course
• provider interest
• potential to cross multiple settings and
  disciplines in continuum of care
• physician interest, initiative and acceptance.

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Clinical Pathways - Development Strategies

• Pathways must be supported by solid research
• review of literature
• Include critical pathways already in existence
• Common practice also included
• Gather key people and agencies for development
• include more than one tool, model or approach
• build in variability
• know your target audience
• First generation Clinical Pathways -
• were diagnosis focused
• Second generation Clinical Pathways -
• are more activity/function based

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Continuum Pathways

• These are transorganizational, multidisciplinary
  pathways (I.e. client goes from hospital to home,
  home to long term care)
• Choose target group for which pathway will be
  developed by the transorganizational,
  multidisicplinary group
• Concentrate on interface between pathways
  (hospital to home, home to long term care)
• Reach a consensus re common definitions
• Use international diagnostic codes
• Use common electronic interface, if computerized.

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Pathway Development Teams

• Choose interested practicing clinicians to
  develop pathways
• form single disciplinary groups to review
  literature
• then combine/form multidisciplinary groups when
  literature search is completed
• Use existing CPGs as the foundation for clinical
  pathways

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Checklist for Development of CPGs and Clinical
Pathways

• Assemble multidisciplinary teams
• Define clinical problems and current practice
• Conduct Literature Search
• Locate and appraise systematic reviews
  Locate and appraise primary studies
• Update systematic reviews
  Generate
  systematic reviews
• Describe and classify research according to
  levels of evidence
• Formulate or reformulate guideline
  recommendations
• Link guidelines to form clinical pathways
• Select process and outcome measures
• Identify documentation requirements and
  preferences
• Adapt effective strategies from systematic
  reviews to local culture
• Disseminate and pilot test guidelines and
  pathways using effective strategies from
  systematic reviews
• Collect and analyze process and outcome measures
• Correct problems and make revisions

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Clinical Pathway Evaluation

• Tools
• The Markers of Quality in Paths
• Checklist for Path Appraisal
• Chart Audits

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Identifying Outcomes - 2 Ways

• Variances
• The difference between what is expected and what
  actually happens.
• Result of patient/client, practitioner, or system
  issues
• Key Indicators or Outcomes
• form milestones that coincide with change in
  level of care or resource utilization.
• broader focus on the continuum of care
• key admission and discharge indicators
• facilitate smooth transitions throughout levels
  of care.

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Similarities and Differences Between CPGs,
Algorithms, and Clinical Pathways

• CPGs and Algorithms
• Focus on identifying best clinical option
• Useful across clinical settings apply generally
• May or may not be provider specific
• Based on evidence, expert opinion, or consensus
• Developed and supported by a group of experts
• Guide practice in an explicit manner

• Clinical Pathways
• Focus on operationalizing options
• Setting/institution specific tailored to fit
  local conditions
• Require multi- or transdisciplinary approach
• Based on evidence
• Produced by a multidisciplinary team
• Define optimum sequence and timing of
  interventions

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Experiential Learning Activity 1

• Instructions
• Break up into your groups.
• Discuss the following questions (see below).
• Be prepared to share your ideas with the larger
  group.
• You are a hospital administrator and wish to
  develop a Clinical Pathway for a particular
  diagnosis.
• What diagnosis would you choose to focus on and
  why?
• What steps would you take to develop a Clinical
  Pathway for that particular diagnosis?
• What steps would you take to avoid/overcome
  resistance to implementing the Clinical Pathway
  in your facility?
• What steps would you take to ensure the Clinical
  Pathway is properly evaluated?

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Experiential Learning Activity 1 - Responses
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Experiential Learning Activity 2

• Instructions
• Break up into your groups.
• Discuss the following questions (see below).
• Be prepared to share your ideas with the larger
  group.
• You are an administrator of a brand new nursing
  home in town and wish to develop a Continuum
  Pathway for a particular diagnosis between the
  hospital and the nursing home, and the home and
  the nursing home.
• What diagnosis would you choose to focus on and
  why?
• What steps would you take to develop a Continuum
  Pathway for that particular diagnosis?
• What steps would you take to avoid/overcome
  resistance to implementing the Continuum Pathway
  in your facility?
• What steps would you take to ensure the Contiuum
  Pathway is properly evaluated?

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Experiential Learning Activity 2 - Responses
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Experiential Learning Activity 3

• Instructions
• Break up into your groups.
• Discuss the following questions (see below).
• Be prepared to share your ideas with the larger
  group.
• You are a clinician in the hospital or nursing
  home in which the new clinical pathway or
  continuum pathway is being implemented.
• What is your reaction to that experience?
• What can you do as a clinician to facilitate that
  process?

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Experiential Learning Activity 3 - Responses
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So, How Do We Integrate Evidence into Practice?
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Questions and Answers

• ?