Evidence Based Practice

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Evidence Based Practice

• January 10, 2006

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Definitions

• Rosenthal and Donald (1996) defined
  evidence-based medicine as a process of turning
  clinical problems into questions and then
  systematically locating, appraising, and using
  contemporaneous research 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.

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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.

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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

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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.

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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.

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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.

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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).

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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.

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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).

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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

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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.

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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)

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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).

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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
  conceptualizationModel-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).

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Mission of Public Health

• Mission to fulfill societys 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.

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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.

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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)

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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

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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

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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.

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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)

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SBS Social Ecological Approach

• Focus on the interrelationships among individuals
  and
• Biological characteristics
• Psychological characteristics
• Behavioral characteristics
• Social environment
• Cultural environment
• Physical environment

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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.

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Public Health Summary

1. Evidence-based public health research is
   essential and challenging (and exciting)!
2. 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.
3. Are you ready to research?