Evidence Based Practice April 2013 version

Evidence Based PracticeApril 2013 version Naomi Trostler, Hebrew Univeristy of Jerusalem, Israel Elke Naumann, HAN University, The Netherlands Julia Eisenblätter, Bern University of Applied Sciences, Switzerland

“This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein“.

Why do we need evidence based health care? http://www.youtube.com/watch?v=OeA_OKqqBJ4

Evidence based practice (international perspective) Evidence-based dietetics practice is informed by ethical principles of dietetics practice and codes of good practice. This includes reflection on how a dietitian’s own perspectives or biases may influence the interpretation of evidence. Evidence-based dietetics practice is about asking questions, systematically finding research evidence, and assessing the validity, applicability and importance of that evidence. This evidence-based information is then combined with the dietitian's expertise and judgment and the client’s or community’s unique values and circumstances to guide decision-making in dietetics. Vienna 2013

What is Evidence Based Practice? • Evidence based practice involves: • best available clinical evidence • patient’s values & expectations • individual clinical expertise https://evidence-based-practice.wikispaces.com/Evidence-Based+Practice

The clinical problem What do youalreadyknowaboutdietcounsellingregardinghypertension? The doctortoldmethat I have a mild hypertension. I am not sureatthemoment, but I will find out anddiscusstheresultswithyou in thenextconsultation? Certainly, I alreadyheardthat a lowsodiumdiethelpstoreducebloodpressure But istheeffectreally so relevant, thatitisworthchangingmywholelifestyle?

Appraise the evidence Whereshould I start?  I haveheardaboutthefivestepsofEvidencebased. Perhapstheyareuseful in thiscase.

REVIEW This is an excellent summary presentation by Pauline Douglas, on Practice Based Practice, that will provide a review on the materials presented just far http://www.youtube.com/watch?v=nzdJ9xWjKfo&NR=1

Evidence based practice The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

Appraise the evidence Thereisthis PICO principle, but whatdoesitmean? Howcanyouformulate a structuredquestion? 

Formulate the question PICO Question:

Formulate a question Example:

Formulate the question Example: ‘in patients with mild hypertension, does nutrition counseling regarding a low-sodium diet, compared with no dietary advice, lead to a fall in blood pressure?’

Appraise the evidence Howcan I transfermy PICO questioninto a searchterm? 

Boolean operator Boolean operators connect your seach words together to either narrow or broaden your set of results. The three basic operators are:

Create a search term Transfer your PICO question into a search term Finaly, connect words with AND when the search should include both of them . Firstly, searchfor Synonyms ofyourkeywords. Forexample: Secondly, connectsynonymswithOR. OR AND Thirdly, connectthepartsofthe PICO questionswithAND . High blood pressure AND AND

Create a search term Resulting search term: (mild hypertension OR high blood pressure) AND nutrition counseling AND low-sodium diet AND blood pressure.

Appraise the evidence Wherecan I searchfor an answertomyquestion? Whichdatabasesuitsbestforthistopic? 

search for answers Examples of common Databases:

Appraise the evidence The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

Appraise the evidence Are theresultsofthestudy relevant ? Istheliterature I retrievedvalid?  Howcan I assesstheliterature?

Appraise the evidence  Whatkindofstudy design was used in theliterature I retrieved?

Appraise the evidence There are several questionairs available in the internet for assessing the validity and relevance of the literature. Which one to choose is dependent on the kind of literature you retrieved. Qualitative Studies Guidelines Quantitative Studies Guidelines or alternatively deside first which study design was used: Algorithm for classifying study design Systematic Revies/Metaanalyses Practical Guidelines

Algorithm for classifying study design for questions of effectiveness Comparison between Interventions/ exposures no Non-comparative Study (case series, case study) yes Did investigator assign interventions/ exposure? yes Observational study Experimental study More than one group studied? no Before–After study/ interrupted time series Interventions/exposures randomly allocated? yes no yes Randomised Controlled Trial Non-Randomised Controlled Trial Exposure and outcome measured at the same time no Cross-sectional Study yes Ccse-control Study yes Groups defined by outcome? no Cohort study Adapted from NICE (www.nice.org.uk)

Apply the results Ismypatientsimilartotheparticipants in thestudy? Whatarethecostsoftheintervention?  Do thebenefitspredominatetheharmsoftheintervention? If not, aretheresults transferable? Will theoutcomes in theliteraturebethebestforthis individual patient?

Apply the results The resultsofmyinvestigationsare... Doesthismeetyourexpectations? ..... Do youthinktheimplementationoftheinterventionfitswithyourlifestyle ?

Reflection Was my PICO questionpreciseanddiditmeettheproblem? Whatdid I do exactly? Did I meetthevaluesandexpectionsofthepatient?  Whatweremyvaluesandexpectations in thiscase? Process 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results Was mysearchwellstructured? Was thevalidityandrelevanceoftheevidencewellassessed? Whatwould I do different next time? t

REVIEW The following overview presentation was prepared by students of the Department of Nutrition and Dietetics at HAN University, The Netherlands. The link is: http://prezi.com/deqtwxwhczd2/ebp/ Click in the picture and when open use these arrows to move the presentation

Keep in mind… Albert Einstein: “not everything that can be counted counts and not everything that counts can be counted”2 • EBP is real, complex and not always controlled, its documented, measured, occurs. • EBP is process of measurements, recording and tracking not controlling how practice is delivered. It answers the question "does practice/intervention “x” cause outcome “y” in the patient?" • Patients are not controlled as research subjects

Guidelines • Developed from systematically collected real outcomes and • synthesized them into a proposed practice/guideline • Clinical practice GL provide the practitioner with a valuable • starting point when faced with a patient scenario • GL are not a binding/restricting "cookbook" for practice, but a base • for decisions regarding the appropriate counseling for the individual patient • Practitioners are responsible to measure and record what they do • and the outcomes to contribute to the growing data base of clinical scenarios • and resulting outcomes to improve guidelines

more information • http://www.youtube.com/watch?v=FMRpZkFwOMA&feature=autoplay&list=PL5C7811609AE54181&playnext=6 • http://www.youtube.com/watch?v=nzdJ9xWjKfo&NR=1 • Evidence-Based practice: an idea whose time has come. Roberts KL, Collegian 1998; 5(3):24-27. • Practice-Based evidence. Swisher AK. Cardiopulm PhysTher J. 2010; 21(20:4.) • Evidence-Based medicine: application in dietetic practice. Gray GE & Gray LK. • J Amer Dietet Asso 2002; 102 (9):1263-1272. • Evidence-Based practice: what are dietitians' perceptions, attitudes, and knowledge? • Byham-Gray LD, Gilbride JA, Dixon LB, King-Sage F. J Amer Dietet Assoc 2005; 105(10):1574-1581. • Evidence-Based nutrition guidelines for diabetes and scope and standard of practice. • Franz MJ, Boucher JL, Green-Pastors J, powers MA. J Amer Dietet Assoc 2008;108(4):S52-S58. • Making research relevant; if it is an evidence-based practice, where’s the practice-based evidence? • Green LW. Family Practice 2008; 25: i20-i24. • The clinical reasoning of novice and expert occupational therapists. Unsworth CA. • Scand. J Occup Ther 2001; 8: 163-173.

questions about EBP • evidence based practice means that practice is mainly baised on scientifica evidence. yes OR no Answer: NO

questions about EBP • 2. The process of EBP consists of five steps in the following order: • formulate the question • search for answers • appraise the evidence • apply the results • assess the outcomes yes OR no Answer: YES

questions about EBP • 3. Let’s imagine: As a dietitian, you have seen a lot of children over the past years with obesity. Your treatment is mainly based on dietary advise. Last week one of the parents indicated that they do not need your advise anymore. They heard that increasing exercise is more helpful to reduce body weight compared to dietary advise. • Formulate the Patient, Intervention, Comparison and Outcome of this question. Answer: In children with obesity (P), does increasing exercise (I) reduces body weight more (O) compared with dietary advice (C)?

Evaluation of this e-course This e-course is developed by the DIETS network. Your comments and suggestions are very welcome! Please let us know what you think about this e-course by completing an online questionnaire: …link to website Your comments and suggestions will help us to improve this e-course. Thank you very much!

EVIDENCE BASED PROFESSIONAL PRACTICE Seminar Developing Clinical Questions & a Search Strategy

Objectives • To develop a clinical question as first step in EBP process. • To develop an appropriate search strategy.

Reasons for Developing a Focused Question 3 key reasons for focusing Qs: • ---------------------------------------------------------- • ---------------------------------------------------------- • -----------------------------------------------------------

Reasons for Developing a Focused Question 3 key reasons for focusing Qs: • To facilitate search for relevant evidence. • To sort best evidence from weaker, less valid evidence. • To decide whether evidence is applicable to your patients. [Craig & Smyth (2002) The Evidence Based Practice Manual for Nurses, p27]

Identifying Clinical Questions Types of questions: • diagnosis and prognosis • intervention • patient experiences • efficiency and effectiveness Elements of questions: • situation (patient or problem) (P) • intervention (I) • comparison treatment (if appropriate) (C) • Outcome (O)

Profession Specific EBP Scenario People in hospital (normally older people) who have had a stroke or other conditions which affects their swallow response will have to have special consideration to make sure that they receive all their nutrients and energy and also do not lose their enjoyment of eating. It is possible to train assistants to support meal and other eating times to make sure that individuals receive their food. In a time of increasing ‘value-for-money’ many hospitals and other institutions are concerned about effectiveness of training assistants or could they use food supplements more cheaply?

Profession Specific EBP Scenario Dietitians are being asked for their professional opinion and any evidence to support their views. You are wondering what the answers may be; would training assistants or providing nutritional supplements improve the nutritional intake. • ? patient or problem • ? intervention • ? comparison • ? outcome

Questions • What question can we answer? • Too many variables make a question difficult to answer • So simplify and focus; be clear; be SMART (Specific, Measureable, Acheiveable, Realistic and Time)

Evidence Based Practice April 2013 version