TIPS FOR TRAINERS: USING EVIDENCE-BASED PRACTICE IN THE CLINICAL PRACTICUM

1. TIPS FOR TRAINERS: USING EVIDENCE-BASED PRACTICE IN THE CLINICAL PRACTICUM *Barbara B. Walker, Ph.D. Indiana University BBWalker@Indiana.edu Beverly E. Thorn, Ph.D., ABPP The University of Alabama Bthorn@as.ua.edu Council of University Directors of Clinical Psychology January 18, 2008

2. Acknowledgements… • Parts of this presentation are taken from a workshop given with Barbara Walker, Ph.D., at the Alabama Psychological Association fall meeting, Nov. 10, 2007. *Although Dr. Walker was not physically present at the CUDCP 2008 meeting, she was the lead in preparing this talk. • UA Dept. of Psychology • IU Dept. of Psychological and Brain Sciences • Society of Behavioral Medicine / Div. 38 APA • SBM Evidence-Based Behavioral Medicine Committee: Karina Davidson, Ph.D. & Bonnie Spring, Ph.D. • IU Ruth Lilly Library • Susan London: EBM Librarian Extraordinaire

3. Evaluation • Clinical interview • Assessment tools • Observation • Case conceptualization • Diagnosis • Appropriate treatment? • Impressions • Hypotheses • Clinical decision

4. Evaluation • Clinical interview • Assessment tools • Observation • Case conceptualization • Diagnosis • Appropriate treatment? • Impressions • Hypotheses • Clinical decision

5. Evaluation • Clinical interview • Assessment tools • Observation • BOTHERSOME… • Questions (ours and patients’) • Case conceptualization • Diagnosis • Appropriate EST? • Impressions • Hypotheses • Outdated information? Staying up to date • Overwhelming amount of information • Better system for teaching • EBM- other health care professions • Clinical decision

6. What is Evidence Based Practice? (EBP) Has its roots in Evidence-based Medicine: “the integration of best research evidence with clinical expertise and patient values” (Institute of Medicine, 2001, pg. 147) Includes a framework and a set of tools and resources for DOING EBP.

7. Psychology introduced EBPP in 2005 Best research available Clinical Expertise CD Patient characteristics, culture and preferences “The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (became policy of the American Psychological Association in August, 2005 – see American Psychologist, 2006, p. 273)

8. Best research available Clinical Expertise Clinical Expertise Patient characteristics, culture and preferences The framework Clinical Decision CD

9. The Framework of EBP Two Components of EBP Operationalization: 5 STEPS • Convert information needs into questions. • 2. Search for the best evidence in the literature. • 3. Critically appraise the evidence. • 4. Integrate with a patient’s characteristics, culture and preferences. • 5. Evaluate the outcome. Best research available CD Patient characteristics, culture, preferences Clinical Expertise

10. STEPS FOR DOING EBP Step 1: Formulate a clinical question Step 2: Acquire the evidence Step 3: Appraise the evidence Best research available

11. In EBP… The evidence ALONE is never enough. Best research available

12. Best research available Clinical Expertise Patient characteristics, culture and preferences One uses clinical expertise to integrate the evidence with the patient HOW? Is there anything about this particular patient that would make me question applicability of the evidence in this case? Clinical Decision CD

13. Patient characteristics, culture and preferences Clinical Expertise • Not opinion • The ability to use clinical skills and past experience to accurately assess patient's • situation • Values • Preferences • risks and benefits of interventions AND • One’s own ability to deliver an intervention Clinical Expertise Best research available CD

14. The Framework of EBP Two Components of EBP Operationalization: 5 STEPS • Convert information needs into questions. • 2. Search for the best evidence in the literature. • 3. Critically appraise the evidence. • 4. Integrate with a patient’s characteristics, culture and preferences. • 5. Evaluate the outcome. Best research available CD Patient characteristics, culture, preferences Clinical Expertise

15. Psychology’s Focus • EBP is both a framework and a process • It includes a set of tools and resources for clinical decision making • Until recently, psychology has focused on the framework • Other disciplines (e.g., medicine, nursing, social work) have focused on the operationalization

16. 2005 2006

17. New for 2008: • Norcross, J.C., Hogan, T. P., & Koocher, G. P. Clinician’s Guide to Evidence-Based Practices: Mental Health and the Addictions. In press. • Rubin, Al. (2008). Practitioner’s Guide to Using Research for Evidence-Based Practice. New Jersey: Wiley & Sons.

18. Also coming in 2008: • Interactive online learning modules • Transdisciplinary • Council for Training in Evidence-Based Behavioral Practice (EBBP) • http://www.ebbp.org

19. Clinical decisions using EBP begin and end with the patient • We begin by asking specific questions relevant to our patient • We find the evidence • We evaluate the evidence • We consider our clinical expertise and patient characteristics • We make clinical decisions in collaboration with the patient • We evaluate the effectiveness of the entire process as it was applied to our patient

20. The 5-Step EBP Process • Convert information needs into a clear question. (Ask) • Search for the best evidence in the literature. (Acquire) • Critically appraise the evidence. (Appraise) • Integrate with a patient’s needs, preferences, circumstances, and values. • Evaluate the outcome.

21. Types of Clinical Questions Diagnosis Therapy Harm Etiology Prognosis Cost-effectiveness Background Foreground By Content By Format THIS SLIDE COURTESY OF SUE LONDON RUTH LILLY LIBRARY

22. Background Questions • What are the criteria for diagnosing …? • What are the known risks associated with… • What is the cost-effectiveness of … • What is the prognosis for… • What treatments have been found to be most effective for…?

23. P = Patient Population or Problem I = Intervention C = Comparison O = Outcome Foreground Questions

24. The 5-Step EBP Process • Convert information needs into a clear question. (Ask) • Search for the best evidence in the literature. (Acquire) • Critically appraise the evidence. (Appraise) • Integrate with a patient’s needs, preferences, circumstances, and values. • Evaluate the outcome.

25. Practical Tools and Resources for an Evidence-Based Practice

26. What are we Searching for? • The Type of Study you Want Depends on the Question you are Asking • Does Treatment A work better than Treatment B for Condition X? (RCT or systematic review) • Etiology Question: prospective or cohort studies

27. Categories of Studies • Systematic Reviews (synthesis of all available randomized controlled trials, meta-analyses offer quantitative estimates of effect sizes) • RandomizedControlled trials (randomization & control group is key) • Cohort studies (prospective – ID two groups of patients – “cohorts”, one that received exposure of interest, one that did not & follow these cohorts forward for outcome) • Case Control studies (retrospective- ID patients who have outcome of interest – “case” & those who do not & look back to see if they had the exposure of interest) • Case Studies/Case Series (Qualitative -several cases, follow long time) • Case Report (Qualitative – one in-depth case)

28. Databases that contain all of these: TRIP • Databases of systematic reviews • Cochrane 2. Evidence-based summaries: • Online EB text books • EB guidelines • ESTs • 3. Medline and PsycINFO • Specific EBP techniques UpTODate Clinical Evidence $$$$$

29. What if yourpatient is the one asking the question (or handing you a printout)?

30. Health on the Net Foundation HON CODE SITES www.hon.ch/

31. The 5-Step EBP Process • Convert information needs into a clear question. (Ask) • Search for the best evidence in the literature. (Acquire) • Critically appraise the evidence. (Appraise) • Integrate with a patient’s needs, preferences, circumstances, and values. • Evaluate the outcome.

32. Caveats • All studies have flaws • You will never find the perfect study • You want to find the best available evidence • Knowing there is no good evidence is not the same as not knowing if there is evidence

33. When Appraising Randomized Controlled Trials: • F: Follow-up? • R: Randomization? • I: Intention to treat analysis? • S: Similar baseline characteristics? • B: Appropriate Blinding? • E: Equal treatment of groups?

34. One Way to Summarize… Comments In general, what was the quality of the research and how directly did it address your question? Clinical bottom line The available research suggests ….

35. EBP in practice…

36. 43-year-old woman with 1-3 migraine headaches per week. • Otherwise healthy. • Stress is a significant trigger for her headaches, • Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost. • She prefers “alternative” approaches • Has heard that acupuncture can help migraines.

37. The patient asks: • Should she pursue treatment with us or try an “alternative” approach such as acupuncture? • What do we think would be the most effective treatment for her?

38. The 5-step process: • Convert information needs into a clear question. • Search for the best evidence in the literature. • Critically appraise the evidence. • Integrate with a patient’s needs, preferences, circumstances, and values. • Evaluate the outcome.

39. Background Questions • What are the most effective treatments for chronic migraine headache? • Pharmacological • Non-pharmacological • Is acupuncture an effective treatment for migraine headache? • Are there any significant risks associated with acupuncture?

40. Foreground Questions P = I = C = O = In middle aged women with migraine headaches is there any evidence that acupuncture compared to sham treatment, biofeedback, relaxation training, and cognitive-behavioral therapy reduces the frequency, intensity, and/or duration of migraines?

41. Where to look… Background questions  established information • EB textbooks • UpToDate • Clinical Evidence • EB guidelines • ESTs Foreground questions  newer information • MEDLINE / PsycINFO search

42. Background Questions • What are the most effective treatments for chronic migraine headache? • Pharmacological • Non-pharmacological • Is acupuncture an effective treatment for migraine headache? • Are there any significant risks associated with acupuncture?

43. www.therapyadvisor.org

44. Background Questions • What are the most effective treatments for chronic migraine headache? • Pharmacological • Non-pharmacological • Is acupuncture an effective treatment for migraine headache? • Are there any significant risks associated with acupuncture?

45. #2 #1 Search for the treatment in thetitle and text e.g. Acup* Search for the disorder in the title e.g. Headache or migraine or “migraine headache” #3 Combine the two : #1 AND # 2

46. #1 and # 2 VIEW 43 documents on headache and acupuncture

47. List of 43 Evidence-based articles FILTERS YOU CAN USE- Systematic reviews (8) E-textbooks (4) Guidelines (4 US; 3EU)

48. If you click on the icon, it shows you the conclusions

49. 4 chapters from e-textbooks: great for background questions

50. Guidelines • and • Specialized filters to find articles in Medline: • Therapy • DX • Prognosis • Etiology • Systematic Reviews