Pammi Raghavendra. Ph.D.

1. Evidence-Based Practice in Augmentative & Alternative Communication: How do you do it? What does it mean for Individuals who use AAC? Pammi Raghavendra. Ph.D. Senior Lecturer, Disability & Community Inclusion, School of Health Sciences Flinders University, Australia Parimala.raghavendra@flinders.edu.au ISAAC-Israel Annual National AAC Conference, Tel Aviv 8 June 2014 All day workshop

2. Workshop Outline • What is EBP? • What does EBP mean for individuals who use AAC and other stakeholders? • Steps involved in EBP – 7 steps • Asking a clinically relevant & answerable question • Searching for the evidence • Critically appraising the evidence • Collating & synthesising the evidence 5. Implementing the evidence into practice 6. Evaluating the use of the evidence 7. Disseminating the EBP process & findings • Facilitators and barriers to EBP • Practical Suggestions to implement EBP • Nature and extent of evidence in AAC • What can you do to add evidence to the AAC field?

3. Evidence Based Practice (EBP) What is it?

4. Background to Evidence-based Medicine (EBM) • Archie Cochrane (1909 - 1988) • The Cochrane Collaboration • David Sackett (1914-) • Definition of EBM, Father of EBM

5. Evidence-based medicine “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett et al., (1997, p.2)

6. What is Evidence Based Practice? Definition: “the integration of best research evidence with clinical expertise and patient values (Sackett et al., 2000)

7. What is Evidence Based Practice in AAC? Proposed Definition: (Schlosser & Raghavendra, 2004) EBP is defined as the integration of best and current research evidence with clinical/educational expertise and relevant stakeholder perspectives to facilitate decisions for assessment and intervention that are deemed effective and efficient for a given direct stakeholder.

8. EBP in AACSchlosser & Raghavendra, 2004

9. What is Evidence Based Practice? – Key concepts • Integration = joining / synthesis of best • research evidence • clinical expertise • stakeholder perspectives (patient values) (Schlosser & Raghavendra, 2004)

10. Key concepts continued… • Best research evidence = • Data : current, verified and replicated • High internal validity • Highest level on hierarchy of evidence • Adequate external validity and social validity (Schlosser & Raghavendra, 2004)

11. Key concepts continued… • Clinical expertise = reasoning, intuition, knowledge and skills related to clinical skills • Educational expertise = reasoning, intuition, knowledge and skills related to educational skills (Schlosser & Raghavendra, 2004)

12. Key concepts continued… • Relevant stakeholder perspectives/values = viewpoints, preferences, concerns and expectations relative to the assessment or intervention • Patient/client = direct stakeholder ie direct recipient of any decision arising from the EBP process (Schlosser & Raghavendra, 2004)

13. What EBP is not? Myths about EBP • EBP is impossible to implement because we do not have enough evidence. • EBP already exists • EBP declares research evidence the authority • EBP is a cost-cutting mechanism. • EBP is cook-book practice. • EBP is impossible to put in place. (Sackett et al., 1997; Schlosser, 2004) • Best and most current research evidence is relative • Some practitioners do implement EBP • EBP in medicine/AAC definition-all 3 • Not always true • EBP requires not only extensive clinical expertise but also skillful integration of all 3 aspects of EBP • some degree of EBP by all.

14. What does EBP mean for an individual with complex communication needs ? • Individuals with CCN (their families) • Central to EBP outcomes, promoting adoption of effective interventions & preventing adoption of ineffective outcomes • Active participants in decision making (ASHA, 2004)

15. What does EBP mean for a practitioner/educator? Best Practice • Use of EBP as a framework for best practice, • Promotes development of skills in finding, appraising and implementing evidence • Emphasises need for high level clinical & communication skills • Provides a framework for self-directed, life long learning Ethical principle: To provide the best available services (assessments & interventions) to consumers & families Practice-research gap

16. What does EBP mean for a service provider/ an organisation? Best Practice at Organisational level What do families think of using iPads/tablet technology for communication and participation? What are the most effective post-school options for students with CCN using AAC? • Use of EBP as a framework for effective and efficient services • Facilitate/support to implement EBP

17. What does EBP mean for researchers? • Excellent opportunity to bridge research-practice gap • High priority clinical questions in diagnostics, screening, prognosis, intervention • Conduct high quality research • Disseminating research in way that can be used in practice

18. How do you do EBP?Adapted from Schlosser & Raghavendra (2003) • Asking the clinically relevant & answerable question • Searching for the evidence • Critically appraising the evidence • Collating & synthesising the evidence • Implementing the evidence into practice • Evaluating the use of the evidence • Disseminating the EBP process & findings

19. Step 1: Ask an clinically relevant & answerable question Broad or general questions • provide background information • Systematic review e.g., • What are the potential barriers and facilitators to high-technology AAC provision and its ongoing use? • What are the attitudes toward Individuals who Use Augmentative and Alternative Communication? • What is the effectiveness of using iPads/iPods with individuals with disabilities?

20. PICO(Richardson, Wilson, Nishikawa & Hayward,1995) • Patient or Population/Problem • Intervention • Comparison or Control • Outcome

21. PICO • To clarify the questions related to specific clients • To develop questions for Systematic Reviews • To identify the information needed to answer the question • To translate the question into searchable terms • To develop and refine your search strategy

22. Patient / Population/Problem • Characteristics of the population e.g age, gender, diagnosis, ethnic group etc • How would you describe your Patient/Population group? • Balance precision with brevity

23. Intervention • Defining the intervention • What intervention are you interested in (be specific)? • Therapy, prevention, diagnostic test, exposure/aetiology

24. Comparison or Control • What alternative or other option are you comparing your intervention/assessment to? • Be specific • You may be comparing your intervention to another intervention, or to no intervention

25. Outcome • What measurable outcome(s) are you interested in? What are you hoping to achieve for the client? • Be specific

27. Group Work Activity 1 Ask an clinically/service relevant answerable question using PICO

28. PESICO template (Schlosser, Koul & Costello, 2007)

29. An example (Schlosser, Koul & Costello,2007)

30. Group Work Activity 2 Ask an clinically/service relevant answerable question using PESICO

31. Step 2: Search for the evidence • To start, use the PICO/PESICO question components to identify the search terms

32. Search for the best evidence • Where to start searching depends on a number of factors: • Available time • Available databases • Subject matter and domain of the question • Currency and level of evidence required

33. Where do I search? Finding the evidence • Courses, proceedings, books, • Journals (Two million journal articles are published annually in some 20,000 ‘biomedical’ journals) • Secondary research – meta-analysis, systematic reviews • Primary research – individual research studies • Grey literature e.g. unpublished research, theses • Indexes and databases • General eg CINAHL, Medline, PubMed, ERIC • Specialist e.g. Cochrane Library, DARE, PEDro

34. Where do I search? Finding the evidence Hand searches • Table of contents • Ancestry search- use reference list and identify other studies • Forward citation search-who has referred to a particular article? Finding evidence on the Internet • General search engines, e.g., Google • Specialised Search engines, Google Scholar

35. Types of Databases • Bibliographic/General • eg Medline • PubMed • Specialist Databases • ERIC • CINAHL • PsyInfo

36. Databases – Full Text/Specialised • DARE- Database of Abstracts of Reviews of Effects (UK) • Cochrane- Cochrane Database of SR (Worldwide) • Expanded Academic ASAP • Science Direct • SCOPUS

37. Strategies for searching databases • Plan the research, efficiency • Create a search plan • Select and access the right databases • Develop a search statement • Limit, refine and evaluate • Locate the source publication

38. Strategies for Searching 1) look for pre-filtered evidence (e.g., EBM reviews, Systematic Reviews, Practice guidelines) 2) look for reviews before individual studies 3) look for peer-reviewed before non-peer reviewed (Schlosser, Wendt, Angermeier & Shetty, 2005)

39. Create a Search Statement • Search commands – Boolean operator/connectors (or, and, not) example: labour not pregnancy • Truncation – symbols used to substitute for characters at the end of a word e.g Ovid uses “$” example: child$ will give children, childlike • Wildcards – symbols used to substitute for a letter within a word e.g Ovid uses # example: wom#n will give woman and women • Check Help Screen for each database

40. Keyword Searching • Keywords – important words that represent a topic. Have no control over how a word is used in the document The use of quotation marks is useful for example “intellectual disability” • Fields – eg author, title, abstract, journal • Limits – by date, by language, to full text, to abstracts, Systematic reviews

41. Hierarchy of Evidence http://gollum.lib.uic.edu/applied_health/?q=node/7, University of Illinois at Chicago

42. Proposed hierarchy of evidence to inform intervention development & selection: Participants with disabilities(Schlosser & Raghavendra, 2004) • Meta-analysis of a) RCTs*, b)SSED, b) Quasi-experimental group designs 2a. One well-designed non RCT, 2b. 1 SSED-1 intervention, 2c. 1 SSED-multiple interventions…….. 3. Quantitative reviews that are non-meta-analytic 4. Narrative reviews 5. Pre-experimental group designs & Single case studies 6. Respectable Opinion

43. Levels of Evidence • Based on the idea that different grades of evidence (study designs) vary in their ability to predict the effectiveness of the health practices • Reducing biases-Sample, Measurement/detection, Intervention/Performance • Higher grades of evidence are more likely to reliably predict outcomes than lower grades • Is a system for making sure that you are aware of the strengths and weaknesses of different study types. • Several Evidence Grading scales eg: Sackett’s Hierachy of Evidence, NHMRC, Cochrane

44. What are Systematic Reviews? • A synthesis of original research • Pre-filtered evidence A SR aims to synthesize the results of multiple original studies by using strategies to reduce bias (Cook et al., 1997: Schlosser, 2003, cited in Schlosser et al., 2005)

45. Systematic Review(Adapted from Cochrane Database of Systematic reviews –www.cochrane.org & Centre for Reviews & Dissemination- www.york.ac.uk) Transparent process to facilitate replication • Pre-defined, explicit methodology is used, • strict protocol to inlcude as much relevant research • original studies apparised and synthesised in a valid way • Minimise risk of bias

46. Systematic Review Meta analysis is a mathematical synthesis of two or more primary studies that addressed the same hypothesis in the same way. (Greenhalgh, 1997, BMJ, 315:672-675)

47. Where to find systematic reviews • N-CEP's Compendium of Guidelines and Systematic Reviews (ASHA) • Cochrane Collaboration • Campbell Collaboration • What Works Clearinghouse(US Department of Education) • Psychological Database for Brain Impairment Treatment Efficacy • National Electronic Library for Health (National Health Service of the UK) • Evidence-based Communication Assessment and Intervention (EBCAI) Journal • Speech Byte http://speechbite.com/

48. Step 3:Critically appraising the evidence What is the evidence telling me? Validity (truth) and usefulness (clinical relevance)

49. What is Critical Appraisal? Appraisal is a technique which offers a discipline for increasing the effectiveness of your reading, by enabling you to quickly exclude papers that are too poor a quality to inform practice, and to systematically evaluate those that pass muster to extract their salient points” Adapted from Miser WF (1999). Critical appraisal of literature, J. of American Board of Family practice, 12, 315-333. Taken from www.shef.ac.uk

50. Are the findings applicable in my Setting? Is the quality of the study good enough to use the results? What do the results mean for my clients?