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Jennifer Hillebrand

Jennifer Hillebrand. Evidence-based practices – background, concepts and EMCDDA activities. Outline of this presentation. Origin of evidence-based medicine What is evidence based medicine/evidence-based practices? Evidence-based practices and drug addiction

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Jennifer Hillebrand

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  1. Jennifer Hillebrand Evidence-based practices – background, concepts and EMCDDA activities

  2. Outline of this presentation • Origin of evidence-based medicine • What is evidence based medicine/evidence-based practices? • Evidence-based practices and drug addiction • Challenges: research-practice gap, research-policy gap • Evidence-based practices, the EMCDDA- EU Action Plan • Conclusions

  3. Pierre Louis (1787-1872)Inventor of the “numeric method” and the “method of observation” Found that, on average, patients who were bled did worse than those who were not.

  4. What is evidence? Etymology: Medieval Latin evidentia (-ae, f),-illustration. Encyclopédie ou dictionnaire raisonne des sciences, des art et des lettres (M. Diderot et M. D´Alambert, 2nd half of 18th century): “ a certainty which is so clear and so manifest by itself that our minds cannot refuse it” Facts, documentation or testimony used to strengthen a claim or reach conclusion. (Oxford dictionary)

  5. What is evidence-based medicine? The conscious, explicit and judicious use of the best current evidence in making decisions about the individual patients. Sackett et al., 1996

  6. What are evidence-based practices? Interventions that show consistent scientific evidence of being related to preferred client outcomes.

  7. Assumptions of evidence-based practices • Not all evidence is equivalent • There is a hierarchy of study design • External evidence can inform but can never replace individual clinical expertise (Sackett et al., 1996) • Starting from the best external evidence and work from there.

  8. Randomised controlled trials Controlled trialsPrimary level research Meta-analyses Systematic reviewsSecondary level research Review of reviews Tertiary level research Evidence pyramid Retrospective

  9. Randomised controlled trials (RCTs) • Often referred to as the “gold standard” • Clients are randomly assigned to a treatment group and to a control group. • Does the treatment cause an improvement on the outcome measures that is independent of other possible causal agents? • RCTs that eliminate purposely the confounding effects of context are not sufficient to study addictive behaviour change

  10. Randomised controlled trials (RCTs) and addiction research • RCTs have established several drug treatments as being efficacious. • RCT designs cannot always investigate key aspects of addictive behaviour change processes • Multivariate models may help further investigations.

  11. Efficacy vs effectiveness • Efficacy: The extent to which a specific intervention produces the intended results under ideal conditions. • Effectiveness: The extent to which a specific intervention when deployed in the field does what it is intended to do for a defined population.

  12. The Trade-offs Efficacy. Maximizes internal validity, i.e., the degree to which one can conclude with confidence that the intervention caused the result. Effectiveness. Maximizes external validity, i.e., the degree to which one can generalize from the test to other times, places, or populations. Threat: External validity gets little attention in the final recommendation of best practices but which is in particular important when social and psychological factors are involved.

  13. Model for evidence-based decisions, Haynes et al. 1996 Clinical expertise Research evidence Clients preferences

  14. Research Evidence Practice Challenges - The research-practice gap Diffusion /Adoption Information overload Application to other populations Lack of consideration of local practitioners, community groups, agencies and governments role and needs Cultural factors Economic factors Social factors Green, 2001, American Journal for Health Behaviour

  15. Research Evidence Policy making Challenges: The research-policy gap Service level National policy level Social, financial reasons Strategic development of services Terms and conditions of employers Dismissal because research comes from a different sector or speciality Lack of consensus Other types of competing evidence: experience, opinions, beliefs Experiential evidence Ideology Electoral considerationsValue judgments Finance Political expediency Intellectual fashion Black, 2001, BMJ

  16. Example: Effects of Media Health Campaigns on Behaviour Mediated health campaigns in the US have small effect sizes in short-term (Snyder et al.2004): ES = .15 –seat belts ES= .13 –oral health ES = .09 – alcohol ES = .05 heart disease prevention ES = .05 –smoking ES= .04 -sexual behaviours A Meta-Analysis of the Effect of Mediated Health Communication Campaigns on Behavior Change in the United States Journal of Health Communication, Volume 9, Issue S1 2004 , pages 71 - 96

  17. American National Youth Anti-drug Media Campaign • planned by the National Drug Control Policy (ONDCP) • funded in 1997 by the United States Congress with $1,2 billion dollars • Aim: To prevent the initiation of or curtail the use of drugs among the nations youths” • alcohol and tobacco were omitted from the main focus of the campaign • focused mainly on minimizing illegal drug use among young adolescents who have not yet become “regular” users of illegal substances • televised anti-drug public service announcements broadcasted 1998-2004 • 2002-2004 Focus on marijuana use

  18. American National Youth Anti-drug Media Campaign • Evaluation by Westats • Recall of campaign advertisement increase over time among youth and parents. • Beliefs about talking about drug use with their children among parents changed. • Parents monitoring of their children's behaviour was not changed • Parental change in attitudes did not lead to changes in youth attitudes or behaviour towards drug use. • No effect on disapproval of drugs among youths. • Past month use of marijuana appeared significantly increased by 2.5% among 14-18 years (Orwin 2006). • Post-2002 results: statistically significant increase in rates of marijuana use initiation among youth who were prior nonusers (2000 to 2004 change 2.1%)

  19. The EMCDDA and best practices

  20. Rationale for the EMCDDA focus on best-based practice • Objective 7 of the EU Action Plan on Drugs 2005-2008 states the need to improve coverage of, access to, quality and evaluation of drug demand reduction programmes and to ensure effective dissemination of evaluated best practices. • The provision of information on best practices in the Member States and the facilitation of exchange of such practices is a task of the EMCDDA (recast of the EMCDDA regulation) • The Centre recognises that it is important to place the descriptive data in the context of identifying and sharing information on best practices.

  21. EMCDDA best practice portal – Main objective and target groups To provide an overview on the latest evidence on what works in demand reduction field. It will also present tools and standards aimed at improving the quality of interventions, as well as highlighting best-practice examples from the field. It is primarily aimed at professionals, policy-makers and researchers in the drugs field.

  22. Why best practice portal and not science-based practice portal? • Corresponds better to the recast of the EMCDDA regulation • Inclusion of "best practices" not yet fully investigated by scientific methods (e.g. innovative best practices in the field).

  23. Best-practice portal + glossary Evidence of what works (and gaps?) Overview on latest systematic reviews on efficacy of Interventions Summary of conclusions on what works/or does not work across latest systematic reviews and information on how the reviews arrived at the conclusions (methodology) Tools to evaluate practices Evaluation Guidelines Prevention Evaluation resource kit (PERK) Evaluation Instrument Bank Standards and guidelines for practices Guidelines, quality standards for practices developed in different MS Evaluated DDR projectsin MS EDDRA + inclusion of quality levels in EDDRA

  24. Conclusion-1 – evidence-based practices • Further analytical development to integrate theory and findings about contextual, psychological and other influences on behaviour over time. • Evidentiary pluralism better than evidentiary dogmatism -Interdisciplinary approach • Diffusion of evidence is not a linear process. • Logos AND pathos AND ethos • Consensus conference – combine evidence with human judgement • Inclusion of various types of evidence in our decisions

  25. No magic bullet but:Best practices for the process of planning for most appropriate interventions for the setting and population Results from self-monitoring Clinical expertise Diagnosis and analysis of context: Place, setting and culture (complementary research) Research evidence Clients needs

  26. Conclusions - EMCDDA • Increased focus and promotion of quality (EDDRA quality levels) • Need to foster effectiveness studies and theory based evaluation • Portal will be a reference point for best practices only that can not guarantee implementation of evidence-based practices

  27. Thank you for your attention.Jennifer.hillebrand@emcdda.europa.eu

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