What do we mean by “evidence-based practice?”

1. What do we mean by “evidence-based practice?”

2. Evidence-Based Practice • Resource Materials for implementation at St. John’s • Where do we go from here?

3. APA Policy Statement adopted August 2005 • “Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” -adapted from IOM, 2001 & Sackett, 2000 Source: Bonnie Spring, CUDCP, 2007

4. The 5 Step EBM Model for Evidence Users (Consumers) Source: Spring, 2007 CUDCP • Ask: formulate the question • Acquire: evidence - search for answers • Appraise: the evidence for quality and relevance • Apply the results • Assess the outcome

5. Core Beliefs of EBP(Chambless, 2007 CUDCP) • Opinion based on clinical experience is an insufficient basis for practice. • Positive evidence trumps lack of evidence. • Graduate Students should learn to base treatment on the highest empirical ground possible. • Students should learn to routinely incorporate on-going assessment into practice.

6. The EBP Model(DiLillo, 2007 CUDCP) Best available research evidence EBP Patient preferences and values Clinical expertise

7. The EBP Model • Relevant Abilities: • Adopt a scientific view of clinical/counseling/school psychology • Knowledge of applied research design and methods • Strategies for accessing best available research • Ability to • evaluate relevant evidence Best available research evidence

8. The EBP Model • Relevant Abilities: • View Psychological interventions as a collaborative endeavor • Knowledge of specific culturally diverse groups • Ability to ascertain client/patient values and preferences • Respond effectively to client/ • patient preferences and values Patient preferences and values

9. The EBP Model • Relevant Abilities: • Understand role and limits of clinical judgment • Skills in relationship building • Assessment and diagnostic skills • Skills to implement EST’s (e.g., specific therapeutic techniques) • Integration of EST with client characteristics Clinical expertise

10. Evaluation • Clinical interview • Assessment tools • Observation Source: Walker, CUDCP 2007 • Case conceptualization • Diagnosis • Appropriate EST? • Impressions • Hypotheses • Clinical decision

11. Secondary Synthesized Evidence(AKA “evidence-based capitulation”) • Research proliferates rapidly. Clinical performance demands increase. Practicing clinicians too busy to use all EBM steps will all patients. • Increased focus on pithy clinical practice guidelines, synopses, and structured abstracts • MD Consult • ACP Journal Club • Cochrane Database of Systematic Reviews • “Up-to-date” • InfoPOEMS (Patient Oriented Evidence that Matters)

12. Best available research evidence Clinical Decision-Making Patient’s values, characteristics, and circumstances Clinical Expertise

13. Synthesizer Locate & Critically appraise Meta-analysis Consumer Locate & Appraise quality & relevance Integrate Researcher Design Conduct Analysis Reporting Best available research evidence Clinical Decision-Making Patient’s values, characteristics, and circumstances Clinical Expertise Psychologist Communicates Assess client Deliver EBP Client/ Patient Understanding Preferences Access

14. The Evidence Pyramid for Treatment Effectiveness Questions (Bonnie Spring, 2007) ***USE THE BEST EVIDENCE AVAILABLE***

15. Clinical Decision-Making • Clinical epidemiology discipline • study of determinants and consequences of clinical decisions • apply EBP/5A’s/critical appraisal at clinical encounter to overcome automatic, unconscious decision-making biases (aka bad clinical intuition) • Source: Bonnie Spring, 2007

16. ESTs: A Component of EBP(Chambless, CUDCP, 2007) • ESTs are not a substitute for training in building a relationship with the client. • EST evidence is not the sole sort of evidence important to practice (Their role is the controversial part). • Effectiveness research • Acceptability research • Alliance and other process research

17. Psychology introduces EBP Best research available Clinical Expertise CD Client/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)

18. Continuum of Evidence(Chambless, 2007) • Case studies with data • Quasi-experiments • Experiments (randomized clinical trials or single-case experiments) _____________________________________ • Uncontrolled effectiveness studies (e.g., benchmarked) • Quasi-experimental effectiveness studies • Randomized, controlled effectiveness studies

19. Evaluation • Clinical interview • Assessment tools • Observation • Evidence - Based Practice • 5 STEPS: • Formulate Questions • Find the evidence • Appraise the evidence • Integrate the evidence • Evaluate the outcome • Case conceptualization • Diagnosis • Appropriate EST? • Impressions • Hypotheses • Questions (ours and patients’) • Staying up to date; tools for lifelong learning • Offers tools for teaching • EBM- other health care professions • Clinical decision

20. Case Presentations = Clinical data + case conceptualization +… (Walker, 2007: Integrating Evidence-Based Practice into Graduate Practica) • What were your foreground and background questions? • What search strategies did you use to find relevant research & literature ;and what did you find? • What is your critical appraisal of the best evidence available? • How did you integrate this evidence with your particular patient and what we call “clinical expertise”? • What is your evidence - based treatment plan? • Did you create a CAT for this topic? • What research studies could be done that would improve your ability to care for clients/patients similar to this one?

21. 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.

22. Our Challenge • Integrating EBP across the curriculum. • Integrating EBP across professional practice: Assessment, consultation, interventions. • Ideas?