Evidence-Based Practice in Clinical Psychology: What It Is, Why It Matters, What You Need to Know

1. Evidence-Based Practice in Clinical Psychology: What It Is, Why It Matters, What You Need to Know Bonnie Spring, Ph.D., ABPP Northwestern University

2. Why it matters: EBBP Rationale • improve quality and accountability for health care practice (IOM, 2001, Crossing the Quality Chasm) • shared vocabulary and concepts for transdisciplinary, biopsychosocial research, practice, health care policy • stimulate development of evidence base for behavioral treatments

3. Why it matters: Potentionally Useful Infrastructure • Clinical Practice Guidelines: • Increasingly based on ongoing systematic review of research (esp. RCTs) (e.g., USPTF, Cochrane, CDC/AHRQ) • Research reporting guidelines (CONSORT, TREND, QUOROM) • Evidence grading & knowledge synthesis systems (e.g., GRADE, AHRQ) • Policy, often coverage/reimbursement implications (VA/DOD, CMS, NICE)(P4P?) • Evidence-Based Practice: (life-long learning) • Question formulation, search strategies, critical appraisal • SUMSEARCH • Clinical Evidence, First Consult, BMJ updates,Best Evidence Topics, CATCRAWLER, CATBANK – clinical scenario & bottom line

4. Overview • History of evidence-based practice (EBP) • Core elements of EBP • EBP pedagogy in psychology • EBP pedagogy in other health disciplines • Useful infrastructure and potential opportunities for synergy

5. Origins of Evidence-Based Practice

6. Emergence of Evidence-Based Medicine 1910 - Flexner report :155(31!) 96 (1915) 76(1930) 1972 - Archie Cochrane – epidemiology, health services research - Effectiveness and Efficiency: Random Reflections on Health Services 1973 – John Wennberg – widespread practice variation 1982 - clinical epidemiology determinants and consequences of health care decisions (McMaster U – David Sackett, Gordon Guyatt) 1985 – IOM: 15% medical practices evidence-based [2001 Crossing the Quality Chasm] 1990 - Evidence-based medicine, Brian Haynes & Ann McKibbon – search strategies 1992-3 -Cochrane Collaboration 2000 - Sackett - How to Practice and Teach EBM

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

8. Alternative Definitions of Evidence-Based Practice Nomothetic • Guidelines:(public health, medicine) – focus onproblem/disorder& level of evidence for practices (based on systematic review) (e.g., NICE, VA, apa) • ESTs:(psychology) focus onintervention (& disorder) • EBP:(psychology, medicine, nursing, social work) focus on decision-making about individual patients Idiographic……….. Lifelong Learning

9. 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

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

11. Syllabus Project • Prompt: Does anyone on the list teach a course on evidence-based practice (EBP)?  Specifically, I am searching for syllabi that cover one or more "legs" of the three-legged EBP stool:  a) research evidence, b) clinical expertise, c) patient values, preferences, characteristics.  November, 2006

12. Listservs Sampled • ABCT • APA Division 12 • SSCPNET (Section III, Div 12) • CUDCP • APA Division 38 • ABMR • SBM EBBM, MRBC, Obesity, CA SIGs

13. Outcome • 39 syllabi • 17 additional recommended articles and books • 273 page document • Discipline: 30 psychology 3 public health 3 medicine 1 nursing 1 PE/health/sport studies • 140 requests November, 2006

14. Modal Course Title: CBT, EST, EVT, Psychological Interventions, Psychotherapy Research Texts: Barlow, Handbook Psychologic Disorders, Bergen & Garfield Handbook of Psychotherapy and Behavior Change Content:ESTs Additional Additional Texts: -Persons, Case Conceptualization -Dawes, House of Cards Additional Content: -Assessment -Case formulation, functional analysis -Clinical judgment -Diversity -Iatrogenic effects -Research methods Evidence-Based Practice

17. courtesy of Barbara Walker, Indiana University, 2006

18. 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 Clinician Communicate Assess patient Deliver EBP Patient Understanding Preferences Access

19. Psychology Design Correlational (convenience classes) Experimental (from animal studies) Conduct Brief, tight control Little missing data; replace cases Analysis - completer Reporting Clinical Medicine Design Observational (population) Clinical Trial –test of policy applied to population Conduct Long, intercurrent events Missing data; Analysis – ITT Reporting – CONSORT Researcher Training in Psychology versus Medicine

20. Psychology ANOVA/regression Clinical Medicine Odds Ratios Researcher, Synthesizer, Consumer Training in Analysis • Epidemiology Terminology • Absolute risk (p[disease] in a particular population) • Relative risk (p[disease/exposed]/p[disease/unexposed) • Attributable risk (p[disease/exposed] -p[disease/unexposed) • Number needed to harm (1/attributable risk) • Odds ratio (odds[disease/exposed]/odds[disease/unexposed])

21. Clinical Significance • NNH = 5. If 5 patients treated with TX1, 1 would be more likely to have AE than if all had received TX0 • NNT = 13. 13 patients would need to be treated with TX1 to see one success not seen with TX0

22. Reporting: Consort Flow Diagram Consolidated Standards of Reporting Trials (CONSORT) www.consort-statement.org

23. Excerpt from CONSORT checklist

24. Evidence Synthesizer and Consumer Skills

25. Synthesizer Locate Critically appraise Meta-analysis Evidence User 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 Clinician Communicate Assess patient Deliver EBP Patient Understanding Preferences Access

26. Synthesizer: Systematic Reviewer- explicit, systematic, transparent to avoid bias • Specific research question (PICO) • Search protocol to select papers – key words • systematic search of the literature (EMBASE, CINAHL, Cochrane Controlled Trial register, DARE) • explicit inclusion and exclusion criteria • Explicit, transparent rating of methodological quality • Data extraction • Analysis: qualitative or quantitative • Conclusion • Discussion of strengths and limitations

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

28. Asking: Well-Built Clinical Questions • Background: What are effective treatments for bulimia nervosa? • Foreground: In patients with Patient: binge eating disorder Intervention:does interpersonal therapy Comparison: compared to CBT reduce Outcome:frequency ofbinge episodes

29. Critically appraising the evidence Use of standardized a priori appraisal methods to answer: • Is the evidence valid? • Internal validity • Is the evidence applicable/relevant? • External validity • Is the evidence clinically significant?

30. 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)

31. barriers between research and practice 30 kg of guidelines per family doctor per year 25000 biomedical journals in print 8000 articles published per day 95% of studies cannot reliably guide clinical decisions 2001 Bazian Ltd

32. Clinical Decision-Making • Health Informaticsdiscipline infrastructure, resources, devices, structures (e.g., algorithms, guidelines) needed to store, retrieve, manage and use health information and the time and place that a decision needs to be made. -Decision support.

33. 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)

34. 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 Clinician Communicate Assess patient Deliver EBP Patient Understanding Preferences Access

35. Clinically Supervised Training in Evidence-Based Treatment • Needs work: 2005-2006 papers by Woody and by Weissman

36. 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 Clinician Communicate Assess patient Deliver EBP Patient Understanding Preferences Access

37. Patient Preferences • Shared decision-making requires information only available to patient (e.g., valuation of harms/hassles, alternative outcomes & treatments) • Utility assessment: All possible outcomes assigned a value between 0 (death) and 1 (perfect health). • Time trade-off approach • The proportion of life in a particular health state (e.g., severe depression) that you would give up to attain perfect health (e.g., 30%). Utility of that health state is 1-(30%) = .70 • Standard gamble approach • The point where you are indifferent to the choice between spending the rest of your life in the health state in question and a gamble between perfect health and instant death where the probability of perfect health represents the utility of the health state.

38. Teaching evidence-based practice = teaching a process • Didactics • Small groups, problem-based learning • Preceptorships/clinical supervision • Standardized patients and evidence stations • Embedded throughout curriculum

39. Medical Decision Making in the NU-FSM curriculum • MDM-I (first week of medical school) • Sensitivity, specificity, pre- and post-test probabilities, innumeracy, uncertainty in medicine • MDM-II (last two weeks of M1 year) • Epidemiology • Statistics • MDM-III (beginning of M2 Spring Quarter) • Decision analysis • Meta-analysis • Cost-effectiveness analysis • Clinical guidelines • M3 MDM (once a month in M3 year) • Review papers pertaining to clinical cases • Use of CAT

40. NIH Office of Behavioral and Social Sciences Research contract N01-LM-6-3512: Resources for Training in Evidence- Based Behavioral Practice, 2006 - 2011 Evidence-Based Behavioral Practice (EBBP)

41. OBSSR 5-Year Plan • Year 1: developtraining website, Council, Scientific Advisory Board, white paper on training, skills, competencies reflecting education in evidence-based behavioral practice (EBBP) • Year 2: develop, implement a web-based, research-focused training module(s) on EBBP; field test in graduate curricula • Year 3: launch interactive web-based training courses; establish practice network, develop first EBBP clinical practice training module

42. OBSSR 5-Year Plan • Year 4: With practice network, develop modules on application of evidence-based clinical decision-making to intervention with specific cases. Field test in internship/residency/post-doctoral training programs and practice network. • Year 5: Link website to systematic reviews of behavioral interventions, treatment manuals, outcome assessments. Develop and field test clinical decision-making modules that integrate patient preference and clinical competency assessments.

43. Suggestions • To enhance the evidence base for psychological treatments and support lifelong learning, clinical psychology training might benefit from enhanced coverage of: • Researcher skills in methods: clinical trial design, analysis, reporting, synthesis • Clinician training in 5-step (5A’s) EBP model – cover 2 A’s

44. Suggestions • Psychology informatics could use infrastructure development (PSYCinfo & Cochrane; library access; coverage in secondary synthesized sources like Up-to-Date; practice-based research networks) • Psychology could use appropriate patient preference measures that support shared decision-making • A discipline of clinical psychology decision-making needs to develop to systematize integration of research evidence, clinical expertise, and patient clinical data and preferences

45. What training modules and materials would be helpful? Will you partner with us to help develop and try these out? Concluding Questions

48. The Evidence Pyramid for Treatment Effectiveness Questions ***USE THE BEST EVIDENCE AVAILABLE***

49. Alternatives to evidence-based medicine • Eminence based medicine • Eloquence based medicine • Vehemence based medicine • Nervousness based medicine (Isaacs and Fitzgerald, 1999, BMJ)

50. Type of Question Methodology Search Filters Therapy Double-Blind RandomizedControlled Trial Randomized Controlled Trial, Double Blind, Clinical Trials Prognosis Cohort Studies, Case Control, Case Series Cohort Studies, Prognosis, Survival Analysis Etiology Cohort Studies Cohort Studies, Risk Quality Improvement RandomizedControlled Trial RCT, Practice Guideline Consensus Development Conference Levels of Clinical Evidence in the Primary Literature (psycINFO, MEDLINE)