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Using Evidence to Make Everyday Decisions

Using Evidence to Make Everyday Decisions. Robin Steed, PhD, LOTR LOTA Conference 2014. Objectives and Agenda. Part One Intro: What? Why? Learn the 5 easy steps: 1. Identify the problem 2. Ask a question 3. Find some answers 4. Evaluate the answers 5. Try the best one out.

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Using Evidence to Make Everyday Decisions

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  1. Using Evidence to Make Everyday Decisions Robin Steed, PhD, LOTR LOTA Conference 2014

  2. Objectives and Agenda Part One • Intro: What? Why? • Learn the 5 easy steps: 1. Identify the problem 2. Ask a question 3. Find some answers 4. Evaluate the answers 5. Try the best one out Part Two • Practice EBP Skills • Easy Checklist • Getting Started

  3. Part One

  4. Introduction to Evidence Based Practice What did you say? Now why would I want to do that?

  5. What is EBP? knowledge wisdom (Sackett ,Straus, Richardson, Rosenberg, & Haynes, 2000).

  6. Why? Client education

  7. Why? Client trust

  8. Why? Do no harm! • NSAIDs do not reduce fibromyalgia pain • No evidence to support psychoanalytic (Freudian) treatment • Stretching does not prevent or improve contracture • Sheltered workshops do not increase employment • Cognitive remediation does not improve function

  9. Why? Your own peace of mind

  10. Why? Our clients deserve the BEST!

  11. The Process of Evidence Based Practice Yes, you too can be an evidenced based practitioner in just 5 easy steps!

  12. Identify the clinical problem 1 I want my clients to: • be more functional • have a higher quality of life • have better outcomes faster • transfer skills to home environment • have maintained gains at follow-up • have better adherence to treatment plan

  13. Types of problems and their questions 1 • Assessment/Diagnostic (What is the best assessment to use to identify performance deficits?) • Intervention efficacy (What is the best treatment?) • Intervention cost-effectiveness (Which treatment gives me the most return for my money?)

  14. Identify your problem 1 Complete the problem identification worksheet. Examples: • My clients don’t like constraint induced therapy, would a modified approach work just as well? • My clients have poor sensory motor skills and have trouble with handwriting. • We send instructions home with the clients but we aren’t sure they understand them.

  15. A good problem 1

  16. Ask a PICO question 2 Patient or Problem Intervention Comparison Intervention Outcomes

  17. PICO Examples 2 • In children with autism, evidence on vigorous vs. mild exercise, on stereotyped behaviors? • In clients with schizophrenia, evidence on environmental supports on ability to transition to community? • In children with hemiplegia, evidence on constraint induced therapy on motor function? Work on step two worksheet

  18. Good Questions 2 • Within occupational therapy domain • “What” questions, not ‘why’ • Just right focus, not too wide, not too narrow • Measurable in some way • Clinically important • Not already answered!

  19. Take a break and relax!

  20. Looking for some answers 3 • P: serious or chronic mental illness, psychosis, schizophrenia, mood disorder, anxiety disorder • I: child care, meal preparation, home management, shopping, time management, safety, social participation, education exploration, retirement exploration, employment seeking • O: employment and education (Arbesman & Logsdon 2011)

  21. Types of evidence 3 • Meta-analysis • Systematic review • Critically appraised papers (CAPs) • Critically appraised topics (CATs) • Individual journal articles wikipedia

  22. Where do we find the (free) evidence? 3 AOTA Evidence Exchange Centre for Evidence-based Mental Health Cochrane Consumer Network McMaster Occupational Therapy EBR Reviews National Guideline Clearinghouse™ (NGC) OT Seeker - The Occupational Therapy Evidence Database OT Evidence at www.otevidence.info Everyday Evidence Podcast from AOTA Centre for Reviews and Dissemination

  23. Where do we find the articles? 3 • Pub Med ncbi.nlm.nih.gov/pubmed • Pub Med Central: pubmedcentral.gov • Directory of Open Access Journals: • NBCOT if registered (ProQuest) • Google Scholar www.doaj.org

  24. PubMed Central 3 • Open Access: • Arthritis • Autism Research • Journal of Pain Research

  25. NBCOT 3 ProQuest RefWorks AJOT OTJR OT International OT Canada, NZ An easy way to keep track of your articles

  26. Google Scholar 3

  27. Critically evaluate the evidence 4 • Read the article • Fill out a form • Critical Review from McMaster’s University • CAP from AOTA • CASP in the UK

  28. Critically evaluate the evidence 4 • Study Design • randomization • control for bias • ethical • control group • Sample • size • described • Assessment Properties • Intervention • detailed/replicable • Statistical Analysis • Threats to Validity • internal • external

  29. Make a decision Given the quality of the evidence, what are the implications for clinical practice?

  30. Implement and evaluate 5 Implement Evaluate What is the risk? What is the cost? Do you need special training? Getting client consent Facility support Choose outcome measures Keep records of outcomes and adverse events Do a ROI assessment

  31. Take a longer break!

  32. Part Two

  33. Evidence Based Practice Practice Easy Checklist Getting Started

  34. Checklist • Are the results valid? • Subject selection • Research design • Data analysis & results • Are the results meaningful? • Are the results applicable to my client? Source: Portney & Watkins (2009)

  35. How were the subjects selected? 1 • Random sampling • Random assignment • Convenience

  36. Sample Size? 2 not that great <30> much better

  37. Sample Size? 3 Inclusion: who we let in Exclusion: of the ones we let in, who do we kick out

  38. How were participants assigned? 4 Did it result in two equal groups at the start?

  39. Was the design reasonable? 5 • Exercise 2x week • Constraint Induced Therapy 20 hours/day • A 4 hour workshop on cultural competence

  40. Was the intervention the reason for results? 6 • History • Measurement Instrument • Statistical Regression • Maturation • Unequal Groups • Attrition • Multiple Treatments • Treatment Diffusion • Participant Responses

  41. History

  42. Instrumentation

  43. Statistical Regression

  44. Maturation

  45. Unequal Groups

  46. Mortality/Attrition

  47. Multiple Treatment

  48. Treatment Diffusion

  49. Participant’s Reactions • Artificial environment in effort to control extraneous variables (can’t generalize to real world) • Hawthorne effect- subjects aware of being studied • John Henry effect- subjects get competitive between groups • Novelty effect- increase motivation because tx is new

  50. Was everyone blind to treatment? 7

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