Evidence-Based Practice: Introduction and Application

1. Evidence-Based Practice:Introduction and Application NORMA J. STUMBO, PH.D., CTRS, FALS EDUCATION ASSOCIATES JAMIE BENNETT, TRS, CTRS UNIVERSITY OF UTAH

2. Session Outcomes • Identify relationship between outcomes and EBP • Identify 3 reasons why EBP is important to your practice and profession • List five steps of EBP • Understand Coping Skills program as example • Explain how to transfer to your programs and practices

3. Section I • Client Outcomes: The Why • Evidence-Based Practice: The How

4. History of EBP in Medicine Middle Ages: Medicine –Technically did not heal you, faith healed you.

5. Neo-Classical Period

6. Mid 1800’s “The fastest knife in the West End”

7. Johns Hopkins Hospital – Mid 1800’s

8. Early 1900’s Earnest Amory Codman The End Result Concept

9. Earnest Amory Codman’s Cartoon

10. American College of Surgeons > The Joint Commission

11. Why are Outcomes Important? • External Accreditation • Third Party Payers • Health Care Consumer Groups • It’s the Right Thing to Do!

12. What are Outcomes? • Observable changes that result from intervention (Client status, functional status, well-being, care satisfaction, cost/resource utilization • Changes over specified time • Clinical results • Results of performance • Direct effects of service • Difference between input (assessment baseline) and output (discharge) • Straightest line between A and B • Both planned and unplanned • Both beneficial and harmful

13. Client Outcomes Client characteristics at baseline (assessment) (e.g., health status, functional status, quality of life, etc.) Client characteristics at end of treatment (re-assessment) (e.g., health status, functional status, quality of life, etc.) Entry Exit Intervention Difference between Point A/Entry and Point B/Discharge = Outcomes

14. Typical Categories of Outcomes • Change in clinical status • Effect of tx. on pt. symptoms • Change in functionality • Effect of tx. on pt. lifestyle • Change in utilization of services • Effect of tx. on using future services • Recidivism • Patterns of relapse or re-entry

15. Outcome Qualities • Identifiable/Measurable • Achievable • Demonstrable/Documented • Predictable/Causal—direct result of intervention • Meaningful • Predetermined—target behavior BEFORE intervention • Accountable—deliverable every time

16. Outcome Measure Selection Relevant/important to clients Result from intervention Compatible with theories (TOA) and practice Incorporate into existing client & program documentation e.g. objectives Understandable by professionals and caregivers Data collection processes quantify results

17. Outcomes Terminology • Effectiveness • Efficacy • Effectiveness research • Outcomes-based management research • Patient outcomes research • Near-patient testing • Evidence-based practice • Practice-based evidence • Clinical practice improvement • Clinical importance

18. Methods for Defining and Measuring Outcomes in TR • Formal Literature Analyses • Clinical Practice Guidelines • Programmatic Data • Treatment Networks • Theory in Action Research • Research Agendas

19. What Do We Know For Sure? • Outcome measurement depends on: • Specification of important, meaningful outcomes • Systematic programming/intervention (standardized practice) • Valid and reliable client assessment • Accurate and meaningful documentation/records • Systematic program evaluation and efficacy/effectiveness research • YOU!!! (yes, YOU!!!)

20. Therapeutic Recreation Outcomes • What are important TR outcomes? • What outcomes are important in your setting? • What TR service model do you use in your practice? • What are the needs of your clients? • What are the goals of your programs? • What outcomes do you program for?

21. What are Important Outcomes of TR Intervention? • Your Views…

22. What is Evidence Based Practice? The How Evolves from systematic study and research Evolves from wisdom about outcomes expected from standardized clinical intervention Targets outcomes based on standardized interventions Promotes selection of treatments which have some evidence Improves predictability and causality of service outcomes Provides regulators and consumers with assurance of increased quality & reduced risk Involves applying results of outcomes research to improve day-to-day TR practices Leads to development of protocols

23. Why Evidence-Based Practice Needed? Three concerns surfaced: • many physicians relying on personal judgment rather than research for treatment of patients • new knowledge exploding at almost direct, inverse relationship to time available to read and absorb it • managed care eroding independence of physician decisions

24. Why Do Healthcare Practices Need to Change? The structures, incentives, and forces at work in the U.S. health system produce exactly what we should expect in the quality of care for chronic disease: highly variable patterns of care, widespread failure to implement recognized best practices and standards of care, and the persistent inability of provider systems to achieve substantive changes in patterns of practice. Moreover, after more than two decades of effort to improve clinical care management and to promote the adoption of evidence-based standards, these variations [still] persist. (Coye, 2001, p. 44)

25. Produced need for… Systematic collection of data, over time, through near-patient research studies as well as the clinician’s reflective approach in applying this information in daily work with clients

26. Evidence Based Practices Range of evidence: clinician wisdom, anecdotes, case studies, pilot/exploratory studies, experimental designs, RCTs Integrate outcome research into practice by identifying outcomes expected from standardized clinical interventions

27. Therapeutic Recreation Practice Evidence-Based Practice: Research Informing Practice Therapeutic Recreation Research Evidence-Based Practice Practice Based Research: Practice Informing Research

28. Definitions of Evidence-Based Practice • The aim of evidence-based healthcare is to provide the means by which current best evidence from research can be judiciously and conscientiously applied to the prevention, detection, and care of health disorders. • Process of systematically reviewing, appraising and using clinical research findings to aid in the delivery of optimum clinical care of patients. • Evidence-based healthcare extends the application of the principles of evidence-based medicine to all professions associated with healthcare, including purchasing and management.

29. Definitions of Evidence-Based Practice • Evidence-based medicine is conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise and patients' own values and expectations with best available external clinical evidence from systematic research. • Evidence-based healthcare is, at its simplest, the idea that care should be based as closely as possible on evidence from well-conducted research into effectiveness of healthcare interventions, thereby minimizing problems of underuse, overuse, and misuse.

30. Definitions of Evidence-Based Practice • Ability to track down, critically appraise (for validity and usefulness), and incorporate this rapidly growing body of evidence into one’s clinical practice has been named ‘evidence-based medicine.’ • Collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and research-driven evidence. The best available evidence, moderated by patient circumstances and preferences, applied to improve quality of clinical judgments and facilitate cost-effective healthcare. • Reliance on current scientific evidence to reach medical decisions.

31. Definitions of Evidence-Based Practice • Evidence-based practice can be described as selection of treatments for which there is some evidence of efficacy • Evidence must be gathered through well-designed and meaningful research efforts with client groups and be applicable to daily practice • Evidence-based practice also is termed empirically validated treatment, empirically supported treatment, empirically evaluated treatment, empirical practice, research-based practice, research utilization, evidence-based treatment, and evidence-based healthcare

32. What is Evidence-Based Practice? That is, through evidence-based service delivery, each practitioner should feel confident that she or he is providing the best possible care that is known to produce the most desirable, intended, and meaningful outcomes.

33. EBP = Focus on Best Practices • Evidence-based healthcare usually involves systematic research – and better yet, the accumulation of systematic research – as applied by conscientious specialists who have the ability to synthesize the research and incorporate it into daily practice decisions with clients. Its aim is to reduce wide variations in practice based solely on clinicians’ preferences or personal experiences, eliminating the worst practices, and embracing the best practices

34. What Does This Mean for You? • Evidence-based clinical judgment: • is neither solely evidence nor judgment • requires understanding of requirements to make satisfactory clinical decision • increases with opportunity and practice • reduces but does not eliminate clinical uncertainties • is currently grounded in Western, allopathic, and professionalized approach to medicine. • Evidence-based healthcare is process of life-long, self-directed, problem-based learning in which caring for patients creates need for clinically important information about diagnosis, prognosis, therapy, and other clinical and healthcare

35. Supporting Evidence-Based Practice • Evidence-based practice can be accomplished in three ways: • through learning the five steps of evidence-based practice, • seeking evidence collected by others • adopting protocols written by other who have done evidence-based practice research. • Evidence-based practice includes performance data from quality improvement efforts, consensus recommendations of recognized experts, and affirmed experience in addition to research findings. • Ultimate expectation of evidence-based service delivery is improved, informed, and more consistent healthcare for all clients.

36. Steps to Evidence-Based Practice • Formulate a clear clinical question from a patient’s problem. Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi? • Search databases for relevant clinical evidence • Appraise the evidence. • Implement and use findings in practice. • Evaluate the impact of change in practice.

37. Definition of EBP Evidence Based Practice means conducting or using research to inform the design and delivery of therapeutic recreation practice. (McCormick & Lee, 2001)

38. Purpose “The overall aim of EBP is to reduce wide (and unintended) variations in practice, and instead use the best, accumulated evidence possible to inform, enlighten, and direct practice.” (Stumbo, 2011. Pg. 4)

39. Client Outcomes! Entry Exit Intervention Difference between Point A/Entry and Point B/Discharge = Outcomes (Stumbo, 2003)

40. Client Outcomes! Entry Exit EBP 5 Steps! Intervention Difference between Point A/Entry and Point B/Discharge = Outcomes (Stumbo, 2003)

41. Steps to Evidence-Based Practice • Formulate a clear clinical question from a patient’s problem. Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi? • Search databases for relevant clinical evidence • Appraise the evidence. • Implement and use findings in practice. • Evaluate the impact of change in practice.

42. Coping Skills Application STEP ZERO: Cultivate a spirit of inquiry TR is more than just activity provision! TR is Process that starts with: • Specifying outcomes (don’t start with activity first!) • Looking at research • Choosing and implementing best practice interventions • Documenting and evaluating outcomes of interventions

43. Coping Skills Application Step 1: Formulate a clear clinical question. Ask questions using PICOT format P – Population of interest I – Intervention or area of interest C – Comparison intervention or group O – Outcome(s) desired T – Time frame

44. P - Population of interest • Characteristics? Age(s)? Diagnoses? • What general needs exist within this population? • What outcomes of intervention are desired? • Example: • Clients lack appropriate coping skills when stressed

45. I - Intervention or area of interest • What are best practice interventions based on needs/desired outcomes? • Example: • What interventions are best used for improving coping skills?

46. C - Comparison intervention or group • What population studied in the research is closest to my group? • Are skills specific to this group or are they universal? • Example: • Are coping skills unique to at-risk youth or are they universal for everyone needing to manage stress?

47. O - Outcome(s) desired • What change(s) are possible with this group? • What are the target behaviors of the interventions? • What should clients understand as a result of these interventions? • Example: • Possess array of effective coping skills to manage stress

48. T - Time frame • How long are the programs described in the research? • How long are clients at my facility? • What can realistically be accomplished within this time frame? • Example: • Agency’s average length of stay is 3 days (or 2 weeks or 4 months, etc.)

49. Step 1: Clinical Question • What coping skills do children need in order to manage stress well and sustain a healthy lifestyle across the lifespan?

50. Step 2: Search Databases University or Hospital Library www.scholar.google.com www.guideline.gov www.findarticles.com www.cochrane.org www.clinicalevidence.com www.ncbi.nlm.nih.gov www.samhsa.gov www.ahrq.gov www.bmj.com www.MedScape.com www.jstage.jst.go.jp www.doaj.org www.samhsa.gov www.ahrq.gov www.bmj.com www.MedScape.com www.jstage.jst.go.jp www.doaj.org