Levels of Evidence and The systematic review process

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Yangama Jokwiro :

Yangama Jokwiro Hierarchy of Evidence and The systematic review process

Evidence-Based Practice:

Evidence-Based Practice

Nursing Began to Define EBP :

Nursing Began to Define EBP Setler, et. al., (1998) Evidenced-Based Nursing De-emphasizes: ritual and isolated unsystematic clinical experience; ungrounded opinions and traditions Emphasizes: Research, findings from Quality Assuarance data and other operational and evaluative data, consensus of experts, affirmed experiences Mulhall (1998) Evidenced-Based Nursing Journal Research evidence Clinical evidence Patient preferences

Elements of evidence based practice:

Elements of evidence based practice Clinical expertise Patient values Best available research evidence EBP Scientific evidence Client family preferences Nursing Decisions & clinical assessment

The Purpose of Evidence-Based Practice:

The Purpose of Evidence-Based Practice Cost Saving http://www.youtube.com/watch?v=0UlXt2g4F9k 17/11/2013 5 SL/HSB

The Purpose of Evidence-Based Practice:

The Purpose of Evidence-Based Practice Meeting National Patient Safety Goals Medication administration Health care acquired infections Staffing and staff competence Benchmarking

The Purpose of Evidence-Based Practice:

The Purpose of Evidence-Based Practice Nursing home deaths investigated (Williams Care Gardens) Caroline Marcus The Sunday Telegraph March 20, 201112:00AM Shameful treatment: Nursing home on the NSW Central Coast where two nurses were sacked for appalling treatment of residents. Picture: Robert McKell. Source: The Sunday Telegraph The first death, in June last year, was that of an 87-year-old war veteran, whose daughter Wendy Smith claims wasted away to a skeleton-like frame after three months in care.Ms Smith says she was asked by the department last week to file a formal complaint against the home. Nursing home spokesman Tim Allerton said the man lost just 5kg while in care, and said he was fed well in their care. The second death was that of a terminally ill resident who passed away in December. A whistleblower alleged an assistant nurse - later sacked by the home - withheld food from him, saying that "he was going to die anyway and this way it would make it quicker". The department is investigating the allegations made by the whistleblower. The nursing home claimed that in the unproven instance that the man was denied food by the nurse, he would have been fed during other shifts, and it could not be said the allegations would have been a factor in his death. 17/11/2013 7 SL/HSB

The Purpose of Evidence-Based Practice:

The Purpose of Evidence-Based Practice Carrington Nursing Home responds to investigation findings Speaking exclusively to the Macarthur Chronicle, Carrington chief Raad Richards said he disagreed with some findings detailed in a draft Aged Care Standards and Accreditation Agency report. The report is based on a review conducted at the facility in August The report flagged staff rostering pursuant to skills; communication between staff and residents, and between staff and residents’ relatives; and the provision of specialised nursing and clinical care, as areas needing improvement, Mr Richards said. “The Carrington board and management is very disappointed with the results of this audit and we take it seriously,” he said. “Cultural changes” were under way, he said, adding that the facility “started addressing those issues straight away”. 17/11/2013 8 SL/HSB

Sources of evidence:

Sources of evidence How do you rank these sources? Dr Doctor Team leader/In charge nurse The know it all nurse Older looking nurse 17/11/2013 9 SL/HSB

Sources of Evidence:

Sources of Evidence National Institute of Clinical Studies Joanna Briggs Institute (JBI) Cochrane Collaboration Campbell Collaboration Evidence-Based Journals

Nursing Reference Group:

Nursing Reference Group 17/11/2013 12

Five Steps of Evidence-Based Practice:

N. McKibbon , 1999 Five Steps of Evidence-Based Practice 1) Define the Question Identify Question ~ Search and Screen Literature ~ Refine Question 2) Collect the Evidence 3) Critically Appraise the Evidence for Validity and Relevance

Five Steps of Evidence-Based Practice:

N. McKibbon, 1999 Five Steps of Evidence-Based Practice 4) Integrate the Evidence and Patient Factors Make & Carry Out the Decision 5) Evaluate the Process Results ~ Self-reflection

Weighing the Evidence:

Weighing the Evidence Not all research is well designed, valid, generalisable The evidence must be appropriate to The question Practice issue Client group Not all evidence is equal

Weighing the Evidence:

Weighing the Evidence http://www.ted.com/talks/lang/en/ben_goldacre_battling_bad_science.html 17/11/2013 16 SL/HSB

PowerPoint Presentation:

JBI Model of Evidence-Based Health Care 2008

JBI Applicability FAME Scale:

JBI Applicability FAME Scale F easibility evidence about the extent to which an activity or intervention is practical. A ppropriateness evidence about the extent to which an activity or intervention is Ethical or culturally apt. M eaningfulness evidence about the personal opinions, experiences, values, thoughts, beliefs or interpretations of clients and their families or significant others. E ffectiveness evidence about the effects of a specific intervention on specific outcomes. (JBI, 2008)

PowerPoint Presentation:

JBI Levels of Evidence (2008)

PowerPoint Presentation:

Level Intervention 1 I A systematic review of level II studies II A randomised controlled trial III-1 A pseudorandomised controlled trial (i.e. alternate allocation or some other method) III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial ▪ Cohort study ▪ Case-control study ▪ Interrupted time series with a control group III-3 A comparative study without concurrent controls: ▪ Historical control study ▪ Two or more single arm study ▪ Interrupted time series without a parallel control group IV Case series with either post-test or pre-test/post-test outcomes NHMRC 2008 Evidence Hierarchy: designations of ‘levels of evidence’ according to type of research question

Key Questions:

Key Questions Evidence base Consistency Clinical impact Generalisability Applicability Other factors NHMRC 2008

PowerPoint Presentation:

Key Questions 1. Evidence base A Several Level I or II studies with low risk of bias B one or two Level II studies with low risk of bias or SR/multiple Level III studies with low risk of bias C Level III studies with low risk of bias or Level I or II studies with moderate risk of bias D Level IV studies or Level I to III studies with high risk of bias 2. Consistency A All studies consistent B Most studies consistent and inconsistency can be explained C Some inconsistency, reflecting genuine uncertainty around question D Evidence is inconsistent NA Not applicable (one study only) 3. Clinical impact A Very large B Moderate C Slight D Restricted 4. Generalisability A Evidence directly generalisable to target population B Evidence directly generalisable to target population with some caveats C Evidence not directly generalisable to the target population but could be sensibly applied D Evidence not directly generalisable to target population and hard to judge whether it is sensible to apply 5. Applicability A Evidence directly applicable to Australian healthcare context B Evidence applicable to Australian healthcare context with few caveats C Evidence probably applicable to Australian healthcare context with some caveats D Evidence not applicable to Australian healthcare context Other factors (NHMRC 2008)

Making Evidence Accessible to Busy Clinicians:

Making Evidence Accessible to Busy Clinicians Systematic reviews Summaries Abstracts Practice sheets Evidence-based clinical guidelines

Systematic Review :

Systematic Review “… a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research” (Cochrane, 2005).

Systematic Review :

Systematic Review A systematic review Has a focused clinical question, protocol Based on research evidence – not authority, opinion Focuses on a client group, intervention, risk factor Examines benefits, harm, cost effectiveness The search is exhaustive Examines rigour of research Includes consultations with clinicians Weighs levels of evidence

Systematic Review :

Systematic Review When are they conducted; The problem requires a response from health professionals There is a recurring practice problem To investigate a common therapeutic practice or approach To develop standards or protocols Recent research generates questions about practice

Practice Based Evidence:

Practice Based Evidence It is a comprehensive analysis of patient differences, process differences and association with outcomes, based on everyday circumstances, not controlled situations

Practice Based Evidence:

Practice Based Evidence Westfall states “What is efficacious in randomized clinical trials is not always effective in the real world of day-to-day practice . . .. Practice-based research provides the laboratory that will help generate new knowledge and bridge the chasm between recommended care and improved care.” Westfall JM, Mold J, Fagnan L. Practice-based research—“Blue Highways” on the NIH Roadmap. JAMA. 2007;297:403– 406. 17/11/2013 28 SL/HSB

Practice Based Evidence:

Practice Based Evidence Data comes from : Outcomes Clinical Health status Cost Patient Factors Psychosocial/demographics Disease Severity of disease Points in time Process Factors Management strategies Interventions Medications

Barriers to Evidence Based Practice:

Barriers to Evidence Based Practice Attitudes Most clinicians do not read research literature, use research findings (eg. Nagy, et al, 1992) Resources Access to libraries, journals, systematic reviews, research expertise, etc. Support Time, financial support to conduct research and disseminate findings Organisational culture / structure Knowledge

Converting to EVP:

Converting to EVP Question practice decisions based on authority alone Reflect on practice Look for evidence as a basis for decision-making Use clinical guidelines based on evidence that have been developed by others Ongoing review of clinical guidelines, based on evidence Evaluate the outcomes of practice Generate questions that need answering

References:

References Sackett DC, Rosenberg WMC, Gray JAM, Haynes RB & Richsrdson WS. (1996) Evidence-based medicine: What it is and What isn’t it. British Journal of Medicine, 312 , 71-2. Popay J, Rogers A, Williams G. (1998). Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res, 8 (3), 341-351.