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What is a definition of evidence-based practice?

integrating the use of best evidence in treating patients which is a balance of clinical expertise, patient feedback and external clinical evidence (research)

Welcomes clinical skill and experience
If there is a better way to practice therapists should find it
Blend old ways with new knowledge
Incorporates patient feedback into best practice


What are the driving forces behind the use of evidence-based practice?

Unexplained variation in practice
Health care costs
Medical errors
Harm now seen in previously approved treatments
Technology trends and advancement in outcome research


What are 3 principle sources of evidence (knowledge) that go into best evidence?

Clinical wisdom – experience from clinical practice
Research wisdom – what gained from research
Patient wisdom – what learned from patient and family


What are the characteristics of a clinician that embraces EBP?

Those practitioners who question their own practice
Those who are “humble about what they know”
Those who always want to improve their own practice


What are the steps in the EBP Process?

Develop clinical questions
Finding of the evidence to answer those clinical questions
Appraisal of this evidence
Application of evidence to their practice
Evaluation of clinical outcomes based upon the application of evidence


What are the myths associated with EBP & what is the reality of those myths?

MYTH - EBP already exists
REALITY - Many practitioners spend little or no time reviewing current medical findings & being introspective about their own practice
MYTH - EBP is impossible to put into place
REALITY - Little work is needed to begin asking clinical questions
MYTH - EBP is cookie cutter health care
REALITY - It is a balance of the 3 factors: practitioner knowledge & practice, clinical research and patient involvement. Guidelines are developed to enhance care and to standardize best clinical practice but allows for appropriate patient based variation in care.
MYTH - EBP is strictly a cost cutting mechanism
REALITY - EBP is designed to eliminate unneeded & ineffective interventions and in that way it is cost cutting. The emphasis is on practice based upon best clinical evidence not the least expensive form of practice.


How do we learn best?

We learn best from intermittent reinforcement – when periodically we receive information


What is confirmation bias?

"confirmation bias" - the tendency we have to see only what confirms our belief, and disregard, or rationalize, contradictory evidence


Good studies designed to eliminate what factor?

A good experimental study is one that is designed to lessen or eliminated the influence of experimenter bias on the outcome of the study
The greater the attempt to eliminated this bias, the higher the quality of the study.


How do we identify a research article?

It is asking a question
It has a methods section
It has a results section
It discusses those results in the context of other studies


What three questions need we answer from all research?

Do these results apply to my patients?
Are the results just by chance or real?
Is there a cause & effect relationship between the intervention and outcome?


What are the levels of evidence from the literature?

Non-experimental research
Experimental Research


What are some problems associated with good research?

Costly & time consuming
Experimental studies & meta-analyses sometimes hard to generalize because of subgroup composition, effect size and quality of outcome measure
Presentation of evidence sometimes hard to translate into practice

Problems from a clinicians viewpoint:
Lack of time & resources for searching for evidence
Availability of articles to answer you clinical questions
Time to apply the results to your patients


Experimental Research

An active intervention is involved
Those that use more than one group of subjects
One of the groups is a control group – do not have the active intervention
Subjects are randomized to groups – that is not assigned to groups because of their characteristics but have an equal chance of being in a group when they enter a study



Not necessarily factual; show a lot bias


Non-experimental research

studies that use single subjects or single groups or do not have an active intervention


Systematic review

when articles are judged for quality with higher quality articles given more weight in conclusions



mathematically assigned weights
combination of articles to strengthen results


Clinical Guidelines

when panels of experts review experimental research, systematic reviews and meta-analyses to state what “best practice” is


What is a theory?

organized set of constructs or concepts that is proposed to describe and explain systematically a phenomenon


What are the two basic hypotheses?

Null hypothesis – no difference between groups

Experimental (research/alternative) hypothesis – difference between groups


What are 3 key clinical (patient-oriented) questions that need to be asked about each article?

Do these results apply to my patients?

Are the results just by chance or real?

Is there a cause & effect relationship between the intervention and outcome?


What are the main types of questions that are asked?

"Background" questions ask for general knowledge about a condition or thing.

"Foreground" questions ask for specific knowledge to inform clinical decisions or actions.


What is the PICO method for formulating clinical questions?

Patient - Describe as accurately as possible the patient or group of patients of interest
Intervention – Indicate the main intervention or therapy you wish to consider (in other forms of research you can also investigate cause or prognosis)
Comparison (optional) – List any alternative treatment which you wish to compare with the primary treatment you have listed under intervention (some include placebo here – some not)
Outcome – List the particular outcome measure you are studying including a time frame over which you expect the change in the outcome measure to occur


Clinical questions can be asked about what 6 content areas?

-clinical measures - reliability, validity, responsiveness
-diagnostic tests - accuracy, risk, cost, etc
-prognostic factors - predict future health and disease

-Self-Reported Outcomes - End point of therapeutic intervention with an analysis of how these outcomes can be measured and the relevance of these outcomes to the patient’s activities

-Clinical Prediction Rules - Clinical prediction rules are systematically derived indications of what types of patients may most benefit from interventions


What is a hypothesis?

a specific prediction of an outcome based upon previous literature or theory/conceptual framework


What is a Boolean operator and why is it valuable in using research databases?

Speeds up a search:
able to combine terms
able to eliminate directions you do not want to go

AND-Narrow search and retrieve records containing all of the words it separates.

OR-Broaden search and retrieve records containing any of the words it separates.

NOT-Narrow search and retrieve records that do not contain the term following it.

() -Group words or phrases when combining Boolean phrases and to show the order in which relationships should be considered


What are search limits and how can they be valuable in searching a database?

Narrow the search to certain categories of articles to enhance the efficiency of the search process


What are the benefits and limits of PubMed (Medline)?

Comprehensive – but many journals is specific areas of physical therapy
Linked to online journal and full text versions of article
Rigorous standards for determining which journals will be included (indexed)
Medical Subject Headings (MeSH) – systematic way to retreave information OR general keyboard search
Search history available
Clinical Queries – evidence-based practice database on the home page
Related articles function
Can personalize it “My NCBI”


What are the types of journal articles and what are the advantages and disadvantages of each?

Peer- reviewed journals – critically reviewed before publication so more sure of quality
Non-peer reviewed journals/magazines – no prepublication review so unsure of quality
Monographs - Less critical review but reviewed at several levels however information rapidly out-of-date (can be out of date at publication)
Conference proceedings – often appearing as monographs related to single topic