Unit 1: Levels of Evidence Flashcards
Evidence
Clinically relevant research that has been conducted using sound methodology (the best available)
Types of Evidence
- Case Reports
- Practice Guidelines
- Data Sources
- Cohort Studies
- Validation Studies
- Systematic Reviews
- Meta Analysis
- Expert Opinions
- Comparative Studies
- Randomized Controlled Trials
Evidence is found in…
Research Literature
Pyramid of Evidence (Hierarchy of Evidence)
HIGHEST>LOWEST Reliability and Quality
- Systemic Review
- Critically Appraised Topics (Evidence Syntheses)
- Critically Appraised Individual Articles (Article Synopses)
- Randomized Control Trials
- Cohort Studies
- Case-Control Studies, Case-Series. Case Reports
- Background Information, Editorials, Expert Opinions
Case-Series. Case Reports
Observational and require the least rigorous methodology (lowest level in research studies and the most prevalent)
-Can be collective or one single case. These are descriptions of clinical cases.
Randomized Control Trials
Require the most rigorous methodology to eliminate bias (least prevalent with highest level of evidence)
Primary Sources
Publications that are written by the author. -First-person reports and are often referred to as original sources. The purpose of a primary source is to present new findings or discoveries about a topic, and to build or add new information to previous findings.
(can be quantitative, qualitative, or mixed method studies)
Secondary Sources
Seek to describe, review, or summarize the available information on a topic by gathering data from several primary resources. The author(s) of a review typically include the analysis of information they found as well, and are usually not involved in the original studies.
Systematic Review vs. ‘Review’
Systematic: Follows rigorous protocol and collects all known research
‘Review’: No protocol and Collection is based on authors preference
Qualitative Research
-Descriptive research
-Information expressed in words
-Subjective because it deals with personal reactions. opinions, and view points
-Data is collected in interviews or focus groups
-Lower Evidence
(Editorials and expert opinions)
Quantitative Research
-Information expressed in numerical data, statics or percentage
-Objective because it seeks a concrete objective answer to a set hypothesis using statistical analysis of collected data
-Higher Evidence
(randomized controlled trials: depend on eliminating bias and subjectivity)
Evidence Based Practice
Combination of information that enables us to work together to make the best use of knowledge.; Combines what we know from research, what we learned from clinical wisdom, and what we learned from the client and the client's family Systemic Approach to Practice -Best Evidence -Clinicians Experience -Patients Preferences and Values
When should Evidence Based Practice be used?
To alter care according to research
Science is…
A systematic approach to knowing and understanding the world around us.
- Collecting information about phenomena in an area
- Building a reliable base of information in an area
- Developing theories to explain phenomena
Information acquired via research is:
- Identifying a problem to study
- Developing hypotheses
- Conducting research and analyzing results
- Disseminating results
A scientist is someone who:
- Adopts scientific methods to acquire information
- Engages in a wide range of activities
- Works in a variety of settings
Science is a way of thinking that involves:
- Carefully defining a problem
- Seeking out relevant information
- Rigorously testing hypotheses
As a clinician you are a scientist…
You are using evidence to carefully define a problem (diagnoses), seeking relevant information to provide treatment, collecting data on the effectiveness of your treatment, and adjusting as necessary.
How Do Scientists Do Science?
As a scientist you will identify variables to examine if there are relationships between the variables, or you will conduct controlled experiments to look for causal connections among variables.
(ex. Does a constraint-induced motor therapy improve the function of an upper limb that has hemiparesis?)
Categories of Basic Research
There are two main categories of research: basic research and applied research. Basic research seeks information to know something. It does not seek to solve a problem or understand how to apply something clinically. It is knowledge for the sake of knowledge.
Basic and Applied Research
The goal of applied research is to evaluate real-world problems. Our clinical research is rooted in applied research principles. Applied research evaluates real problems. Hypotheses may come from theory, but the goal of applied research is to apply results to real-world problems. There is substantial overlap between basic and applied research, and each type of research has implications for the other.
Evidence-Based Medicine (EBM)
The integration of the best research evidence with clinical expertise and patient values.
Best Research Evidence (EBM)
Clinically relevant research; Often from the basic sciences of medicine, but especially from patient-centered clinical research—into the accuracy and precision of diagnostic tests/clinical examination, prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.
Clinical Expertise (EBM)
Uses clinical skills and past experience to identify a patient’s unique health state and diagnosis, individual risks and benefits of potential interventions, and personal values and expectations.
-Includes our education, thoughtfulness, and compassion as well as our knowledge of effectiveness and efficiency. (before 1970s, we relied on older, wiser colleagues, but these sources of information can be flawed)
Patient Values (EBM)
The unique preferences, concerns and expectations each patient brings to a clinical encounter that must be integrated into clinical decisions. You must take into account the practice context in which you work.
You must use clinical reasoning to integrate information from the four sources:
Clinical Expertise, Research Evidence, Information from the Practice Context, and the Client’s Values and Circumstances.
The purpose of EBP is to…
Assist in clinical decision making; To make informed clinical decisions, you must integrate several pieces of info. You may be good at seeking information from clients, their families, and from your work settings, but you may not be aware of the research information. The evidence you need is evidence from research. You have research for testing theories and providing you with the background information that forms part of your clinical knowledge. That information may come from anatomy, physiology, psychology, or the social structure and is essential to our work and has been refined over many years through research. Having an understanding of the mechanisms is important.
EBP aims to provide… (Why is EBP Important?)
The most effective care available with the aim of improving client outcomes.
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EBP promotes an… (Why is EBP Important?)
Attitude of inquiry that encourages you to ask yourself, “Why am I doing this in this way? Is there evidence that can guide me in a more effective way?”
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EBP encourages… (Why is EBP Important?)
Professional accountability when you integrate the best available evidence with information from your clinical knowledge, clients, and practice context. The reasoning behind your clinical decisions becomes apparent.
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EBP ensures that… (Why is EBP Important?)
Health care resources are used wisely and relevant evidence is considered when decisions are made about funding health services.
Ideally, with EBP:
- Clients receive treatment that works based on the evidence (up to a certain point).
- Clinicians rely less on opinions and feelings, and work side-by-side with researchers to develop clinically relevant treatments.
- Payors and policy makers recognize treatments that are effective and cost efficient.
The development of Evidence-Based Medicine (EBM)
The development of strategies for efficiently tracking down and appraising evidence for its validity and relevance.
The development of Evidence-Based Medicine is the…
- Creation of systematic reviews and concise summaries of the effects of health care (e.g. Cochrane Collaboration)
- Creation of evidence-based journals of secondary publication (that publish the 2% of clinical articles that are both valid and of immediate clinical use)
- Creation of information systems for making this information readily available
- Identification and application of effective strategies for lifelong learning and improvement of clinical performance
Practicing EBP
When you practice EBP as a practitioner, you should aim for awareness, consultation, judgment, and creativity.
Awareness (Practicing EBP)
- Be aware of evidence applicable to practice and seek it out.
- Find effective ways to stay up to date with new research.
- Be knowledgeable of where to look and where to focus awareness.
- In each profession there are practitioners and organizations that help to raise awareness and deliver easy access for where to find the research and interpret it.
Consultation (Practicing EBP)
- Be a good communicator.
- Be able to discuss why you are practicing EBP.
- Communicate what is happening to your clients.
- Communicate in a way that helps your clients understand the assessments and treatments.
Judgement (Practicing EBP)
- There can be issues inherent in the evidence used by EB practitioners, so they must possess good clinical judgment.
(ex. Meta-analyses which are successful for “average” randomized clients may not apply to specific cases and can be misleading) - Use clinical judgment to tailor the evidence to each client’s situation.
(ex. Ppl with brain injuries can often be a heterogenous group and exhibit unique symptoms. Sometimes certain evidence may not apply or be helpful for your specific patient. You must use your judgment to find evidence that will best support your individual client)
Creativity (Practicing EBP)
- Use the best evidence in the best way, which may not always be straightforward.
- Use insight and creativity to meet the challenges of real-life practice.
- Use independent, critical thinking.
- Remember, EBP is both an art and a science.
5 steps of evidence-based practice
Answerable Question, Find Evidence, Appraise Evidence, Integrate appraisal & evidence, Evaluate Steps
Answerable Question (5 steps of evidence-based practice)
Convert the need for information into an answerable question.
Find Evidence (5 steps of evidence-based practice)
Track down the best evidence with which to answer that question.
Appraise Evidence (5 steps of evidence-based practice)
Critically appraise the validity, impact, and applicability of the evidence.
Integrate appraisal & evidence (5 steps of evidence-based practice)
Integrate the critical appraisal with your clinical expertise and your patient’s values, needs, and preferences.
Evaluate Steps (5 steps of evidence-based practice)
Evaluate effectiveness and efficiency in executing Steps 1-4 and seek ways to improve them.
PICO Questions
The PICO process (or framework) is a mnemonic used in evidence-based practice (and specifically evidence-based medicine) to frame and answer a clinical or health care related question. We can pose a question using the PICO formula
PICO Formula
- Ask a Clinical Question
- Search for best evidence
- Evaluate Evidence
- Make a decision w pt and family
- Implement Treatment
- Evaluate Outcome
- Start Over
Posing a question (PICO)
P: Population Patient Problem
I: Intervention or Exposure
C: Comparison or Contrast
O: Outcome
P (PICO)
Population Patient Problem
- Who are the patients
- What is the problem?
I (PICO)
Intervention or Exposure
-What do we do to them
-What are they exposed to?
(Can include diagnostic or screening procedures)
C (PICO)
Comparison or Contrast
-What do we compare the intervention with
O (PICO)
Outcome
- What happens?
- What is the outcome?
Searching for Evidence
There are numerous sources and databases to search for the evidence. The USAHS Library is a great place to start! PubMed, PsychINFO, Cochrane, and CINAHL are a few of the databases that are available via the USAHS Library that may be relevant. There are also resources available on our professional organization sites, including the ASHA practice portal, AOTA, and APTA.
Selecting an Article
2 Steps:
- Select the Right Article: Determine the type of article(s) that will best help you get the information needed.
- Perform an Analysis: Perform a quick analysis to determine if the article contains relevant information.
Evaluating the Evidence
Once we find the information, we need to evaluate the evidence for validity and relevance. To effectively do this, you need to understand reliability, validity, types of variables, sampling methods, types of research designs, and statistics.
Examples of Primary Sources:
- Randomized Control Trials
- Controlled Clinical Trial
- Expiraments
- Surveys
- Cohort Studies/Case-Control Studies
- Case-Series/Case Reports
- Case Studies
Examples of Secondary Sources:
Include Narrative or Systematic Literature Reviews
Narrative Reviews
Non-systematic.
-They are a descriptive, broad overview of a topic. They do not tend to address a specific question.
Systematic (Literature) Reviews
Use systematic methods to collect secondary data, critically appraise research studies, and synthesize findings either qualitatively or quantitatively.
- Collect and critically analyze multiple studies on a given subject (Compilations of research from primary sources)
- Follow rigorous methods when analyzing and assessing original research
- Must follow a predetermined protocol that is used to compile and provide a statical analysis of all evidence available on a topic
- Non literature are answering a clearly formulated question
Determine the Strength of the Evidence
First, classify the type of information as primary or secondary.
Then, identify the level of evidence.
Level I Evidence.
Evidence provided by one or more well-designed, randomized, controlled clinical trial, including overviews (meta-analyses) of such trials
Level II Evidence.
Evidence provided by well-designed observational studies with concurrent controls (e.g., case control or cohort studies)
Level III Evidence.
Evidence provided by expert opinions, case series, case reports and studies with historical controls
Meta-Analysis
Similar to systematic review however, a statistical analysis is used to combine the results of multiple studies addressing the same question.
Evidence Guidelines
Systematically developed papers to assist clinicians with decisions about intervention.
Filtered Information
- Systematic Reviews
- Meta-Analysis
- Evidence Guidelines
Unfiltered Information
- Randomized Controlled Trials
- Cohort Studies
- Single Case-Controlled Study
- Case Reports
- Expert Opinions
Randomized Controlled Trials
Randomly assign participants to experimental or control groups and are tightly controlled. The outcome is due to the variable being studied.
Cohort Studies
Longitudinal studies that track people over a long period of time
Single Case-Controlled Study
A retrospective design that looks at the differences between two groups
Expert Opinions
ideas and anecdotal evidence are the lowest on the evidence table that do not hold much weight
Critical Appraisal of the Evidence
Once you find the evidence, determine the level, and then critically appraise it.
Facts about EBP
- Critically examines all clinical procedures critically evaluating their appropriateness for the specific situation
- The use of evidence is only one piece of the clinical decision making proces. Client situations, preferences, and values are key components to the process
- It is impossible to keep up with the entire health care literature. should remember to search for evidence to support or refute practice methods
- EBP insists that eacb client is treated with the best available evidence and practitioners make a genuine effort to find best solutions with given resources
- Many practitioners take little or no time to review current medical findings
- Emphasizes the best available clinical evidence for each clients situation
Evidence from systematic research is the only acceptable basis for clinical decision making. (T/F)
False
The EBP framework recognizes that the experiences, values, and preferences of ourselves and our clients can and should contribute to our clinical decisions.
True
You should spend a lot of time searching through articles and textbooks for pieces of evidence like you would search for “gold”.
False
The amount of information available for review is overwhelming, so you should focus on “high-yield” sources in your area.
True
Only people who have completed years of specialized study can do a critical appraisal of research studies.
False
