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Evidence-Based Practice in Augmentative & Alternative Communication: How do you do it? What does it mean for Individuals who use AAC? Pammi Raghavendra.

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Presentation on theme: "Evidence-Based Practice in Augmentative & Alternative Communication: How do you do it? What does it mean for Individuals who use AAC? Pammi Raghavendra."— Presentation transcript:

1 Evidence-Based Practice in Augmentative & Alternative Communication: How do you do it? What does it mean for Individuals who use AAC? Pammi Raghavendra. Ph.D. Senior Lecturer, Disability & Community Inclusion, School of Health Sciences Flinders University, Australia ISAAC-Israel Annual National AAC Conference, Tel Aviv 8 June 2014 All day workshop

2 Workshop Outline 1.What is EBP? 2.What does EBP mean for individuals who use AAC and other stakeholders? 3.Steps involved in EBP – 7 steps 1.Asking a clinically relevant & answerable question 2.Searching for the evidence 3.Critically appraising the evidence 4.Collating & synthesising the evidence 5.Implementing the evidence into practice 6.Evaluating the use of the evidence 7.Disseminating the EBP process & findings 4.Facilitators and barriers to EBP 5.Practical Suggestions to implement EBP 6.Nature and extent of evidence in AAC 7.What can you do to add evidence to the AAC field?

3 Evidence Based Practice (EBP) What is it?

4 Background to Evidence- based Medicine (EBM) Archie Cochrane ( ) –The Cochrane Collaboration David Sackett (1914-) –Definition of EBM, Father of EBM

5 Evidence-based medicine “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett et al., (1997, p.2)

6 What is Evidence Based Practice? Definition: “the integration of best research evidence with clinical expertise and patient values (Sackett et al., 2000)

7 What is Evidence Based Practice in AAC? Proposed Definition: (Schlosser & Raghavendra, 2004) EBP is defined as the integration of best and current research evidence with clinical/educational expertise and relevant stakeholder perspectives to facilitate decisions for assessment and intervention that are deemed effective and efficient for a given direct stakeholder.

8 EBP in AAC Schlosser & Raghavendra, 2004

9 What is Evidence Based Practice? – Key concepts Integration = joining / synthesis of best research evidence clinical expertise stakeholder perspectives (patient values) (Schlosser & Raghavendra, 2004)

10 Key concepts continued… Best research evidence = –Data : current, verified and replicated –High internal validity –Highest level on hierarchy of evidence –Adequate external validity and social validity (Schlosser & Raghavendra, 2004)

11 Key concepts continued… Clinical expertise = reasoning, intuition, knowledge and skills related to clinical skills Educational expertise = reasoning, intuition, knowledge and skills related to educational skills (Schlosser & Raghavendra, 2004)

12 Key concepts continued… Relevant stakeholder perspectives/values = viewpoints, preferences, concerns and expectations relative to the assessment or intervention Patient/client = direct stakeholder ie direct recipient of any decision arising from the EBP process (Schlosser & Raghavendra, 2004)

13 What EBP is not? Myths about EBP EBP is impossible to implement because we do not have enough evidence. EBP already exists EBP declares research evidence the authority EBP is a cost-cutting mechanism. EBP is cook-book practice. EBP is impossible to put in place. (Sackett et al., 1997; Schlosser, 2004) Best and most current research evidence is relative Some practitioners do implement EBP EBP in medicine/AAC definition-all 3 Not always true EBP requires not only extensive clinical expertise but also skillful integration of all 3 aspects of EBP some degree of EBP by all.

14 What does EBP mean for an individual with complex communication needs ? Individuals with CCN (their families) –Central to EBP outcomes, promoting adoption of effective interventions & preventing adoption of ineffective outcomes –Active participants in decision making (ASHA, 2004)

15 What does EBP mean for a practitioner/educator? Best Practice Use of EBP as a framework for best practice, –Promotes development of skills in finding, appraising and implementing evidence Emphasises need for high level clinical & communication skills Provides a framework for self-directed, life long learning Ethical principle: To provide the best available services (assessments & interventions) to consumers & families Practice-research gap

16 What does EBP mean for a service provider/ an organisation? Best Practice at Organisational level What do families think of using iPads/tablet technology for communication and participation? What are the most effective post-school options for students with CCN using AAC? Use of EBP as a framework for effective and efficient services Facilitate/support to implement EBP

17 What does EBP mean for researchers? Excellent opportunity to bridge research-practice gap High priority clinical questions in diagnostics, screening, prognosis, intervention Conduct high quality research –Disseminating research in way that can be used in practice

18 How do you do EBP? Adapted from Schlosser & Raghavendra (2003) 1.Asking the clinically relevant & answerable question 2.Searching for the evidence 3.Critically appraising the evidence 4.Collating & synthesising the evidence 5.Implementing the evidence into practice 6.Evaluating the use of the evidence 7.Disseminating the EBP process & findings

19 Step 1: Ask an clinically relevant & answerable question Broad or general questions provide background information Systematic review e.g., What are the potential barriers and facilitators to high- technology AAC provision and its ongoing use? What are the attitudes toward Individuals who Use Augmentative and Alternative Communication? What is the effectiveness of using iPads/iPods with individuals with disabilities?

20 PICO (Richardson, Wilson, Nishikawa & Hayward,1995) Patient or Population/Problem Intervention Comparison or Control Outcome

21 PICO To clarify the questions related to specific clients To develop questions for Systematic Reviews To identify the information needed to answer the question To translate the question into searchable terms To develop and refine your search strategy

22 Patient / Population/Problem Characteristics of the population e.g age, gender, diagnosis, ethnic group etc How would you describe your Patient/Population group? –Balance precision with brevity

23 Intervention Defining the intervention What intervention are you interested in (be specific)? Therapy, prevention, diagnostic test, exposure/aetiology

24 Comparison or Control –What alternative or other option are you comparing your intervention/assessment to? Be specific –You may be comparing your intervention to another intervention, or to no intervention

25 Outcome What measurable outcome(s) are you interested in? What are you hoping to achieve for the client? –Be specific

26 ELEMENTSUBJECTKEY WORDS P School aged children with cerebral palsy, complex communication needs Child Children School aged, 12-13, primary school, transition, high school Paediatric/paediatric Cerebral palsy, physical disability, spasticity, hemiplegic, CCN, AAC, severe communication/speech impairment, I Group-Peer training of high school students (workshops) Peers, classmates, training, communication, support C Visit by student with CCN plus training O Increased acceptance, welcoming classroom, social networks Social networks, friends, friendships,

27 Group Work Activity 1 Ask an clinically/service relevant answerable question using PICO

28 PESICO template (Schlosser, Koul & Costello, 2007) Person/Problem (P)Person & problem Environment (E)Current/future envt & partner’s knowledge/skills, etc., Stakeholders (S)S’s perspectives, attitudes towards problem Intervention (I)Steps to change persons, envts. interaction, events, procedures Comparison/Control (C)Compare bet. Interventions or intervention & no intervention Outcome(s) (O)Desired outcomes

29 An example (Schlosser, Koul & Costello,2007) Person/pr oblem Envt.StakeholdersInterventionComparisonOutcomes In a 7 year- old boy with profound ID who exhibits self- injurious behavr. Who is currently in a self- contained classroom And whose teacher and aides suspects that his behaviour is communicati on based Is it sufficient to rely on informant- based assessment methods Or is it necessary to also conduct descriptive and experimental assessments In order to identify the communic ative functions that maintain his problem behavr. In a valid and reliable manner/

30 Group Work Activity 2 Ask an clinically/service relevant answerable question using PESICO

31 Step 2: Search for the evidence To start, use the PICO/PESICO question components to identify the search terms

32 Search for the best evidence Where to start searching depends on a number of factors: –Available time –Available databases –Subject matter and domain of the question –Currency and level of evidence required

33 Where do I search? Finding the evidence Courses, proceedings, books, Journals (Two million journal articles are published annually in some 20,000 ‘biomedical’ journals) –Secondary research – meta-analysis, systematic reviews –Primary research – individual research studies Grey literature e.g. unpublished research, theses Indexes and databases –General eg CINAHL, Medline, PubMed, ERIC –Specialist e.g. Cochrane Library, DARE, PEDro

34 Where do I search? Finding the evidence Hand searches Table of contents Ancestry search- use reference list and identify other studies Forward citation search-who has referred to a particular article? Finding evidence on the Internet –General search engines, e.g., Google –Specialised Search engines, Google Scholar

35 Types of Databases Bibliographic/General eg Medline PubMed Specialist Databases –ERIC –CINAHL –PsyInfo

36 Databases – Full Text/Specialised DARE- Database of Abstracts of Reviews of Effects (UK) Cochrane- Cochrane Database of SR (Worldwide) Expanded Academic ASAP Science Direct SCOPUS

37 Strategies for searching databases Plan the research, efficiency Create a search plan Select and access the right databases Develop a search statement Limit, refine and evaluate Locate the source publication

38 Strategies for Searching 1) look for pre-filtered evidence (e.g., EBM reviews, Systematic Reviews, Practice guidelines) 2) look for reviews before individual studies 3) look for peer-reviewed before non-peer reviewed (Schlosser, Wendt, Angermeier & Shetty, 2005)

39 Create a Search Statement Search commands – Boolean operator/connectors (or, and, not) example: labour not pregnancy Truncation – symbols used to substitute for characters at the end of a word e.g Ovid uses “$” example: child$ will give children, childlike Wildcards – symbols used to substitute for a letter within a word e.g Ovid uses # example: wom#n will give woman and women Check Help Screen for each database

40 Keyword Searching Keywords – important words that represent a topic. Have no control over how a word is used in the document The use of quotation marks is useful for example “intellectual disability” Fields – eg author, title, abstract, journal Limits – by date, by language, to full text, to abstracts, Systematic reviews

41 Hierarchy of Evidence University of Illinois at Chicago

42 Proposed hierarchy of evidence to inform intervention development & selection: Participants with disabilities (Schlosser & Raghavendra, 2004) 1.Meta-analysis of a) RCTs*, b)SSED, b) Quasi-experimental group designs 2a. One well-designed non RCT, 2b. 1 SSED-1 intervention, 2c. 1 SSED-multiple interventions…….. 3. Quantitative reviews that are non-meta-analytic 4. Narrative reviews 5. Pre-experimental group designs & Single case studies 6. Respectable Opinion

43 Levels of Evidence Based on the idea that different grades of evidence (study designs) vary in their ability to predict the effectiveness of the health practices –Reducing biases-Sample, Measurement/detection, Intervention/Performance Higher grades of evidence are more likely to reliably predict outcomes than lower grades Is a system for making sure that you are aware of the strengths and weaknesses of different study types. Several Evidence Grading scales eg: Sackett’s Hierachy of Evidence, NHMRC, Cochrane

44 What are Systematic Reviews? A synthesis of original research Pre-filtered evidence A SR aims to synthesize the results of multiple original studies by using strategies to reduce bias (Cook et al., 1997: Schlosser, 2003, cited in Schlosser et al., 2005)

45 Systematic Review ( Adapted from Cochrane Database of Systematic reviews –www.cochrane.org & Centre for Reviews & Dissemination- ) Transparent process to facilitate replication Pre-defined, explicit methodology is used, strict protocol to inlcude as much relevant research original studies apparised and synthesised in a valid way Minimise risk of bias

46 Systematic Review Meta analysis is a mathematical synthesis of two or more primary studies that addressed the same hypothesis in the same way. (Greenhalgh, 1997, BMJ, 315: )

47 Where to find systematic reviews N-CEP's Compendium of Guidelines and Systematic Reviews (ASHA)N-CEP's Compendium of Guidelines and Systematic Reviews Cochrane Collaboration Campbell Collaboration What Works Clearinghouse (US Department of Education)What Works Clearinghouse Psychological Database for Brain Impairment Treatment Efficacy National Electronic Library for Health (National Health Service of the UK)National Electronic Library for Health Evidence-based Communication Assessment and Intervention (EBCAI) JournalEvidence-based Communication Assessment and Intervention (EBCAI) Journal Speech Byte

48 Step 3:Critically appraising the evidence What is the evidence telling me? Validity (truth) and usefulness (clinical relevance )

49 What is Critical Appraisal? Appraisal is a technique which offers a discipline for increasing the effectiveness of your reading, by enabling you to quickly exclude papers that are too poor a quality to inform practice, and to systematically evaluate those that pass muster to extract their salient points” Adapted from Miser WF (1999). Critical appraisal of literature, J. of American Board of Family practice, 12, Taken from

50 Are the findings applicable in my Setting? What do the results mean for my clients? Is the quality of the study good enough to use the results?

51 Difference between reading for content vs. reading for critical appraisal Abstract Introduction ( background, literature review), aims of the study Methodology Results Discussion Abstract Introduction ( background, literature review), aims of the study Methodology Results Discussion

52 Type of Study The next step is to work out what study design will best answer your question Levels of Evidence – reflect the methodological rigour of the study

53 Type of Question Different types of questions are best answered by different types of studies Your question may be: - Intervention or therapy - Diagnosis/screening - Prognosis - Aetiology or risk factors

54 Questions -> Research Designs Therapy/intervention effectiveness……. Test an association between…..… Descriptive info. about relationship in one participant Explore what factors influenced outcomes at one point in time Describe experiences……  Experimental  Observational- Cohort/case-control  Case Study  Cross-sectional  Qualitative

55 What do you need to look for in studies? Why was the study done? What type of study design was used? What are the study characteristics (PICO/PESICO)? RELIABILITY- Test-retest, intra-rater & Inter-rater VALIDITY (Internal validity - What biases exist?) –Participant selection, comparable groups at baseline, blinding, follow-up, drop-outs,outcomes, procedural reliability/treatment integrity)? –What are the results (size and precision of the effect)? External validity -Are the results relevant in my clinical situation? Social Validity

56 Critical Appraisal Tools Systematic Reviews EVIDAAC Systematic Review Scale (Schlosser, R. W., Raghavendra, P., & Sigafoos, J., Eysenbach, G., Blackstone, S., & Dowden, P. (2008) Protocol –Source selection bias –Trial selection, criteria for pooling –Study quality Data extraction Statistical analysis –Clinical Impact

57 Appraisal of Systematic Review Paper Group Work Activity 3 Barriers and facilitators to the use of high-technology augmentative and alternative communication devices: a systematic review and qualitative synthesis Susan Baxter, Pam Enderby, Philippa Evans and Simon Judge, INT J LANG COMMUN DISORD, MARCH–APRIL 2012, VOL. 47, NO. 2, 115–129

58 Critical Appraisal Tools Randomised Control Trials (RCTs &Non-RCTs) PEDro – P Scale- (Moseley, 1999; Maher et al., 2003) Physiotherapy Evidence Database To rate RCTs and Non-RCTs, not for SR, case-series, SSED 11 item scale, score 1 or 0 (based on info. found in the paper) 1 st criterion - external validity internal validity Max.10, Min 0 (RCT=10, Non-RCT=8) Rated for methodological quality- sources of bias A high rating does not reflect relevance to practice

59 Critical Appraisal Tools McMaster Forms- Developed by Law et al., 1998, Letts et al., Quantitative Review Form: –Was the sample described in detail? –Were the outcome measures reliable? –Was intervention described in detail? –Were the analysis methods appropriate? Qualitative Review Form: (ver 2.0, Letts et al., 2007) –Was sampling done until redundancy in data was reached? –Was the process of transforming data into themes described adequately? –Was member checking used to verify findings?

60 Appraisal of a Qualitative Study Group Work Activity 4 A Qualitative Analysis of Interactions of Children who use Augmentative and Alternative Communication ANETT SUNDQVIST* and JERKER ROONNBERG Augmentative and Alternative Communication, December 2010 VOL. 26 (4), pp. 255–266

61 References Auperin, A., Pignon, J.-P., & Poynard, T. (1997). Review article: critical review of meta-analyses of randomized clinical trials in hepatogastroenterology. Aliment Pharmacological Therapy, 11, 215 Maher, CG., Sherrington, C., Herbert, RD., Moseley, A., & Elkins, M. (2003). Reliability of the PEDro scale for rating methodological quality of randomised controlled trials. Physical Therapy, 83, Moseley, AM., Maher, C., Herbert, RD., Sherrington, C. (1999). Reliability of a scale for measuring the methodological quality of clinical trials. Proceedings of the VIIth Cochrane Colloquium, Rome, Italy: Cochrane Centre, p.39. Richardson, W., Wilson, M., Nishikawa, J., & Hayward, R. (1995). The well-built question: A key to evidence-based decisions, ACP Journal Club, 123, A12-A13. Schlosser, R. W., & Raghavendra, P. (2004). Evidence-based practice in augmentative and alternative communication. Augmentative and Alternative Communication, 20(1), Schlosser, R., Wendt, O., Angermeir,K., & Shetty, M. (2005). Searching for evidence in augmentative and alternative communication: Navigating a scattered literature, Augmentative & Alterntaive Communication, 21, Schlosser, R. & O’Neil-Pirozzi, T. (2006). Problem formulation in EBP and systematic reviews. Contemporary issues in communication science and disorders, 33,5-10. Schlosser, R., Koul, R., & Costello, J. (2007). Asking well-built questions for evidence-based practice in augmentative and alternative communication. Journal of Communication Disorders, 40 (3), www.cochrane.org - Cochrane Collaboration - DARE


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