Presentation on theme: "Connective Solutions 21/08/2012"— Presentation transcript:
1 Connective Solutions21/08/2012Evidence-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 SciencesFlinders University, AustraliaISAAC-Israel Annual National AAC Conference, Tel Aviv8 June 2014All day workshopEmma Grace
2 EBP Workshop, Northcott, Sydney 2/11/2009Workshop OutlineWhat is EBP?What does EBP mean for individuals who use AAC and other stakeholders?Steps involved in EBP – 7 stepsAsking a clinically relevant & answerable questionSearching for the evidenceCritically appraising the evidenceCollating & synthesising the evidence5. Implementing the evidence into practice6. Evaluating the use of the evidence7. Disseminating the EBP process & findingsFacilitators and barriers to EBPPractical Suggestions to implement EBPNature and extent of evidence in AACWhat can you do to add evidence to the AAC field?
3 EBP Workshop, Northcott, Sydney 2/11/2009Evidence Based Practice(EBP)What is it?
4 Background to Evidence-based Medicine (EBM) Archie Cochrane ( )The Cochrane CollaborationDavid 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.
9 What is Evidence Based Practice? – Key concepts Integration = joining / synthesis of bestresearch evidenceclinical expertisestakeholder perspectives (patient values)(Schlosser & Raghavendra, 2004)
10 Key concepts continued… Best research evidence =Data : current, verified and replicatedHigh internal validityHighest level on hierarchy of evidenceAdequate external validity and social validity(Schlosser & Raghavendra, 2004)
11 Key concepts continued… Clinical expertise = reasoning, intuition, knowledge and skills related to clinical skillsEducational 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 interventionPatient/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 existsEBP declares research evidence the authorityEBP 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 relativeSome practitioners do implement EBPEBP in medicine/AAC definition-all 3Not always trueEBP requires not only extensive clinical expertise but also skillful integration of all 3 aspects of EBPsome degree of EBP by all.
14 EBP Workshop, Northcott, Sydney 2/11/2009What 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 outcomesActive participants in decision making(ASHA, 2004)
15 What does EBP mean for a practitioner/educator? EBP Workshop, Northcott, Sydney2/11/2009What does EBP mean for a practitioner/educator?Best PracticeUse of EBP as a framework for best practice,Promotes development of skills in finding, appraising and implementing evidenceEmphasises need for high level clinical & communication skillsProvides a framework for self-directed, life long learningEthical principle: To provide the best available services (assessments & interventions) to consumers & familiesPractice-research gap
16 What does EBP mean for a service provider/ an organisation? Best Practice at Organisational levelWhat 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 servicesFacilitate/support to implement EBP
17 What does EBP mean for researchers? EBP Workshop, Northcott, Sydney2/11/2009What does EBP mean for researchers?Excellent opportunity to bridge research-practice gapHigh priority clinical questions in diagnostics, screening, prognosis, interventionConduct high quality researchDisseminating research in way that can be used in practice
18 How do you do EBP? Adapted from Schlosser & Raghavendra (2003) Asking the clinically relevant & answerable questionSearching for the evidenceCritically appraising the evidenceCollating & synthesising the evidenceImplementing the evidence into practiceEvaluating the use of the evidenceDisseminating the EBP process & findings
19 Step 1: Ask an clinically relevant & answerable question EBP Workshop, Northcott, Sydney2/11/2009Step 1: Ask an clinically relevant & answerable questionBroad or general questionsprovide background informationSystematic reviewe.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/ProblemInterventionComparison or ControlOutcome
21 PICO To clarify the questions related to specific clients To develop questions for Systematic ReviewsTo identify the information needed to answer the questionTo translate the question into searchable termsTo develop and refine your search strategy
22 Patient / Population/Problem Characteristics of the population e.g age, gender, diagnosis, ethnic group etcHow 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 ControlWhat alternative or other option are you comparing your intervention/assessment to?Be specificYou may be comparing your intervention to another intervention, or to no intervention
25 OutcomeWhat measurable outcome(s) are you interested in? What are you hoping to achieve for the client?Be specific
26 ELEMENT SUBJECT KEY WORDS P I C O School aged children with cerebral palsy, complex communication needsChildChildrenSchool aged, 12-13, primary school, transition, high schoolPaediatric/paediatricCerebral palsy, physical disability, spasticity, hemiplegic, CCN, AAC, severe communication/speech impairment,IGroup-Peer training of high school students (workshops)Peers, classmates, training, communication, supportCVisit by student with CCN plus trainingOIncreased acceptance, welcoming classroom, social networksSocial networks, friends, friendships,
27 Ask an clinically/service relevant answerable question using PICO Group Work Activity 1Ask an clinically/service relevant answerable question using PICO
29 An example (Schlosser, Koul & Costello,2007) Person/problemEnvt.StakeholdersInterventionComparisonOutcomesIn a 7 year-old boy with profound ID who exhibits self-injurious behavr.Who is currently in a self-contained classroomAnd whose teacher and aides suspects that his behaviour is communication basedIs it sufficient to rely on informant-based assessment methodsOr is it necessary to also conduct descriptive and experimental assessmentsIn order to identify the communicative functions that maintain his problem behavr. In a valid and reliable manner/
30 Ask an clinically/service relevant answerable question using PESICO Group Work Activity 2Ask 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 timeAvailable databasesSubject matter and domain of the questionCurrency 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 reviewsPrimary research – individual research studiesGrey literature e.g. unpublished research, thesesIndexes and databasesGeneral eg CINAHL, Medline, PubMed, ERICSpecialist e.g. Cochrane Library, DARE, PEDro
34 Where do I search? Finding the evidence Hand searchesTable of contentsAncestry search- use reference list and identify other studiesForward citation search-who has referred to a particular article?Finding evidence on the InternetGeneral search engines, e.g., GoogleSpecialised Search engines, Google Scholar
35 Types of Databases Bibliographic/General eg Medline PubMed Specialist DatabasesERICCINAHLPsyInfo
36 Databases – Full Text/Specialised DARE- Database of Abstracts of Reviews of Effects (UK)Cochrane- Cochrane Database of SR (Worldwide)Expanded Academic ASAPScience DirectSCOPUS
37 Strategies for searching databases Plan the research, efficiencyCreate a search planSelect and access the right databasesDevelop a search statementLimit, refine and evaluateLocate 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 studies3) 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 pregnancyTruncation – symbols used to substitute for characters at the end of a word e.g Ovid uses “$”example: child$ will give children, childlikeWildcards – symbols used to substitute for a letter within a word e.g Ovid uses #example: wom#n will give woman and womenCheck Help Screen for each database
40 Keyword SearchingKeywords – important words that represent a topic. Have no control over how a word is used in the documentThe use of quotation marks is useful for example “intellectual disability”Fields – eg author, title, abstract, journalLimits – by date, by language, to full text, to abstracts, Systematic reviews
41 Hierarchy of Evidence http://gollum. lib. uic. edu/applied_health/ Hierarchy of Evidence University of Illinois at Chicago
42 b) Quasi-experimental group designs 2a. One well-designed non RCT, Connective Solutions10/10/2013Proposed hierarchy of evidence to inform intervention development & selection: Participants with disabilities (Schlosser & Raghavendra, 2004)Meta-analysis ofa) RCTs*, b)SSED,b) Quasi-experimental group designs2a. One well-designed non RCT,2b. 1 SSED-1 intervention,2c. 1 SSED-multiple interventions……..3. Quantitative reviews that are non-meta-analytic4. Narrative reviews5. Pre-experimental group designs & Single case studies6. Respectable OpinionEACD, Raghavendra et al., 2013
43 Levels of EvidenceBased on the idea that different grades of evidence (study designs) vary in their ability to predict the effectiveness of the health practicesReducing biases-Sample, Measurement/detection, Intervention/PerformanceHigher grades of evidence are more likely to reliably predict outcomes than lower gradesIs 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? EBP Workshop, Northcott, Sydney2/11/2009What are Systematic Reviews?A synthesis of original researchPre-filtered evidenceA 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 replicationPre-defined, explicit methodology is used,strict protocol to inlcude as much relevant researchoriginal studies apparised and synthesised in a valid wayMinimise risk of bias
46 Systematic ReviewMeta 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)Cochrane CollaborationCampbell CollaborationWhat Works Clearinghouse (US Department of Education)Psychological Database for Brain Impairment Treatment EfficacyNational Electronic Library for Health (National Health Service of the UK)Evidence-based Communication Assessment and Intervention (EBCAI) JournalSpeech 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 findingsapplicable in mySetting?Is the quality of thestudy good enough touse the results?What do the resultsmean for my clients?
51 Difference between reading for content vs Difference between reading for content vs. reading for critical appraisalAbstractIntroduction (background, literature review), aims of the studyMethodologyResultsDiscussionAbstractIntroduction (background, literature review), aims of the studyMethodologyResultsDiscussion
52 Type of StudyThe next step is to work out what study design will best answer your questionLevels of Evidence – reflect the methodological rigour of the study
53 Type of QuestionDifferent types of questions are best answered by different types of studiesYour 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 participantExplore what factors influenced outcomes at one point in timeDescribe experiences……ExperimentalObservational-Cohort/case-controlCase StudyCross-sectionalQualitative
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-raterVALIDITY (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)ProtocolSource selection biasTrial selection, criteria for poolingStudy qualityData extractionStatistical analysisClinical Impact
57 Appraisal of Systematic Review Paper Group Work Activity 3Barriers and facilitators to the use of high-technology augmentative and alternative communication devices: a systematic review and qualitative synthesisSusan 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 DatabaseTo rate RCTs and Non-RCTs, not for SR, case-series, SSED11 item scale, score 1 or 0(based on info. found in the paper)1st criterion - external validityinternal validityMax.10, Min 0 (RCT=10, Non-RCT=8)Rated for methodological quality- sources of biasA high rating does not reflect relevance to practice
59 Critical Appraisal Tools McMaster Forms- Developed by Law et al., 1998, Letts et al., 2007Quantitative 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 4A Qualitative Analysis of Interactions of Children who use Augmentative and Alternative CommunicationANETT SUNDQVIST* and JERKER ROONNBERGAugmentative and Alternative Communication, December 2010 VOL. 26 (4), pp. 255–266
61 References www.york.ac.uk - DARE 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, 215Maher, 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),- Cochrane Collaboration- DARE
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