1. What is E3BP? How do you integrate the findings from CAPs/CATs into everyday clinical practice? Elise Baker, Ph.D. The University of Sydney NSW SPEECH PATHOLOGY EBP NETWORK EBP EXTRAVAGANZA, 9 th December 2009 Sydney Children’s Hospital, Randwick, Lecturer Theatre

2. Outline What is EBP? Is EBP really a regular part of clinical practice? What is E 3 BP? Guidelines for conducting E 3 BP

3. What is evidence-based practice (EBP)? From: http://www.asha.org/members/ebp/default 10/23/08http://www.asha.org/members/ebp/default Current best evidence Client’s values Clinical expertise

4. However, EBP “has not become a regular part of clinical practice”. Brackenbury, Burroughs and Hewitt (2008, p. 78)

5. Why?  Lack of time to search for, read and critique published evidence relevant to every clinical decision  Too much information  Aphasia therapy – 220,000 hits  Dysphagia treatment – 3,290 000  Voice therapy – 2,760 000  Phonology therapy – 1,050 000  Too little information - how many systematic reviews have you come across in your search for evidence?

6. Why?  Need time and resources to develop efficient searching skills  Even then….Brackenbury et al., (2008) reported that “it is doubtful that most SLPs can afford to take 3 to 7 (or more) to provide evidence for each of the clinical decisions that must be made” (p. 85).

7. Why?  Have found, read, critiqued the research... the findings may not be easily applied to clinical practice  O’Conner and Pettigrew (2009) reported that half their participants did not feel that research results were generalizable to their own setting.

8. Why?  EBP has been thought of as simply using research to justify an intervention approach.  Sense that ….“until EBP came along, clinicians were basing their clinical decisions on something other than evidence, which is simply not true” (Dollaghan, 2007, p. 1)

9. Why?  How many clients/patients in the past week have you...  Searched for and answered a clinical question (or known the answer to a clinical question based on work you have done on a CAP or CAT?)  Provided the client / patient with the information necessary to make an informed choice

10. Outline What is EBP? Is EBP really a regular part of clinical practice? No….not completely. What is E 3 BP? Guidelines for conducting E 3 BP

11. What is E 3 BP? “the conscientious, explicit, and judicious integration of 1. best available external evidence from systematic research, 2. best available evidence internal to clinical practice, and 3. best available evidence concerning the preferences of a fully informed patient” (Dollaghan, 2007, p. 2)

12. What is E 3 BP? Best external evidence Best internal evidence (from client factors & preferences) Best internal evidence (from client factors & preferences) Best internal evidence (from clinical practice) Best internal evidence (from clinical practice)

13. External published evidence To date, our CAPS seem to focus primarily on the level of identified evidence To facilitate the integration of difference sources of evidence we need to:  Consider the validity of the evidence and...  Consider the importance of the evidence  Effect size  Precision  Practical significance (Based on Dollaghan, 2007)

14. Yeah but..... I can’t exactly replicate that in my service Gap between what is possible and what is practical

15. Internal evidence from clinical practice Internal evidence about what is possible in your clinical practice However....determining what is possible in clinical practice is a challenging task, as, “our strong preferences for what we already believe to be true makes us poor judges of whether it is actually true” (Dollaghan, 2007, p. 3).

16. Internal evidence from clinical practice It is perhaps, best derived from the systematic and regular collection and analysis of clinical case-based outcome data. How are you currently doing this? Could you compare your outcomes with another colleague?

17. Internal “client” evidence: client factors, values and preferences  Client factors  ICF / ICF-CY frameworks (integrated impairment and socially- based perspective)  structure,  function  activity and participation  environmental factors and Personal factors – that could act as barriers or facilitators  Client values and preferences Consider – Is there any external published evidence on client factors? Consider – Is there any external published evidence on client factors?

18. Outline What is EBP? Is EBP really a regular part of clinical practice? No….not really. What is E 3 BP? How to conduct E 3 BP

19. How can individual clinicians incorporate EBP in a meaningful and realistic manner? (Brackenbury, Burroughs, & Hewitt, 2008)

20. 7-Step process for engaging in E 3 BP (Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006) STEP 1. Pose a “PICO” question (Patient, Intervention, Comparison, Outcome) “In children with a phonological impairment and no other concomitant conditions, does the Hodson (2007) cycles approach lead to significantly greater gains in percent consonants correct as compared with the Williams (2010) multiple opposition approach?” STEP 1. Pose a “PICO” question (Patient, Intervention, Comparison, Outcome) “In children with a phonological impairment and no other concomitant conditions, does the Hodson (2007) cycles approach lead to significantly greater gains in percent consonants correct as compared with the Williams (2010) multiple opposition approach?” STEP 2. Search for external evidence Use electronic databases – SpeechBITE; HighWire Press via ASHA membership, ERIC, Medline, Cochrane…. STEP 2. Search for external evidence Use electronic databases – SpeechBITE; HighWire Press via ASHA membership, ERIC, Medline, Cochrane…. (Based on Baker & McLeod, 2008)

21. 7-Step process for engaging in E 3 BP (Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006) STEP 3. Evaluate the external evidence Consider the validity and importance of the evidence STEP 3. Evaluate the external evidence Consider the validity and importance of the evidence (Based on Baker & McLeod, 2008)

22. STEP 4. Evaluate the internal client evidence Use the ICF and/or ICF-CY framework Consider your client / patient’s activity and participation Consider the family beliefs and cultural values, financial resources, and informed preferences STEP 4. Evaluate the internal client evidence Use the ICF and/or ICF-CY framework Consider your client / patient’s activity and participation Consider the family beliefs and cultural values, financial resources, and informed preferences International Classification of Functioning Disability and Health – Children and Youth (WHO, 2007) 7-Step process for engaging in E 3 BP (Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006) (Based on Baker & McLeod, 2008)

23. STEP 5. Evaluate your internal clinical evidence Think about what you currently do and why Think about the efficiency of your intervention How do your outcomes compare with the research? How do your outcomes compare with your colleagues or other similar departments? STEP 5. Evaluate your internal clinical evidence Think about what you currently do and why Think about the efficiency of your intervention How do your outcomes compare with the research? How do your outcomes compare with your colleagues or other similar departments? 7-Step process for engaging in E 3 BP (Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006) (Based on Baker & McLeod, 2008)

24. Remember…. “our strong preference for what we already believe to be true makes us poor judges of whether it is actually true… …E3BP requires honest doubt about a clinical issue, awareness of one’s own biases, a respect for other positions, a willingness to let strong evidence alter what is already known, and constant mindfulness of ethical responsibilities to patients” (Dollaghan, 2007, p. 3). “our strong preference for what we already believe to be true makes us poor judges of whether it is actually true… …E3BP requires honest doubt about a clinical issue, awareness of one’s own biases, a respect for other positions, a willingness to let strong evidence alter what is already known, and constant mindfulness of ethical responsibilities to patients” (Dollaghan, 2007, p. 3). (Based on Baker & McLeod, 2008)

25. STEP 6. Make a decision by integrating your three sources of evidence STEP 7. Evaluate the outcome of your decision Did it work? What is efficient? (This adds to your own internal clinical evidence) STEP 7. Evaluate the outcome of your decision Did it work? What is efficient? (This adds to your own internal clinical evidence) (Based on Baker & McLeod, 2008) 7-Step process for engaging in E 3 BP (Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)

26. Where to from here?  E 3 BP and the NSW EBP Network  Implications –  Focus of current CAP is on external evidence  Could we develop “CAPs” for internal clinical and client evidence?  How might they be used within clinical groups?

27. QUESTIONS AND DISCUSSION Elise: e.baker@usyd.edu.aue.baker@usyd.edu.au