Effective evidence-based occupational therapy An inspiring implementation challenge Dr. Esther Steultjens

Where systematic reviews lead me

Systematic reviews by Steultjens et al. Efficacy of OT for RA Efficacy of OT for stroke Efficacy of OT for MS Efficacy of OT for children with CP Efficacy of OT for community dwelling elderly Overview of systematic reviews Steultjens E, 2002, 2003, 2004, 2005 indexed in Pubmed

Conclusions PhD thesis Evidence in OT exists! High methodological quality studies show efficacy of OT interventions There are evidence gaps Systematic (Cochrane) reviews can be performed in OT Methodological challenges occur Steultjens E, 2005. NIVEL VU University Amsterdam NL

OT practice High quality OT is: Effective Client centred Evidence based Occupation based Efficient

Content From systematic review to evidence-based guideline Into systematic reviews Best Practice

Guidelines level 1 Using meaningful activities as tool in OT treatment leads to higher functional abilities and participation. Training self-maintenance activities does not lead to better performance in leisure activities Leisure activities need to be trained to raise satisfaction with performing leisure activities

Themes Client centeredness Occupational performance Multi-disciplinary collaboration Caregivers and social context Organisation of healthcare

One year after dissemination Changes in OT practice One year after dissemination 60% active implementation of client centeredness 70% active implementation of occupation based treatment Focus on caregiver, multi-disciplinary collaboration, organisation of care need more attention Implementation Stroke OT guideline, 2006, HVA, Amsterdam

3 years after dissemination Changes in OT practice 3 years after dissemination 70% implemented guideline 90% changed practice 98% use meaningful activities as treatment tool 90% collaborates with client and caregiver in treatment goal decision Evaluating the stroke OT guideline, 2008, HVA, Amsterdam

Conclusion Systematic reviews change practice OT becomes more Client centred Evidence-based Occupation-based Efforts in developing and implementing guidelines are necessary.

Into systematic reviews From chaos to confidence

Experienced difficulties with Evidence-based Practice 53% perceive using evidence as requiring too much effort 70% reported difficulty in evaluating quality of evidence as greatest barrier 60% did not think research is written in an understandable manner C. Döpp et al, 2008

Systematic review Research question relevant to practice Inclusion criteria stated Patient characteristics Intervention or situation characteristics Comparison intervention or situation Outcome Search strategy replicable Databases searched Keywords used Dates of search

Systematic review Inclusion process reliable Transparent Independent Data extraction process reliable Presentation of key characteristics Synthesis process transparent Description of statistical analyses and best evidence syntheses Implications for practice

An example Steultjens et al. Efficacy of OT for MS (Cochrane review). first published 2003, issue 3 Baker et al. The effectiveness of physical, psychological and functional interventions in treating clients with multiple sclerosis: a meta-analyses. Am J Occup Ther. 2001;55:324-331

An example Efficacy of OT treatment vs efficacy of OT related treatment Inclusion criteria: Clear definition of OT vs multidisciplinary, physical, psychological and social work interventions Searches till December 2002 vs searches till 2000 Inclusion of: 3 studies (1 RCT, 1CCT, 1 not controlled design) vs 23 studies (RCT and CCT only)

Conclusion inclusion of literature Big differences between reviews Results based on 3 studies evaluating specific OT interventions Results based on 23 non-specific OT related interventions

An example 2 Qualitative best-evidence synthesis for 3 studies incorporating heterogeneity Meta-analyses of 23 studies without addressing issue of heterogeneity

Implications for practice? An example 2 No conclusions can be stated whether occupational therapy improves outcome in multi-sclerosis patients Overall medium effect size of 0.52 Implications for practice?

A professional reasoning perspective Best Practice A professional reasoning perspective

Implementation phases Acquiring new knowledge Knowing acquired change Positive attitude to change Changing process Established new care

Professional reasoning Process of OT treatment Content of OT treatment Decision making process Explicit Professional reasoning

Explicit reasoning model Thinking: When What HOW

Evidence-based decision Bio-psychosocial state CCEBE-Model Client society society Evidence-based decision Experience and expertise of client and therapist Bio-psychosocial state Scientific evidence society Logister, 2007

Who is the OT?

Self-esteem