Evidence Based Practice RCS /9/05

Definitions  Rosenthal and Donald (1996) defined evidence-based medicine as a process of turning clinical problems into questions and then systematically locating, appraising, and using contemporaneous research findings as the basis for clinical decisions.  Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) described evidence-based practice as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Definitions  DePalma (2000) further refined the definition of evidence-based practice as a complete process beginning with knowing what clinical questions to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation. The best evidence then must be applied by a clinician with expertise in considering the patient's unique values and needs. The final aspect of the process is evaluation of the effectiveness of care and the continual improvement of the process.  Ottenbacher and Mass (1998) indicated that the “ best evidence ” used to support evidence-based practice is derived from a series of research studies results in an empirical consensus regarding the effectiveness of a treatment approach.

Evidence-Based Practice  Gold standard of best practice in medicine  In medicine, with its positivist scientific methods tradition, the “ gold standard ” for scientific evidence is still randomized clinical trials and the method of choice for determining the cumulative evidence of the effectiveness of a treatment is meta-analysis.  Randomized clinical trials  Meta-analysis

Evidence Based Practice  Steps for the evidence-based practice of medicine by practitioners: 1. Formulate a clear clinical question from a patient's problem. 2. Search the literature for relevant clinical articles. 3. Evaluate (critically appraise) the evidence for its validity and usefulness. 4. Implement useful findings in clinical practice.

A Hierarchy of Levels of Best Evidence  Level 1 evidence is defined as strong evidence from at least one systematic review of multiple well- designed randomized controlled trials.  Level 2 evidence is defined as strong evidence from at least one properly designed randomized controlled trial of appropriate size.  Level 3 evidence is defined as evidence from well- designed trials without randomization, single group pre-post, cohort, time series, or matched case- controlled studies.

A Hierarchy of Levels of Best Evidence  Level 4 evidence is defined as evidence from well- designed non-experimental studies from more than one center or research group.  Level 5 evidence is defined as opinions of respected authorities, based on clinical evidence, descriptive studies, or reports of expert committees.

Related Concepts – Empirically Supported Treatment  APA Division 12 defined empirically supported treatment (EST) as clearly identified psychological treatments shown to be efficacious in controlled research studies with a delineated population.  EST should be evaluated in terms of efficacy (statistical and clinical significance), effectiveness (clinical utility), and efficiency (cost-effectiveness).

Related Concepts – Empirically Supported Treatment  Patterned after the FDA guidelines for approval of new drugs, the APA Div 12 Task Force on the Promotion and Dissemination of Psychological Procedures established two criteria for establishing the empirical validity of a psychotherapeutic approach:  The approach is superior to a placebo or other treatment or  The approach is equal to an established treatment, in at least two studies established by different investigators.

Related Concepts – Meta-Analysis  Meta-analysis is a method used to review research literature based on statistical integration and analysis of research findings.  In treatment effectiveness meta-analysis, the dependent variable is the effect size (i.e., the outcomes or results of each study selected for review transformed into a common metric across studies) and the independent variables are study characteristics (i.e., participants, interventions, and outcome measures).

Related Concepts – Meta-Analysis  Meta-analysis is an effort to review the results of a research domain in quantitative terms. The intent is to identify what significant relationships exist between study features (independent variables) and effect sizes (dependent variable).  Benefits: The benefits of meta-analysis include its ability to:  Synthesize the results from many studies succinctly and intuitively for nonscientific communities,  Illustrate the amount and relative impact of different programs on different criteria for policy decision-making purposes, and  Identify the most effective programs and highlight gaps or limitations in the literature to suggest directions for future research

Related Concepts – Meta-Analysis  A common index of the size of the effect produced by each study is the effect size index g, which is the standardized difference between the sample mean of the treatment group and the sample mean of the control group (Wampold, 2001). A positive score indicates that the treatment group outperformed the control group, and a negative score has the reverse meaning. However, the effect size index g is a sample statistics. As such, it is a biased estimator of the true (i.e., population) effect size.

Evidence-Based Practice: Implications for Rehabilitation Counseling 1. Implications for counseling research – The need for level 1 evidence (empirical supported treatment and meta-analysis) related to the effectiveness of rehabilitation interventions (individual ingredients/components of RC as well as RC as interventions) 2. Implications for practitioners – For practitioners, evidence-based practice is a research utilization issue (ability to judge the quality of an individual research study and a collection of studies, the ability to select the best interventions on an individualized basis, and the ability to search for research information using the Internet and other library tools)

Problems of RC research  A weak theoretical base and poor quality are two major criticisms of rehabilitation research. These two criticisms are inter-related. Bellini and Rumrill (2002) contended that rehabilitation counseling operates essentially atheoretically, with no general theory to account for a significant proportion of the knowledge content of rehabilitation counseling. Their observations are consistent with many rehabilitation scholars (e.g., Arokiasamy, 1993; Cottone, 1987; Hershenson, 1996).

Problems of RC research  The view that rehabilitation counseling has a deficient theoretical base may also due to our failure to adequately distinguish between theories and models.  According to Bellini and Rumrill (2002), theories are more general than models: “…models typically operate at an intermediate level of conceptualization…Model-generated hypotheses are often tied to practical concerns in the role performance of rehabilitation counselors and delivery of services to persons with disabilities.” (p.127).