بسم الله الرحمن الرحيم اللهم وفقنا لما تحب و ترضي و لا تکلنا طرفه عينا ابدا

1. بسم الله الرحمن الرحيم اللهم وفقنا لما تحب و ترضي و لا تکلنا طرفه عينا ابدا

2. دکتر محمد کمالی استاديار دانشکده علوم توانبخشی دانشگاه علوم پزشکی ايران www.mkamali.com http://healthedu.blogspot.com kamali@mkamali.com تهران - صندوق پستی 183-17445

3. دومين کنگره کشوري آموزش بهداشت و ارتقاء سلامت زاهدان – آذرماه 1384

4. چند نکته • رسانه ها و آموزش بهداشت • تحقيق کيفي • وضعيت اسلايد ها • عادي شدن نگارش مقالات • فرصت ها در اينترنت • نگرش

5. Evidence-Based Health Education and Health promotion

6. “How do you know that what you do and how you do it really works?” • Holm, 2000

7. How confident are you….. That your interventions do what they are intended to do?

8. Evidence based Medicine

9. Why Did Evidence-Based Medicine Develop? • Wide variations in clinical practice • Some practices must be better than others • Concerns about cost and quality • Gap between research and practice • Up to 40% of clinical decisions are not supported by evidence from research

10. Information Needs and the Research-Practice Gap • Effective treatments are not readily adopted • Too many articles, no one can keep up • Contradictory results (false +/false -) • Most reviews are not systematic; instead are subjective • Ineffective treatments adopted/maintained • Over-reliance on clinical experience • Uncritical acceptance of results of studies • Over-reliance on expert opinion • Pharmaceutical company influences

11. What is evidence-based __ ? …? What is evidence? “…fact or datum which is used, or could be used, in making decision or judgment or in solving a [MCH] problem..” McQueen, 2001

12. What is Evidence-Based Medicine? • “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients” --David Sackett, MD • Blends best available evidence with clinical expertise and patient values • Applies working knowledge of medical informatics and clinical epidemiology to treatment of individual patients

13. Background • EBP comprises 3 components:

14. Patient Preferences Evidence from research Evidence based decision Professional expertise Available resources

15. What Evidence-Based Medicine Is Not • It is not “cookbook medicine:” it requires clinical expertise and takes into account patient preferences and values • It is not cost-cutting: it is about cost effectiveness by eliminating ineffective treatments • It is not primarily about guidelines and pathways: these are not always evidence-based • It is not a “top-down” approach to changing clinician behavior: it empowers clinicians to seek their own answers

16. Basic 5-Step Process of Evidence-Based Medicine • Formulate the question • Search for answers • Appraise the evidence • Apply the results • Assess the outcome

17. Development of EBM • 1990: Dept. of Medicine at McMaster Univ. (Canada) develops new philosophy of medical education -- MDs will rely heavily on research literature rather than textbooks or opinion in approaching patient problems • 1992: JAMA article on new approach • 1993-2000: Evidence-Based Medicine Working Group publishes 25-part series on Users' Guides to the Medical Literature in JAMA

18. Methods of Evidence-Based Medicine • Formulate the question • Patients or problem of interest • Intervention • Control or alternative treatment • Outcome of interest • Search for answers • Appraise the evidence • Apply the results • Assess the outcome

19. Methods of Evidence-Based Medicine • Formulate the question • Search for answers • What type of study best answers the question? • Where can I quickly find the evidence? • Appraise the evidence • Apply the results • Assess the outcome

20. Haynes’s Typology of Research Information (4S) Systems synopses Synopses Syntheses (reviews) syntheses Studies

21. Searching for Answers: The “4S” Approach of HaynesHaynes RB: EBMH 2001;4:47 and ACP Journal Club 2001;134:A11 • Systems (comprehensive resources) • Clinical Evidence (www.clinicalevidence.com) • Collection of evidence-based guidelines • Synopses (structured abstracts) • Evidence-Based Mental Health (http://ebmh.bmjjournals.com/) • ACP Journal Club (www.acpjc.org) • Syntheses (systematic reviews) • Cochrane Database (OVID) • DARE (http://agatha.york.ac.uk/darehp.htm) • Studies (original research)

22. Methods of Evidence-Based Medicine • Formulate the question • Search for answers • Appraise the evidence • Critical appraisal worksheets • Apply the results • Assess the outcome

23. Methods of Evidence-Based Medicine • Formulate the question • Search for answers • Appraise the evidence • Apply the results • Assess the outcome • Patient response to treatment • Clinician’s performance applying methods of EBMH

24. Evidence – Based Practice

25. Background of EBP Practice variations – in line with international recognition that many health care interventions and practices are perpetuated for a number of reasons.

26. Reasons? • Personal preference • Habit and custom • Ritual and routine • What the doctor ordered • That is done in an area – this is the way we do things here • Things have always been done that way

27. Two Different Approaches to Evidence-Based Practice • Clinical practice guidelines • “Top-down” approach • Tell clinicians how to practice • Favored by health care systems • Evidence-based medicine • “Bottom-up” approach • Teach clinicians how to find answers • Favored by medical educators

28. 3- pronged to EBP • EBP is the integration of best research evidence with clinical expertise and client values. When these three elements are integrated, clinicians and clients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life. • Sackett et al, 1996

29. Types of Evidence • Peer reviewed journals • Book Chapters • Case Studies • Clinical Data • Online Resources • Clinical Experience • Expert Opinion • Peer reviewed • Non-peer reviewed

30. Evidence Based Practice Process • Define problem • Find evidence • Appraise evidence • Apply results of appraisal • Evaluate change • Redefine problem

31. Define a problem – SPICE Up Your Life • SETTING – in which context are you addressing the question? • POPULATION – who are the users/potential users of the service? • INTERVENTION – what is being done to them/for them? • COMPARISON – what are your alternatives? • EVALUATION – how will you measure whether the intervention has succeeded?

32. Question formation - PICO • Population (who are the relevant people?) • Interventions or exposures (diagnostic tests, foods, drugs, environmental hazards etc) • Control or Alternative intervention/exposure • Outcome (what are the person-level consequences we are interested in?)

33. Population Who are the relevant people?

34. Intervention What are they exposed to?

35. Alternative or control intervention

36. Outcome (what are the person-level consequences we are interested in?)

37. Focusing Answerable Questions

38. “When did you last search for evidence to support your own practice?”

39. Hierarchy of Effectiveness

40. But what about? Qualitative research Non-research SRs RCTs Audits, surveys etcetera Focus groups, Delphi techniques, Interviews

41. How do we do Evidence-Based Practice? • “Health care is an imperfect science that requires both overarching clinical guidelines and individual judgment in equal parts” • Law, 2001

42. Application to Health Care • Articulate your hypothesis • Ask a target question • Complete a search • Analyze the evidence • Draw conclusions • Implement intervention • Use data to support or adjust your intervention plan

43. Articulate your Hypothesis • Ask questions like: • What are the strengths/concerns? • What intervention are you considering? • What are some potential contraindications?

44. Ask a Target Question • PICO Model • Patient • relevant characteristics of child/student or population • Intervention • strategy or approach you are considering applying • Comparison Intervention • may or may not use this – strategy or approach you want to compare with “I” • Outcome • anticipated benefit from the intervention

45. Complete a Search • Access to university? Access to the internet? • Websites to consider • Medline – www.ncbi.nlm.nih.gov/PubMed • CINAHL (Cumulative Index of Nursing and Allied Health Literature) – www.cinahl.com • PsychInfo – www.psycinfo.com/psycinfo/ • ERIC (Educational Resources Information Center) – www.eric.ed.gov

46. Evidence Based Journals • Evidence Based Medicine • Evidence Based Mental Health • Evidence Based Nursing • Evidence Based Health Care • Effectiveness Matters • Effective Health Care Bulletins • Evidence Based Purchasing • ACP Journal Club • Bandolier

48. Evidence Based Health Care • Formerly known as Evidence-Based Health Policy and Management the principal purpose of the journal of Evidence-Based Health Care is to provide managers with the best evidence available about the financing, organisation and delivery of health care. Appraisal criteria for different types of study design are available from this site.  • http://www.harcourt-international.com/journals/ebhc/

50. How to Complete Search • If unfamiliar with search strategies, consider an online tutorial to learn strategies such as: • Choosing appropriate key words • Narrowing/widening search strategies • Combining words (use of “and”, “or”, etc..) • Online tutorial site: • Centre for Evidence-Based Medicine www.cebm.net/searching.asp