Evidence-based practice

1. Evidence-based practice A marriage made in heaven Sue Jenkins APA Conference 2013

2. Outline • EBP • What it is, what it isn’t and why do we need it? • Physiotherapy evidence • Impact of research on clinical practice • Barriers to the uptake of evidence • My journey into EBP • Strategies for implementing EBP • New moves – Journal of Physiotherapy

3. EBP – what it is Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sackett 2000)

5. EBP – what it isn’t It is NOT • Cookbook physiotherapy • Mindless application of research findings • Entirely based on RCTs and systematic reviews • Too time-consuming

6. EBP – why do we need it? • Informed decisions about healthcare in order to make the best use of resources • National Health Reform Agreement (2011) • Activity Based Funding

7. Physiotherapy in Australia • Accreditation of entry-level physiotherapy programs • Universities must provide evidence that graduates can apply an evidence-based approach to their own practice • Australian Standards for Physiotherapy • Physiotherapy in Australia uses an evidence-based clinical reasoning process

8. Physiotherapy evidence • PEDro • >25,000 randomised trials, systematic reviews and clinical practice guidelines Absence of evidence ≠ evidence of absence (Altman & Bland 1995)

9. Physiotherapists’ perceptions of the importance of research • Survey of 355 physiotherapists • 171 participants (51% response rate) • Predictors of perceived importance of research • Previous research experience • Being positive about undertaking further research • Postgraduate Degree • Working in hospitals (Grimmer-Somers et al 2007)

10. Impact of research on clinical practice Respiratory physiotherapy following cardiac surgery

11. Cardiac surgery: randomised trials • No effect on important patient outcomes • Addition of DBE or IS to regimen of ambulation + cough (CABG surgery, UK, Jenkins et al 1989) • DBE + cough vs. control (ambulation by nursing staff) (CABG surgery, Australia, Stiller et al 1994) • Removal of DBE from pre-op education + early post-op mobilisation (Cardiac surgery, Australia, Brasher et al 2003)

12. Did the research influence clinical practice? • Why not? • 17 year lag for uptake of research findings (Morris et al 2011) (1Tucker et al 1995, 2Filbay et al 2012)

13. Barriers to the implementation of EBP

14. Knowledge Awareness Barriers to the implementation of EBP in healthcare Motivation Skills Practicalities Acceptance and beliefs

15. Barriers to EBP in physiotherapy • Unaware of what needs to change • Institution • Funding / time • Lack of authority / support • Other healthcare professionals • Published research • Volume / time / skills to appraise • Doesn’t ask the right questions • Statistical vs. meaningful • Conflicting results • Implications unclear • (Fruth et al 2010, Iles & Davidson 2006, Jetteet al 2003)

16. Criticisms of RCTs & systematic reviews • External validity • Single intervention vs. treatment package • Real people are ‘unique’ • How the ‘average’ patient might respond or likely outcome for a group of patients • nof 1 trials! • Systematic reviews – strong conclusion often lacking

17. Recruitment to RCTs % patients recruited * # PAH – pulmonary arterial hypertension, *ongoing trial, (#Calverley et al 2007)

18. My journey into EBP 1991 – King’s College London 1992 – Curtin University

19. Journey cont’d • 1992-97 – F/T academic • 1997 – sought P/T clinical work • Area with strong evidence (pulmonary rehabilitation) • Patient-centred outcomes • Research opportunities • Team of 3 physios (Nola Cecins, Jackie Frankel) • Approached teaching hospitals – 0.3 FTE appt at Sir Charles Gairdner Hospital • 1998 – clinical and research placement (UK)

20. Pulmonary rehabilitation • Symptomatic patients with chronic respiratory disease • Improve physical and psychological condition • Promote long-term adherence to health-enhancing behaviours • Components: assessment, exercise training*, education, behaviour change • Exercise training – LL endurance training (Nici et al 2006)

21. Outcome-based program Charlie's Easy Breathers • 8 week program – exercise + education • Assessment – validated tools, developed highly standardised protocols (6MWT) • Ex training – developed prescription for high intensity LL endurance training • Education • ‘Lectures’ by MDT • Evaluated Lorig self-mx program (Cecins & Jenkins 2001) • Informal education sessions

22. Evaluation of program • Justify ongoing funding • Outcomes (Jenkins et al 2001) • Exercise capacity • HRQoL • Patient satisfaction • Benchmark with international data • Healthcare utilisation • Program costs • Process evaluation • Gradual increase in staff to 0.8 FTE Charlie's Easy Breathers

23. Program database • Report on program outcomes • Generate research questions • Output • 24 conference abstracts • 7 papers • Pilot data – research, grant applications

24. Comparison of program outcomes with international data mean ± SD, MID – minimal important difference *Data from 9 trials - North America, Europe

25. Outcomes – healthcare utilisation • Hospitalisations for acute exacerbations of COPD 12 mths pre-rehab vs. 12 mths post-rehab • RCT (200 patients) (Griffiths et al 2000) • Decrease of 4 bed days per patient rehabilitated • Our program (256 patients) (Cecins et al 2008) • 46%* decrease in number of patients admitted • 62%* decrease in total bed days • *p<0.001

26. Process evaluation – unmet needs • Process evaluation (Cockram et al 2006) • 15% patients unable to attend out-patient program • 2002 – supervised home-based program • Benefits of pulmonary rehab last 6-12 mths(Nici et al 2006) • 1998 – maintenance classes in non-medical facilities (Community Physiotherapy Services) • Maintained gains in 6MWD and HRQoL, reduction in HCU sustained (Cockram et al 2006, Cecins et al 2013)

27. Pulmonary rehabilitation and EBP = A marriage made in heaven Unlike this one!

28. Overcoming barriers to the implementation of EBP • “Change is not made without inconvenience, even from worse to better” Richard Hooker 1554-1600

29. Strategies/drivers for implementing EBP Mentorship - QI, clinical audits, research Education University courses PD, EBP sessions Journal clubs Professional associations • The expert patient • Clinician-led research • NHMRC TRIP Fellowships • Clinicians • Evidence-based clinical pathways • Clinical guidelines / consensus statements • Support from managers, academics

30. Clinical guidelines – stroke rehabilitation • Adherence with recommended management and outcomes (D/C home, increase ≥22 pts FIM score) • (Australian Guidelines for Stroke Rehabilitation & Recovery, 2005) • National audit – 63% response rate • 68 units – 2,119 patient cases • Adherence – 13 to 94% • Improved outcomes when practice adhered to recommendations relating to ADL, balance and home Ax • (Hubbard et al 2012) FIM – Functional Independence Measure

31. Journal of Physiotherapy • Clinical trials – prospective registration (2012) • Trial protocols (2013) • Systematic reviews • High quality, firm conclusions, important clinical implications • Co-publication of condensed Cochrane Reviews • Commentaries – critically appraised papers, clinical guidelines, clinimetrics

32. Importance of EBP in the future • More competition for scare healthcare $$$$$$ • Need robust evidence to sustain our profession • Physiotherapists as leaders among healthcare professions in translating research into clinical practice

33. Acknowledgements • Nola Cecins • Jeffrey Tapper & Ian Cooper, Physiotherapy Department, Sir Charles Gairdner Hospital • Research colleagues and students • Patients • Dr Kathy Stiller

34. Thank you for your attention

35. Sue Jenkins GradDipPhys, PhD Associate Professor & Pulmonary Rehabilitation Physiotherapist School of Physiotherapy and Exercise Science Email | S.Jenkins@curtin.edu.au Phone | +61 8 9266 3639

36. Citations for images Slide 4 http://www.cancer-clinical-trials.com/p/clinical-trials-in-cartoons.html#.UljzXODcK5. [accessed 11.10.2013] Slide 10 http://www.universityhospital.kramesonline.com.253151.img. [accessed 10.10.2013] Slide 13 http://www.graphics8.nytimes.com/images/2012/08/08/sports/HURDLES2/HURDLES2-article.jpg[accessed 10.10.2013] Slide 18 http://www.abc.net.au/news/image/4892924-16x9-940x529.jpg. [accessed 10.10.2013]  Slide 23 http://www.lungfoundation.com.au/wp-content/uploads/2012/06/COPDPatientGuide2012_chapt_10. [accessed 10.10.2013]  Slide 27 http://www.resources2.news.com.au/images/2011/10/12/1226164/643242.jpg. [accessed 10.10.2013]

37. References Altman DG, Bland JM (1995): Absence of evidence is not evidence of absende. British Medical Journal 311: 485 Australian Physiotherapy Council. Australian Standards for Physiotherapy. http://www.physiocouncil.com.au/files/the-australian-standards-for-physiotherapy. [Accessed 19.9.2013]. Brasher PA, McClelland KH, Denehy L et al (2003): Does removal of deep breathing exercises from a physiotherapy program including pre-operative education and early mobilisation after cardiac surgery alter patient outcomes? Australian Journal of Physiotherapy 49: 165-73. Calverley PMA, Anderson JS, Celli B et al (2007): Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. New England Journal of Medicine 336: 775-89. Cecins N, Geelhoed E, Jenkins SC (2008): Reduction in hospitalisation following pulmonary rehabilitation in patients with COPD. Australian Health Review 32: 415-22. Cecins N, Jenkins S (2001): Evaluation of an education program for patients with COPD. Australian Journal of Physiotherapy 2001; 47: 283.

38. Cecins N, Jenkins S, Cockram J (2013): Community-based maintenance (Phase 3) pulmonary rehabilitation – uptake, attrition and hospitalisation. Respirology; 18: A52. Cockram J, Cecins N, Jenkins S (2006): Maintaining exercise capacity and quality of life following pulmonary rehabilitation. Respirology 11: 98-104. FilbaySR, Hayes K, Holland AE (2012): Physiotherapy for patients following coronary artery byass graft (CABG) surgery: Limited uptake of evidence into practice. Physiotherapy Theory and Practice 28: 178-87. Fruth SJ, Van VeldRD, Despos CA et al (2010): The influence of a topic-specific, research-based presentation on physical therapists' beliefs and practices regarding evidence-based practice. Physiotherapy Theory and Practice 26: 537-57. Grimmer-Somers K, Lekkas P, Nyland L et al. (2007): Perspectives on research evidence and clinical practice: a survey of Australian physiotherapists. Physiotherapy Research International 12: 147-161. Griffiths TL. Burr ML, Campbell IA et al. (2000): Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. The Lancet 355: 362-8.

39. Hubbard IJ, Harris D, Kilkenny MF et al. (2012): Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice. Archives of Physical Medicine and Rehabilitation 93: 965-71. Iles R, Davidson M (2006): Evidence based practice: a survey of physiotherapists’ current practice. Physiotherapy Research International 11: 93-103. Jenkins SC, Cecins NM, Collins GB (2001): Outcomes and direct costs of a pulmonary rehabilitation service. Physiotherapy Theory and Practice 17: 67-76. Jenkins SC, Soutar SA, Loukota JM et al. (1989): Physiotherapy after coronary artery surgery: are breathing exercises necessary? Thorax 44: 634-9. Jette DU, Bacon K, Batty C et al (2003): Evidence-based practice: Beliefs, attitudes, knowledge and behaviours of physical therapists. Physical Therapy 83: 786-805. Journal of Physiotherapy. http://www.physiotherapy.asn.au/JOP/Homenav/About_JoP.aspx [Accessed 19.9.2013]. Morris ZS, Wooding S, Grant J et al. (2011): The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine 104: 510-20.

40. Nici L, Donner C, Wouters E et al. (2006): American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine 171: 1390-1413. PEDro Physiotherapy Evidence Database. http://www.pedro.org.au/ [Accessed 10.9.2013]. Puhan MA, Mador MJ, Held U et al. (2008): Interpretation of treatment changes in 6-minute walk distance in patients with COPD. European Respiratory Journal 32: 637-43. Sackett DL, Straus SE, Richardson WS et al (2000): Evidence-based medicine: How to practice and teach EBM. Edinburgh: Churchill Livingstone, pp. 3-4. Stiler K, Montarello J, Wallace M et al. (1994): Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery. Chest 105: 741-7. Tucker B, Jenkins S, Davies K et al. (1996): The physiotherapy management of patients undergoing coronary artery surgery: A questionnaire survey. Australian Journal of Physiotherapy 42: 129-37.