Research for practice – the origins and importance of Evidence-based Practice (EBP)

1. Research for practice – the origins and importance of Evidence-based Practice (EBP) Getting research findings into the working environment

2. Aim To understand the importance of evidence based practice in healthcare

3. Objectives • To consider the role of evidence-based practice (EBP) in healthcare delivery • To comment on the research-based resources to incorporate into practice • To understand the constraints associated with EBP

4. So what is not EBP? • Healthcare decisions based on: • Tradition • Routine • Opinions and personal preferences • EBP aims to: • Do the right things in the right way • Consider resources • Base healthcare decisions on sound evidence of the effectiveness of interventions

5. So what is EBP? ‘the conduct of healthcare according to the principle that all interventions should be based on the best available scientific evidence’ (Wallace et al, 1997) ‘evidence based healthcare integrates the best evidence from research with clinical expertise, patient preferences and existing resources into decision making about the healthcare of individual patients’ (DiCenso et al 1998)

6. So why is EBP a priority now? • Changing health care demands • A growing and ageing population • New knowledge and new technology • Consumer knowledge and expectations • (Government driven) healthcare policy aimed at reducing inequalities in NHS care • Concerns with effective use of resources and effectiveness of treatments or interventions

7. So what are the first steps in EBP? • Find the evidence • Review the evidence (critical appraisal) • Use the evidence (e.g.) • Share information with a workgroup and or patients (dissemination) • Incorporate the evidence into your practice (implementation)

8. So where do we get our evidence from? • Textbooks • Peer reviewed professional Journals Bibliographic databases e.g. Cinahl & Medline • Distilled (already reviewed) information sources Bandolier, Hitting the Headlines (via the National Electronic Library for Health) http://www.nelh.nhs.uk/hth/statin_drug.asp

9. So where do we get our evidence from? • Consolidated Information Sources e.g. Systematic Reviews & Meta Analyses - see the Cochrane Collaboration and NICE (National Institute for Health and Clinical Excellence) http://www.nice.org.uk • The Internet but not via Google (caution re quality and rigour of any web based material) • Also conferences and study days (again use caution)

10. We all are We have to ask about the evidence which underpins action and decisions in healthcare practice Who is responsible for EBP?

11. But what constitutes evidence? A ‘Hierarchy’ of different types of evidence (Muir-Gray 1997) Type Strength of Evidence I Strong evidence from at least one systematic review of multiple well-designed randomised controlled trials (RCT’s) II Strong evidence from at least one properly designed RCT of appropriate size III Evidence from well designed trials without randomisation, single group pre & post, cohort, time series or matched case control studies IV Evidence from well designed non-experimental studies from more than one centre or research group V Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees

12. So what about the MMR issue? • Established practice since 1988 in the UK MMR vaccine administered between 12 and 18 months • Wakefield et al (1998) suggested a link with Autism and a form of inflammatory bowel disease • Level of evidence? Level V • Sample size (n=12) representativeness? • Study reviewed by other researchers (1998 on) and the Medical research Council (2001)

13. So what about the MMR issue? • Findings of Wakefield et al (1998) challenged both in terms of the quality of the research (methods) and the strength of the evidence (absence of a causal link) • Findings of large scale epidemiological studies consistently finding no evidence of a causal link (Gillberg & Heijbel, 1998; Peltola et al, 1998; Taylor et al, 1999; Honda, 2005). Level of evidence III and IV

14. So what about the MMR issue? • So given the controversy professionals (and parents) have to make decisions on MMR vaccine administration • Where can you find guidance? • Department of Health MMR Information Pack 2005 (http://www.dh.gov.uk ) • MRC report (2001)

15. What are the barriers to implementing evidence based practice? • Organisational and professional culture • Individual Interest • Support (within organisations) • Psychological resistance from practitioners • Lack of confidence in non-medical research • Time and other resources

16. So how do we overcome these barriers? • Leadership and status e.g. consultant and advanced practitioner grades • Research strategies in an inter-professional environment • Recognising the link between research and practice • Education and training in EBP

17. Objectives • To consider the role of evidence-based practice (EBP) in healthcare care delivery • To comment on the research-based resources to incorporate into practice • To understand the constraints associated with EBP