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Irish Evaluation Network. Finding and Using Evidence: The Healthcare Experience. Prof. Seamus Cowman Royal College of Surgeons in Ireland December 2005. How do we know what we do and the decisions we make are derived from best practice? The importance of evidence in making decisions

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Irish Evaluation Network

Finding and Using Evidence: The Healthcare Experience

Prof. Seamus Cowman

Royal College of Surgeons in Ireland

December 2005

central thesis of the paper
How do we know what we do and the decisions we make are derived from best practice?

The importance of evidence in making decisions

Determine a process of finding and validating knowledge for use in day to day activities

Research based knowledge is fundamental to effectiveness and valid and reliable outcomes

Central thesis of the paper
evaluation finding and using evidence the links
Evaluation: what is said

A means of systematically collecting and analysing of information.

Purpose of evaluation is to improve effectiveness – activities and outcomes

Necessary not only to improve practice but prove it

Inevitably concerned with decision making

Evaluation finding and using evidence – the links
Decision making often based on values and opinion:

Confusion about best practice

The Importance of Evidence

Public Expectation & Consumerist ethos

Quality Assurance, User Satisfaction

Accountability and efficient use of available resources

The Importance of Evidence

Patients as informed consumers want more, expect more and complain more

The Importance of Evidence

Research utilisation is a ‘systematic method of implementing sound, research based innovations in clinical practice, evaluating the outcomes and sharing the knowledge through the process of research dissemination.’

(LoBiondo-Wood & Haber, 1994)

Research Utilisation



Lack of focus on outcomes research

Inadequate dissemination of research findings

Failure to maximise potential avenues for dissemination eg; on line, Internet, Intranet

Research Utilisation

Policy makers rarely signal a demand for research, many appear allergic to research and pay lip service to evidence based policy; even when there is an appetite for change

Pestieau 2003

Research Utilisation

It has proved difficult to uncover many instances where social sciences research has had a clear and direct influence on policy even when it has been specifically commissioned by government

Quinn Patton 1997

Research Utilisation

Communication gap between researcher and practitioner

Findings communicated primarily to other researchers

Practitioner may not value research findings

Barriers to Research Utilisation

Researcher originated studies

Policy making perceived exclusively as an art rather than a science.

Practitioners and decision makers do not know how to apply research findings

Barriers to Research Utilisation

In a study with medical doctors, therapy issues and critical appraisal of literature on appropriate clinical practice only 5 out of 36 searched the Cochrane library, appraisals were sometimes inaccurate.

When article was retrieved for appraisal usability was found to be high

Information Retrieval

In a nursing study it was reported that it is not the research knowledge per se that carries little weight in the clinical decision making process but rather the medium through which it is delivered and the process of retrieval

(Thompson et al 2001)

Information Retrieval

The average time span between discovery and utilisation is 20 years

Decrease in time for utilisation of discoveries

1185 - 1919 30 years

1945 – 1965 17 years

The Time Lag

the time lag
The Time Lag

(Glaser et al 1983) Putting knowledge to use Jossey Bass.

Collaborate with Practitioners

Disseminate Research Findings Aggressively

Communicate in a way comprehensible to non researchers

Suggest practical implications, how can findings be utilised

Message for Researchers

Read widely and critically online searching of www and data bases – Start up a Journal Club: Create a learning culture

Attend professional conferences/seminars

Learn to expect evidence that a procedure is effective

Collaborate with researcher

Participate/initiate institutional projects

Message for Practitioners/decision makers

Foster a climate of intellectual curiosity

Offer support and facilitation to researchers

Offer financial support and resource support for utilisation

Reward efforts of research utilisation

Support an Evidence Based Practice culture

Message for Administrators


Finding Best Evidence

  • Too much information available
  • Literature reviews can be biased

Cochrane Collaboration (2003)


Finding Best Evidence

  • Publication Bias
        • Time lag bias
        • Multiple (duplicate) publication bias
        • Citation bias
        • Language bias
        • Outcome reporting bias
  • Systematic reviews attempt to minimise bias and provides confidence with the use of knowledge.

Egger et al, (2001)


Finding Best Evidence

Case Study

A Practical Problem becomes

a Cochrane Review .

Egger et al, (2001)


The Importance of Research Evidence

An EU study found that 18% of hospital patients had a pressure ulcer (EPUAP 2002)

Cost of Pressure Ulcer management in the UK estimated to be £1.4 - 2.1 billon

(4% total healthcare budget).


Objective of Systematic Review

To assess the effects of wound cleansing solutions and techniques on the healing rates of

pressure ulcers


Cochrane Database

The Cochrane library contains 2,500 reviews. – Randomised Control trials (RCTs)

A data base of evidence about different


It assess intervention across all areas of health

care and brings together sufficient research

evidence to draw conclusions about the

effects of an intervention.

A Systematic Review

A way of Finding, Assessing, and Using evidence from studies (usually RCTs) to obtain a reliable overview

Cochrane Collaboration (2003)

Finding the Evidence


Types of Study included in Review

  • RCT's comparing wound cleansing with no wound cleansing
  • RCT's comparing different wound cleansing solutions
  • RCT's comparing different wound cleansing techniques
  • No restrictions regarding year or language of publication

Type of Participant

Studies involving people of any age, in any health care setting, with existing pressure ulcers

(defined as a break in the continuity of the skin caused by pressure with or without shearing/friction forces)


Type of Outcome Measure - Primary

  • An objective measure of pressure ulcer healing
  • Time to complete healing
  • Rate of change in pressure ulcer area or volume
  • Proportion of pressure ulcers healed

Type of Outcome Measure - Secondary

  • Pain, using validated scales where reported
  • Ease of use of the method of cleansing
  • Secondary outcomes only reported from studies which also report primary outcomes

Search Strategy

  • Cochrane Central Register of Controlled Trials (CENTRAL)
  • Specialised Trials Register of the Cochrane Wounds Group (up to August 2005)
  • Hand search of relevant bibliographies
  • Contacted experts and researchers in the field

Data Extraction & Analysis

  • 2 authors extracted data independently
  • Structured narrative summary initially
  • Data entered into Cochrane RevMan 4.2 and analysed with Cochrane MetaView.
  • For dichotomous outcomes RR & 95% CI calculated
  • For continuous outcomes WMD & 95% CI calculated
  • Meta analysis not conducted due to small number of diverse RCT’s

Data Extraction Criteria

  • Were the eligibility criteria clearly specified
  • Was the generation of the randomisation truly random
  • Was the allocation to treatment group concealed
  • Were the groups similar at base line in term of prognostic factors
  • Were outcome assessors blinded to treatment allocation
  • Were measures of variability for each group presented for the primary outcome measure
  • Were participants analysed in groups in which originally allocated.

Initial search


33 letters written

13 replies received

no new studies

Abstracts reviewed

12 papers

possibly eligible


Criteria applied

3 papers




Overall, there is no good trial

evidence to support use of any

particular wound cleansing solution

or technique for pressure ulcers



  • 19 months work
  • Greatest challenge lay in the lack of clarity in publications
  • Lack of data a disappointment
Moore Z., Cowman S. Wound cleansing

for pressure ulcers. The Cochrane

Database of Systematic Reviews 2004,

Issue 4, Art, No.: CD004983. DO1:


Cochrane Review