Evidence-Based Practice Exam Questions and Correct Answers

Evidence-Based Practice Exam Questions and Correct Answers EBP was becoming known as a framework for answering __________ - Ans: clinical questions by evaluating and incorporating the best clinical knowledge related to the patient's state, the clinical setting, and clinical circumstances present EPB process: - Ans: begins with clinical questions (find best practice), appraisal of the evidence, application of the evidence (validity and applicability to a particular care situation) considering the client's wishes and needs, and finishing with an evaluation of the clinical outcomes The basis of EBP is ______ - Ans: knowing one's own limitations and when to look for help Four steps of EBP: - Ans: questioning searching evaluating implementing should be used in a constant cycle for the dedicated practitioner of EBP The goal of EBP is to _______ - Ans: create strategies and tools for practitioners to access, understand, and use the latest research knowledge to improve services for clients What stops practitioners from incorporating EBP into current clinical practice? - Ans: 1. design of studies (RCT and meta-analysis are best) 2. presentation of evidence (language) 3. lack of time and resources Myths vs Reality - Ans: 1: EBP already exists ----> many practitioners take little to no time to review current medical findings 2. EBP is impossible to put into place ----> even extremely busy practitioners can initiate EBP through little work 3. EBP is cookie-cutter medicine ----> EBP requires extensive clinical expertise 4. EBP is a cost-cutting mechanism ----> EBP emphasizes the best available clinical evidence for each client's situation First target misconception - Ans: EBP is either already in place or impossible to practice EBP: - Ans: Take-home Messages There are misunderstandings of EBP because ______ - Ans: of the way in which it breaks with traditional practice; it should be seen as a powerful tool, not a burden EBP maintains a fine balance between ______ - Ans: clinical expertise and external clinical evidence EBP is based on an ______ - Ans: ongoing and self-directed learning model EBP can support a ______ - Ans: strongly client-centered approach to rehabilitation Clinical expertise remains _______ because ________ - Ans: crucial knowledgeable practitioners will best implement their findings based on the evidence EBP makes use of the _______ - Ans: current best methods of treatment EBR: - Ans: Take-home Messages EBR is an ______ - Ans: adaptation of the concepts of EBP to rehabilitation practice and necessitates specific skills that allow clinicians to use evidence within the complex decision making required for rehabilitation practice Important concepts of EBR include - Ans: awareness consultation judgment creativity Judgment - Ans: the practitioner differentiates between cases about how to apply recommendations of EBP; tailored to specifics of each client's situation Consultation - Ans: specialized set of skills and knowledge, and the ability to communicate well; the practitioner works as an educator/service provider *transparency is one of the most important aspects of health care *practitioners who are able to clearly explain the practice of EBR to their clients, how they have found the clinical data they are using and what they are doing with it, will be the most successful Awareness - Ans: the clinician must be aware of the evidence that has to do with practice and maintain focused awareness (aka knowledge of where to look) Creativity - Ans: EBR requires a great deal of creativity and insight to work correctly because the practice and application of the best available evidence is not always straightforward *creativity is essential CH 2 - Ans: Knowledge is a ______ - Ans: collection of ideas and facts about a topic Evidence is ______ - Ans: information that makes a conclusion apparent, and it is the accumulation of these conclusions that leads to new insights EX: Deinstitutionalization movement - Ans: 1900 - standard practice to institutionalize persons with disabilities -people with disabilities can learn and can be members of society and realize their potential -people who have different lived experience and unique interests have something to contribute that no one else can Evidence-based knowledge serves a _______ - Ans: generative function in the evolution of information for practice it invites us to simultaneously gain insight to solve a current problem and see the dilemmas that are only visible from the next vantage point 3 vantage points for knowledge development - Ans: 1. individual professional's responsibilities 2. professionals within a discipline 3. professionals across disciplines 1. Individuals professional responsibilities - Ans: 1. must first develop awareness of their own beliefs (beliefs emerge from experiences, viewpoints of those we trust, and sociocultural influences) 2. evaluate effectiveness (life long learning, evaluating outcomes is vital in the absence of knowledge) 3. willingness to abandon ineffective methods and/or erroneous ideas/beliefs in favor of more effective options (beliefs and conceptual frameworks are interwoven; if one's framework does not change, the beliefs within the framework will be difficult to alter) - acknowledge the client and family as active participants in planning *professionals must share their emerging insights/broader beliefs with others to meet the responsibility of knowledge development 4. professionals must participate in activities that are effective in their practices (awareness of personal beliefs, evaluating the effectiveness of current practices, maintaining open dialogue and feedback regarding current practices, and participating in activities, will enhance current practice) Professional knowledge development - Ans: preservice experiences novice professional period experienced professional period expert professional period Preservice experiences - Ans: becomes aware of own beliefs and learns initial strategies for questioning beliefs -occurs while students learn the knowledge and skills necessary to practice once their educational preparation is complete -learn how to use the available evidence to construct preliminary professional reasoning strategies and decision-making guides -meet 1 & 2 responsibilities of becoming evidence-based professionals (aware of own beliefs & learn initial strategies for questioning those beliefs in the interest of effectiveness) Novice professional period - Ans: begins to generalize ideas, determine effective and ineffective methods for practice, and test knowledge and beliefs -occurs within first 5 years of practice -learn how others apply knowledge and evaluate evidence -begin to generalize ideas across people and settings -this period forms the foundation for understanding how professional reasoning occurs within the broader context of work environments and for professional reasoning as knowledge and personal beliefs, now grounded in experience, begin to emerge Experienced professional period - Ans: establishes methods for evaluating effectiveness, hypothesizes successful therapeutic techniques, and shares with colleagues -occurs within 2nd decade of practice -create personal "database" -better able to hypothesize those therapeutic techniques that will be most successful for clients admitted with particular functional concerns -make EBP decisions by weighing multiple factors including their practice context, practice expertise, knowledge of expert colleagues, the evidence from relevant literature, and their client's preferences *also risk during this period! - because professionals have their own experience to reflect on, it becomes easier to disregard new evidence from the literature, particularly if that evidence challenges current practices Expert professional period - Ans: participates in formal methods of collecting data and evaluating interventions, shares knowledge more globally, and critiques the work of others -occurs after 2 decades of practice experience -may solicit funding to conduct research, participate in randomized controlled studies, may publish a case study -can mentor less advanced colleagues -this period includes critiquing the works and insights of others to advance knowledge for the discipline 2. Professionals within a discipline - Ans: challenge current beliefs, share information with colleagues, introduce new ideas, and formally test hypothesis for their new ideas growth of knowledge is only possible when others challenge current belies and theories *theories within the profession guide practice decisions, and practice experiences, in turn, inform the theory *tension between research and practice is inevitable and a necessary struggle for the advancement of knowledge -how a professional community adopts or rejects innovative or controversial information determines its evolution and viability 3. Professionals across disciplines : responsibilities - Ans: 1. must remain open to other points of view 2. important to remain aware of how decisions made by a variety of disciplines may impact families and individuals being served (i.e. family-centered care: must identify the unique and complementary knowledge that will enable a family to act on their goals without creating undue burden on the family) 3. must facilitate awareness about the similarities and differences in approaches to problem solving and knowledge development for each discipline 4. conduct collaborative research (interdisciplinary perspective = range of theoretical frameworks = comprehensive perspective) (aka barrier-free/universal design) 5. must recognize uncomfortable places as opportunities for knowledge development (reflective feedback) Challenges in developing evidence for practice - Ans: -producing generalizable evidence -disseminating evidence in an accessible and relevant format -implementing evidence into practice EX: sensory integration ---> sensory processing - Ans: evolving from one diagnosis to many and all people OT unique contribution and advancing knowledge has influences work in related disciplines not focused on the person as disordered but rather on the best match between person and context authentic contexts and routines are effective methods for supporting functional outcomes Simultaneous activities occurring that enable knowledge to emerge and evolve - Ans: -professionals develop along their respective career paths -as individuals in a profession we gather and discuss ideas -collective insights form hypotheses that can be formulated and tested -interdisciplinary discourse advances knowledge by adding perspectives to evolving ideas *these are the processes that occur to produce evidence for practice Take-Home Messages - Ans: Knowledge develops at ______ - Ans: many different levels; simultaneously within a discipline and in collaboration with other disciplines The tension between practice and knowledge development is _______ - Ans: inevitable and acts in a positive way as the source for the advancement of knowledge The role of the individual professional within a discipline area passes through 4 distinct stages: - Ans: 1. preservice experience 2. novice professional period 3. experienced professional period 4. expert professional period *knowledge, skill, and professional reasoning evolve through these stages An understanding of how knowledge develops must include ______ - Ans: recognition of 3 different vantage points for knowledge 1. individual professional 2. professional within a discipline 3. professionals across disciplines Novices can enact a _________ - Ans: positive influence on knowledge development by becoming aware of their research selves, choosing a methodical and critical approach to finding and implementing new knowledge, and encouraging new ideas There are different responsibilities for the practitioner in each of the 3 different vantage points for the development of knowledge: - Ans: Individual Professional: -remaining aware of the influence of one's own personal beliefs/biases -evaluating effectiveness through questioning current information and seeking answers -willingness to use this information to abandon ineffective practices Professional Within a Discipline: -challenging current beliefs and sharing information with colleagues -introducing new ideas and formally testing hypotheses Professional Across Disciplines: -conducting research collaboratively and being open to other points of view -remaining aware of how decisions are being made by a variety of disciplines, because this may impact families/clients -facilitating awareness of various approaches to problem solving between disciplines -recognizing that there are several challenges in developing evidence in rehabilitation: producing generalizable evidence, evidence dissemination, and the implementation of evidence into practice ________ is one of the most challenging aspects of becoming an evidence-based practitioner - Ans: changing practice in line with new evidence CH 3 - Ans: (to pg. 44) Steps in the process of EBP - Ans: 1. posing a clinical question 2. searching for the evidence 3. appraising the literature 4. making a decision 5. assessing the effectiveness of the intervention (or test/assessment) and one's proficiency with the EBP process 1. Posing a Question - Ans: P. I. C. O. P=population I=intervention C=comparison (to another group or intervention) O=outcome comparison is optional outcome should be measurable 2. Searching the evidence - Ans: -check your PICO question -ID key concepts, relevant synonyms, alter terms/spelling -many resources for information (scholarly databases) -challenging to determine legitimate evidence -lack of regard for qualitative research 3. Appraising the Literature - Ans: -critical appraisal is one of the most challenging steps of the EBP process -addressing 3 questions: --what are the results? --are the results valid? --how will these results help me work with my client? -critical appraisal of published research can be conducted in one of two ways: --critical appraisal checklist or form ---PEDro scale --refer to critically appraised topics (CATs) or critically appraised papers (CAPs) CAT - Ans: a synopsis of evidence on a specific topic of interest and is typically focused around a clinical question CAP - Ans: when professionals summarize a single study (a CAP is the outcome of this) 4. Making a decision - Ans: appropriate decision making integrates the context, values, and preferences of the client as well as the available resources which include the available research evidence and the practitioner's expertise 5. Assessing the effectiveness of the intervention (or test/assessment) and one's proficiency with the EBP process - Ans: 1. evaluating the outcome of the intervention you implemented 2. evaluating your skill in navigating the different steps of the process -good practice to engage in self-assessment of your ability to undertake EBP process and determine areas where there may be shortcomings in your skills CH 6 - Ans: When starting to conduct clinical research (on patients), it is important to be able to ______ - Ans: identify (diagnostic studies) and measure the clinical phenomenon (clinical measurement studies) once diagnosis and measurement are in place, it can help us predict intensity or change, or which interventions best affect change (treatment effectiveness) effectiveness studies can be designed to look into whether treatments work under ideal circumstances (efficacy trials) or in routine clinical practice situations (effectiveness trials) once treatments are implemented research informs us of potential harms from those interventions once we know the benefits and harms, we will e interested in how much it costs (cost-effectiveness research) and how it can be transferred into practice (knowledge translation) Although descriptive research is classified as lower level of evidence, this work is _______ - Ans: foundational to achieving higher levels of evidence lower levels serve as foundation blocks but are insufficient to provide confidence when used to make clinical decisions about what to do with an individual patient Descriptive research - Ans: aims to describe or explain whether it is qualitative or quantitative Analytical research - Ans: is based on asking testable research questions and answering those questions with a certain level of confidence through hypothesis testing *hypothesis testing implies the use of inferential statistics Mixed methods that combine _______ - Ans: qualitative and quantitative methods can build on strengths of each and can be powerful when mixed methods research is carefully applied Qualitative researchers must ask themselves these 6 questions when appraising whether the results can be trusted and applied to their own practice settings - Ans: 1. was the sample used in the study appropriate to its research question? 2. were the data collected appropriately? 3. were the data analyzed appropriately? 4. can I transfer the results of this study to my own settings? 5. does the study adequately address potential ethical issues, including reflexivity? 6. overall: is what the researchers did clear? Qualitative research can serve different purposes reading from _________ - Ans: pure description to development and testing of theory 5 major approaches or designs are used in qualitative research - Ans: 1. narrative 2. ethnography 3. phenomenology 4. grounded theory 5. case study *case study, ethnography, phenomenology, and grounded theory used most often in rehabilitative research Case study - Ans: an in-depth study of a bounded system such as a process, activity, event, program, or interaction -can use multiple sources of data such as interviews, observation, documents, artifacts, etc. Ethnography - Ans: qualitative research approach whose purpose is to study a particular culture or group of people to identify their daily life patterns, meanings, and beliefs -often performed through observation and interviews -may involve collecting multiple sources of information over an extended period of time (field research) -sampling is intended to locate representatives of the "culture-sharing group" Phenomenology - Ans: is to understand the lived experience, interpret that experience, and provide information that can be shared with and used by others -interview is most common Grounded theory - Ans: used when generating or verifying theoretical concepts -themes that emerge from research are used to develop an understanding and theoretical explanation of the social world of the people being studied -typically collect data through interviews Qualitative research: Sampling - Ans: participants are selected for a specific purpose - purposive sampling -sample size is generally smaller -no specific formulae to calculate appropriate sample size Data collection procedures - Ans: methods, training of data gatherers, length of time of the study, and the data collected Interviews are the - Ans: most common -can also have verbal records, text, direct observation, records, and artifacts Procedures to enhance rigor of qualitative study - Ans: triangulation (cross-referencing multiple sources), member checking (asking participants to verify the findings), and consistency of coding themes (examining whether different interpreters agree) 5 categories that are evaluated criteria and scored (pg. 136) - Ans: -descriptive vividness -methodological congruence -analytical preciseness -theoretical connectedness -heuristic relevance Quantitative research is _____ - Ans: the main focus of EBP -it can define how accurate a diagnostic test is or how big a treatment effect is expected -can be descriptive but often tests hypotheses to make conclusions -needed to understand and operationalize EBP 2 categories of error in quantitative research are _____ - Ans: -random error (leads to imprecision) -systematic error (bias) Random error - Ans: -a sample that does not provide an accurate representation of the population from which it is drawn -quantitative studies are used to represent the population -smaller samples are less likely to represent the population than larger samples -contributes to lack of precision, called wide confidence intervals Systematic Error or Bias - Ans: -can result in false conclusions and be more difficult to detect than random error -many types of potential bias -biases can arise from how participants are entered into studies (sampling/selection bias), how interventions are provided, how outcomes are measured (measurement bias), or how data are analyzed ex: intervention bias: participants in control group are able to access the active intervention (contamination) or a different intervention (co-intervention) if treatments are not provided according to plan (proficiency bias or treatment fidelity) ex: measurement biases can arise when instruments are not properly calibrated, expectations the evaluator or patient affect their responses (expectation bias), and when information is differentially remembered (recall bias) EPB requires us to consider the ________ - Ans: direction and size when applying evidence to individual patients Most important strategies for improving truthfulness of conclusions and accuracy of estimated size of effects include: - Ans: randomization, concealment of randomization, blinding, and intention to treat analysis Randomization: single most powerful tool for discounting effects of factors that could potentially bias study findings Concealment of allocation: the allocation sequence and individual assignments are withheld from those involved in a trial until the participant has consented to participate in the study Blinding: protects against a number of biases that are difficult to detect --double-blind: when both the health care provider and the patient are blind --should blind: participants, health care providers, data collectors, outcome assessors, and data analysts **concern is loss of subjects over course of the study so that final comparisons do not provide a valid reflection of the group differences Critical appraisal: - Ans: -can be performed using simple classification systems or more detailed appraisal instruments -instruments can range from very structured tools that contain specific questions and defined response categories to open-ended scales where the accessor is guided to make judgements about specific issues -structured tool is preferable when learning because it provides direction Types of appraisal of quantitative research: - Ans: 1. instruments that assess the methodological quality of studies 2. instruments that assess the quality of the reporting of clinical studies 3. tools/processes for assessing the risk of bias Applicability - Ans: is determining whether a study result can be applied to a certain situation Precision - Ans: dependent on sample size and outcome measurement properties Types of Bias: - Ans: Selection bias: due to inadequate generation of a randomized sequence Performance bias: due to knowledge of the allocated interventions by participants and personnel during the study Detection bias: due to knowledge of the allocated interventions by outcome assessors Attrition bias: due to amount, nature, or handling of incomplete outcome data Reporting bias: due to selective outcome reporting Risks/issues that might introduce bias are often _____ - Ans: context dependent Quality rating is performed _______ , whereas risk of bias is __________ - Ans: at the level of the study and are generally multidimensional scales that focus on elements of design and conduct of the study (tools can be generic or specific to type of research design, structured, or open-ended) --these tools focus on randomization, allocation, recruitment, retention, sample size, blinding, and statistical analyses assessed for each individual study outcome Consolidated Standards of Reporting Trials (CONSORT) criteria - Ans: developed for reporting of clinical trials What is the best evidence upon which to base clinical decision making? - Ans: observations on patients that are rigorous and free of bias Randomized controlled trial (RCT) - Ans: only experimental design that can ascertain effectiveness -considered L1 evidence of treatment effectiveness -susceptible to bias if execution is poor Level 1 - Ans: considered to be sufficiently rigorous provide highest international validity, enhancing our confidence that if we select this intervention for our patients, we will be able to achieve similar outcomes L1 A - Ans: consist of systematic review of a number of RCTs students substantially agree with each other in terms of the direction and approximate size of the effects observed L1 B - Ans: an individual RCT size of the treatment effect was relatively precisely defined, as indicated by a narrow confidence interval L1 C - Ans: very unusual circumstance in rehabilitation occurs when, in the absence of a randomized study, an overwhelmingly dramatic change in outcomes can be demonstrated once a new treatment becomes available **see chart on page 142 - Ans: **as we lose confidence in internal validity, we are less likely to achieve similar outcomes for our patients L2 - Ans: lost randomization and have less protection against potential biases and confounders -cohort study - identifies patients prior to having their outcome and follows them forward in time - reduces some potential sources of bias such as recall bias L2 A - Ans: systematic review of cohort (prospective) studies that agree with each other in terms of the direction and approximate size of the effects obtained L2 B - Ans: a sigle high-quality cohort study with greater than 80% follow-up of patients *substantial emphasis on follow-up in cohort studies because therein lies the greatest potential bias L3 - Ans: occurs when studies are case-controlled Case-control study: one where patients are identified for research after exposures (treatments) have been completed -lost the potential protection against biases that result from collecting information on patients before their outcomes have been achieved -lost prospective data collection -primary threat to internal validity is the reasons/mechanisms by which patients are available for study may introduce a bias in which patients are included in the study L3 B - Ans: single individual case-control study L3 A - Ans: systematic review of case-control studies that agree with each other L4 - Ans: -lost comparison group -case series evaluates that clinical outcomes of a single group of patients -remain uncertain as to what would have happened to these patients if an alternate intervention had been selected case series: a descriptive study because we cannot test hypotheses about differential treatment effects L5 - Ans: -lose a critical component of research design - AKA observations made on patients -consists of expert opinion without explicit critical appraisal, physiology, bench (lab) research, or first principles (theory) L1 evidence does not always mean __________ - Ans: RCTs Consistencies evident across different types of questions and their associated levels of evidence: - Ans: -a systematic review of high-quality studies always provides the highest level of rigor -an individual study using the optimal design for that type of clinical question is typically considered high-quality (L1) evidence -prospective data collection indicates higher study quality than retrospective data collection -expert opinion, bench research, and conceptual frameworks/theories/first principles are always considered the lowest (L5) evidence GRADE system classifies the _______ - Ans: quality of evidence in one of four levels (high, moderate, low, and very low) -combines considerations about the evidence with other considerations to decide on overall recommendations GRADE recommendations consider a balance of evidence and focus on the following: - Ans: -the quality of evidence -uncertainty about the balance between desirable and undesirable effects -uncertainty or variability in values and preferences -uncertainty about whether the intervention represents a wise use of resources No single rating system addresses __________ - Ans: all study designs or covers all potential types of evidence -evidence ratings should have the same theme: moving from systematic reviews down to more individual assessments Quality appraisal tools: - Ans: 2 = optimal study design 1 = suboptimal study design 0 = inappropriate methods were used or methods were not reported Judging the quality and relevance of research evidence requires knowledge about differences in ________ - Ans: qualitative, quantitative, and mixed method paradigms TAKE HOME MESSAGES - Ans: EBP requires that clinicians ________ - Ans: search through reappraised evidence repositories and conduct their own appraisals to determine their confidence in study conclusions Different levels of evidence for effectiveness include: - Ans: -systematic reviews or overviews -randomized controlled trials -cohort studies -case-control studies -case series -expert opinion -bench research -theoretical principles Different clinical questions require _______ - Ans: different study designs, each with their own potential sources of bias and quality appraisals Qualitative and mixed methods evidence _________ - Ans: enriches our understanding of clinical practice and clinical research methods for appraisal of qualitative evidence focus on the trustworthiness of the findings and their relevancy Therapists must consider research design issues and their ________ - Ans: potential to introduce bias before implementing the conclusions of research studies A variety of structured and semi-structured appraisal tools are _________ - Ans: available to assist with quality appraisal Critical appraisal is a skill that _______ - Ans: improves with practice -evidence-based journal clubs provide a useful mechanism to achieve this CH 7 - Ans: 2 main categories of quantitative review - Ans: narrative and systematic Differences between narrative and systematic reviews - Ans: question addressed: n: often broad overview of the topic but can focus on a particular perspective s: a specific research question is posed and drives study methodology search strategy: n: not usually specified or systematic s: a strategy designed to find all relevant research is explicitly stated in the methods selection of studies included: n: not usually specified s: specific inclusion and exclusion criteria are applied in a standardized way to determine the studies included appraisal of study quality or potential for bias: n: can absent or integrated in discussion (inconsistent) s: performed on all included papers using a standardized process and tools synthesis of evidence across studies: n: usually narrative with differential emphasis on different studies s: can be narrative or quantitative recommendations: n: driven by authors s: considers and communicates strength of evidence inclusion of author expertise, experience, and opinions: n: commonly present s: absent A narrative review is a ______ - Ans: gathering of information by an individual who may be considered an expert in the field -it sets out to answer a research question but lacks the explicit description of an organized approach to gathering the literature (chief limitation) Scoping reviews - Ans: a more systematic approach to narrative reviews - exploratory projects that systematically map the literature available on a topic, identifying key concepts, theories, sources of evidence, and gaps in research the purpose is to examine the range of information available on a particular topic or research question, determine the necessity of undertaking a full systematic review, summarize and disseminate research findings, and finally, identify gaps in the literature surrounding a specific topic 6 stages to completing a scoping review - Ans: 1. identifying the research question 2. identify the relevant studies (practical issues related to time and resources available are determined to balance comprehensiveness and feasibility) 3. study selection 4. charting the data (according to themes and key issues) 5. collating, summarizing, and reporting the results 6. consultation (optional) (opportunities for consumer and stakeholder involvement to suggest additional references and provide insights beyond those in literature) A systematic review is a _______ - Ans: summary of the literature that uses clear methods to perform a thorough search and critical appraisal of individual studies on a defined topic area for which there are sufficient studies of a similar design the goal is to investigate a specific research question in ways that minimize bias and random error time consuming and costly General process of a systematic review - Ans: 1. formulating a review question 2. conducting a comprehensive search of the literature 3. critically appraising each study 4. synthesizing the findings 5. reporting the results Step 1: Formulating a review question - Ans: cost effective research: questions set out to examine which treatment is most cost effective for a particular situation Questions for a systematic review focus on one of the following areas: diagnosis, etiology, prognosis, treatment, or prevention clinical research can be defined on the basis of four elements: population, intervention, comparison, and outcome (PICO) Step 2: Conducting a comprehensive search of the literature - Ans: the most common place to begin searching for information is through electronic databases Level of evidence in a systematic review: (review type ---- level of best evidence) -treatment and/or prevention: RCT -diagnostic tests: comparison to a gold standard -prognosis: cohort studies -review of risk factors: cohort, case/control, or ecologic studies risk of reference bias: can result in more favorable results being referenced more often Step 3: Critically appraising each study - Ans: publication bias: articles with favorable results may be published more often than those with unfavorable results Step 4: Synthesizing the findings - Ans: clinical judgement should be used to determine the appropriate combination of the reviewed studies Step 5: Reporting the results - Ans: most important to the reader entire process must be written up all variables and choices made along the way affect how the final outcome emerges must cite all possibilities for bias The quantitative approach of a meta-analysis contains ______ - Ans: a statistical summary of at least one outcome in two or more trials forest plot: a graphic form that shows the reader information from the individual studies that went into the meta-analysis and an estimate of the overall results -it represents the pooled odds ratios of all the studies in a review -meta-analyses are useful because they provide one overall estimate of the effectiveness of an intervention, but they also have some disadvantages -the goal of a systematic review, aside from offering a summary of original articles, is to be published -publishing both positive and negative systematic reviews is the only way in which a more complete knowledge of which interventions or treatments are beneficial can be garnered The scoring distinguishes between a systematic review that has _______ (pg. 164) - Ans: minimal (a score of 7), minor (a score of 5-6), major (a score of 3-4), or extensive (a score of 1-2) flaws the more questions receiving a yes response, the higher the quality of the review Critically appraising systematic reviews: Section 1: Are the results valid? - Ans: 1. did the overview address a focused clinical question? 2. were the criteria used to select articles for inclusion appropriate? 3. is it unlikely that important, relevant studies were missed? 4. was the validity of the included studies appraised? -Validity: refers to the study's level of truth or potential freedom from bias --the higher the validity of each included study, the greater the overall validity of the final review 5. were assessments of studies reproducible? 6. were the results similar from study to study? -examined through tests of homogeneity --homogeneity: means that the results of each individual trial are mathematically compatible with the results of any of the others Section 2: What are the results? - Ans: 1. what are the overall results of the review? -odds ratio: the ratio of odds of having the target disorder in the experimental group relative to the odds in favor of having the target disorder in the control group (in a cohort study) or the odds in favor of being exposed in subjects with the target disorder divided by the odds in favor of being exposed in control subjects (without the target disorder) -relative risk: the ratio risk in the treated group to the risk in the control group 2. how precise were the results? -should present results in terms of how precise they are --> called a confidence interval: which quantifies the uncertainty of the measurement -confidence intervals: usually reported as a 95% CI, which is the range of values within which we can be 95% sure that the true value for the whole population lies -NNT: the number of patients who need to be treated in order to prevent one additional (successful or poor) outcome Section 3: Will the results help me care for my patients? - Ans: 1. can the results be applied to my patient care? 2. were all clinically important outcomes considered? 3. are the likely treatment benefits worth the potential harms and costs? Cochrane collaboration: based around 10 founding principles - Ans: 1. collaboration 2. building on the enthusiasm of individuals 3. avoiding duplication 4. minimizing bias 5. keeping up to date 6. ensuring relevance 7. ensuring access 8. continually improving the quality of its work 9. continuity 10. enabling wide participation -the collaboration itself is a first step toward creating a more integrated, evidence-based network for drawing on the vast resources of the entire medical profession to serve clients Metasynthesis: In qualitative research the investigator sets out to _______ - Ans: understand the thoughts, feelings, and experiences of individuals, focusing on direct, face-to-face knowledge of patients as human beings coping with their treatment in a given social setting -results from qualitative literature offer a holistic picture of the participants in their natural setting and can be used to provide an in-depth understanding of a particular phenomenon or experience from the participant's point of view -relies on language-based data rather than the numerical statistics found in quantitative research The main difference between the meta-analysis and the meta synthesis is that _______ - Ans: the researcher in the meta synthesis offers an interpretive product as well as an analytic process from the findings of primary authors rather than raw data -the goal of a meta synthesis is to produce a new and integrative interpretation of findings that is more substantive than those resulting from individual investigations and can offer clinicians a picture of the meaning or impact a particular phenomenon or intervention can have on their clients -metasyntheses can also generate new models and theories and determine the existence of different schools of thought and complement the findings of a systematic review -subjective nature and qualitative research, so may not be appropriate to synthesize it at all 3 types of metasynthesis: - Ans: -theory building -theory explication -descriptive metasynthesis Theory building - Ans: -sets out to investigate a number of studies in order to move forward with a given theory beyond what is possible in a single study --includes grounded formal theory and metastudy grounded formal theory: uses substantive grounded theory findings to create formal theories metastudy: brings about three types f formal qualitative analysis to create new theoretical interpretation Theory explanation - Ans: examines abstract concepts within the original findings and expands upon them, resulting in a new understanding of that particular phenomenon Descriptive metasynthesis - Ans: involves the broad translation of finding across studies dealing with a particular phenomenon There is no single _______ - Ans: accepted method for conducting a metasynthesis Conducting a metasynthesis: - Ans: 1. determine study focus 2. sampling 3. data analysis Step 1: Determine study focus - Ans: must have a clear focus in order to offer more precise results Step 2: Sampling - Ans: the sampling process of current research sets out to answer that question setting inclusion criteria is important to guide the investigator's choice sampling should occur across disciplines, internet, conferences, databases, and demographic elements Step 3: Data analysis - Ans: have a list of primary studies to be included and now must determine whether these studies can be compared as well as the similarities and differences between these qualitative research several methodologies from which to choose (i.e. ethnography phenomenology, grounded theory) Critically appraise metasytheses: in general, readers should pay close attention to the following characteristics: - Ans: -did the reviewers ask a clear question that is relevant to your clinical practice? -what was the rigor of the included studies> -were the reviewers clear about heir methods for analyzing data? -was there a clear description of the similarities and differences between the primary studies? -did the reviewer synthesize the studies in an understandable way? Take-Home Messages - Ans: Systematic reviews: - Ans: -use scientific strategies to incorporate clinical trials done by different researchers on the same topic -there are various methodologies for preparing systematic reviews -analyze RCTs with respect to methodological quality, precision, and external validity -all RCTs within the study will have some small error, but those studies with significant error should be rejected -CONSORT statement consists of checklists and flowcharts to help standardize the researcher-reported RCTs and to guard against methodological error -even without positive results, systematic reviews should still be published Meta-analysis: - Ans: -analysis of analyses; integrate findings from a large variety of individual studies to achieve a systematic review -results portrayed in a forest plot with a diagram using confidence intervals -meta-analysis often critiqued for publication bias and missing data Cochrane Collaboration: - Ans: -database of systematic reviews and meta-analyses from around the world -main output is systematic reviews; groups and databases to address different practice areas -represents an integrated evidence-based network CH 10 - Ans: EBP is not only about using research evidence, but about _________ - Ans: using it in partnership with excellent clinical reasoning and paying close attention to the client's stated goals, needs, and values Implementing EBP in a 5 step process: - Ans: 1. convert your information needs into answerable questions 2. track down, with maximum efficiency, the best evidence with which to answer them 3. critically appraise that evidence for its validity and usefulness 4. integrate this appraisal with your clinical expertise and apply it in practice 5. evaluate your performance Once a clinical problem or issue is identified, the therapist can carry out the following steps: - Ans: 1. write a clinical question/formulate a relevant practice question -break it down into components -decide if the focus of the practice encounter is assessment, intervention, or both -PICO 2. search for evidence related to the question 3. evaluate/critically appraise evidence to determine the evidence that best informs the clinical question 4. speak with the client and his or her family and decide in partnership with them whether to act upon the evidence -determine if the evidence fits with the features of the client's context (personal skills/values/preferences, living environment, and daily activities/demands) -client's environment, cultural beliefs, values, and priorities ultimately determine the usefulness of the research -consideration is also given to the practice setting, clinical expertise, and resources available 5. evaluate the outcomes of these actions 6. save the evidence-based information you have acquired for future reference for you and your colleagues; post this information on a website EBP proposed process: - Ans: 1. assess -need for change in practice -include stakeholders, collect internal data about current practice, compare internal data with external data, identify problem 2. link -problem interventions and outcomes -use standardized classification systems and language, identify potential interventions and activities, select outcomes indicators 3. synthesis -best evidence -search research literature related to major variables, critique and weigh evidence, synthesize best evidence, assess feasibility benefits and risks 4. design practice change -practice change -define proposed change, identify needed resources, plan implementation process, define outcomes 5. implementation and evaluation -change in practice -pilot study demonstration, evaluate process and outcome, decide to adapt, adopt, or reject practice change 6. integration and maintenance -change in practice -communicate recommended change to stakeholders, present staff inservice education on change in practice, integrate into standards of practice, monitor process and outcomes Attitude and knowledge - Ans: attitude: important to provide client with current information to offer the best possible treatments, professional and ethical obligation knowledge: learn about evidence and how to apply it Skills to make using evidence a vital part of everyday clinical reasoning: - Ans: -familiarize yourself with the EBP resources that are available via the Internet -bookmark the sites that will help you quickly obtain the best information -learn how to use keywords -look for services that find information for you Clinicians can perfect the art of searching by moving through 3 stages of questioning: - Ans: 1. patient-focused questioning to ascertain specific functional problems 2. primary research questioning 3. secondary research questioning EBP is a process that involves ________ - Ans: clinical expertise, relevant research, colleague support, and family and client choice To integrate EBP into practice, clinicians must do the following: - Ans: -ask a clinical question classified into diagnosis, treatment prevention, or prognosis -formulate the question into PICO -critically appraise the evidence, deciding whether the information is valid and clinically significant. Ask 4 questions: --do the results apply to my client? --does the treatment fit into my client's values and preferences? --do I have the resources to implement this treatment? --do I have the training or skill necessary to implement these interventions? Through strategic planning and the use of __________ - Ans: strengths, weaknesses, opportunities, and threats (SWOT) analyses, managers and therapists together can plan opportunities and strategies most suitable to the organization in order to facilitate EBP 3 stages to implementing EBP: - Ans: 1. motivational or educational interventions to prepare for change 2. enabling or skill building interventions to enact a new practice 3. reinforcing, structuring, or financing interventions to sustain change __________ can all affect implementation success - Ans: factors within the change itself (quality, complexity, clarity) the practitioner (experience, perceptions, and beliefs) the patient (expectations and preferences) the practice context (resource availability, organizational culture, and opinion leaders) Barriers to implementing EBP - Ans: -difficulty finding the time to search for evidence -limited quantity of evidence -lack of resources -insufficient quality of evidence -lack of access to computers and journal articles -lack of training about EBP and how to carry it out -the influence of personal factors -research does not provide certainty -clinical research does not tell of client's experiences -lack of clinical confidence in how to search for, interpret, and implement evidence -lack of useful research summaries -lack of organizational support Solutions to implementing EBP - Ans: -support from managers -access to and effective distribution of relevant resources -personal factors (self-motivated, interest) -postgraduate education was linked to greater use of current research literature -use of alerting services or technological services that push out evidence -databases of preappraised evidence such as PEDro and OTSeeker -availability of clinical trials and synthesized evidence In order to deal with barriers, managers and organizations should do the following: - Ans: -produce policies for how to develop evidence-based clinical guidelines -use information systems that integrate evidence and guidelines with patient care -develop facilities and incentives to encourage effective care and better disease-management systems -improve effectiveness of educational and quality improvement programs for practitioners -implement technology designed for practice -point of care evidence summaries When therapists see EBP as a strategy to provide effective and efficient care ________ - Ans: time is less of a barrier Instructions for clinicians on how to overcome EBP - Ans: -seek out continuing education opportunities -make use of EBP resources such as websites and journal clubs -participate in research evaluating interventions within your discipline -participate in or establish a journal club -seek out or contribute to evidence-based clinical practice guidelines -negotiate work time to search and appraise research Using technology to support EBP: MacPLUS - Ans: -identifies the clinical interest of individual practitioners -rates the scientific merit, clinical relevance, and newsworthiness of new evidence -alerts practitioners about new high-quality research findings in their area -provides a cumulative database so that practitioners can look up information when needed Evidence lacking in one field may be _____ - Ans: plentiful in other disciplines Best way to begin tracking outcomes or doing small studies is often through ______ - Ans: a research partnership with a rehabilitation faculty member in a university Barriers/solutions requiring help from all stakeholders: These barriers include ______ - Ans: current health policies, organizational barriers, and biases within the research evidence -clinicians and researchers need to work together to do the following: --publish all RCTs regardless of outcome --petition MEDLINE and CINAHL for complete coverage in rehabilitation journals --expand free access to databases --expand access to free text --include translations of non-english research --use relevant research to predict the treatment effect and adjust that prediction based on clinical experience Other suggestions on how to narrow the gap between research and practice are for_______ - Ans: research professionals to demand or emphasize the timely transfer of research and theoretical knowledge into practice model proposed found these conclusions: -in order to create an EBP, there must be a research alliance with all key stakeholders (researchers, students, administration, and clinicians) -these stakeholders can join to form a community of practice, or community of practice scholars -in order to successfully close the gap between theory and practice, three factors should be considered: --those who use knowledge should be involved in helping to generate and refine it --a scholarship of practice should be developed to create new educational and research opportunities --models developed should show clear links between theoretical concepts and the everyday work of therapists Model to ensure studies are relevant to current practice: - Ans: -develop the research question in the setting where it is to be treated -initial efficacy trial under controlled conditions to determine potential benefit -single case applications in a clinical setting -initial effectiveness trial in a clinic -full test of effectiveness under everyday practice conditions -effectiveness of treatment variations -assessment of goodness of fit with host organization, practice setting, or community -dissemination of information to other organizations How to enhance EBP: - Ans: CAT is excellent for organizing your thoughts and keeping your evidence straight Critically Appraised Topics (CATs) - Ans: are the preferred categorization format for quick studies in EBP it is a one or two page summary of a search and critical appraisal of the literature related to a focused clinical question, which should be kept in an easily accessible place so that it can be used to help make clinical decisions most essential characteristic of CATs are that they be simultaneously brief, informative, and useful Evidence-based information search process into 5 parts - Ans: -translate these needs into answerable questions -track down the best evidence to answer them -appraise that evidence for its validity and applicability -integrate that evidence with clinical expertise and apply it in practice -evaluate the performance of the intervention CATs have a hand in _____ - Ans: all steps of the evidence-based process the require that one have a focused question, categorize the evidence found, allow for the evaluation of that evidence, and produce a clinical bottom line that will be developed into practice can be reviewed on a regular basis and their successes passed on for further analysis and use 5 major types of CATs - Ans: 1. diagnosis/screening 2. prognosis 3. evaluating risk and harm in a case-control study 4. evaluating risk and harm in a cohort study 5. intervention studies (treatment, prevention, screening) Diagnosis/Screening - Ans: 2 equal and opposite types of results to consider when examining the results of clinical tests ---> sensitivity and specificity the sensitivity of a diagnostic test is the proportion of people who actually have the disease or problem in question who come up with a positive test the specificity of a test is the equal and opposite results - the proportion of people who do not have the disease who come up (rightfully) with a negative test likelihood ratios are most often used by physicians for medical diagnostic questions, but they are also used in rehabilitation for screening issues (e.g. the identification of a developmental delay) Prognosis - Ans: a CAT for prognosis will assess the ability of a symptom to forecast probable outcomes a diagnosis CATs attempts to establish whether or not persons have a condition, whereas prognosis CATs try to predict the future of a condition for one person Evaluating risk and harm in a case-control study - Ans: risk: the probability that an event will occur case-control study: starts with identification of people with the disease or outcome of interest (cases) and a suitable control group without the disease or outcome the case-control CAT, therefore, analyzes information on the presence of risk factors using a statistical technique called an odds ratio (OR) OR: simply the odds of a patient in the experimental group suffering an adverse event relative to the odds of a patient in the control group suffering the same event Evaluating risk and harm in a cohort study - Ans: cohort studies differ from case-controlled studies in that the two types of studies approach populations differently cohort studies are studies in which subsets of a defined population are identified a relative risk is simple the number of people exposed to a risk factor who developed the unwanted outcome taken as a percentage of the whole Intervention studies (treatment, prevention, and screening) - Ans: this type of CAT distills information from an article on a treatment into a final conclusion on the number needed to treat (NNT) NNT: number of persons you need to treat to prevent one additional bad outcome (NNT of 5 = have to treat 5 people with the intervention to prevent one additional bad outcome or create one good outcome) The date of completion - Ans: CATs have a "shelf life" hovering between a few months and a few years The question - Ans: at the heart of the CAT is your clinical question the question's "anatomy" should consist of PICO The clinical bottom line - Ans: is where you summarize your findings for yourself and others to have readily available The evidence - Ans: there is room on the CAT to list the evidence that you have found that pertains to the question good idea to summarize evidence you are using The gold standard - Ans: on CATs that specifically have to do with diagnosis or screening, there is room to describe the current gold standard test the gold standard will be a known, valid diagnostic or screening tool Notes - Ans: where information goes that does not fit into any of the other categories but that you feel should be added to the CAT note important issues and record personal reflections CATs are used to _____ - Ans: summarize and organize evidence for specific clinical situations in practice Drawbacks of CATs - Ans: -subject to error, bias, and other limitations that re inherent to non-peer-reviewed material -are only used as short-term or interim guides until more conclusive evidence in the form of RCTs or systematic reviews can provide more conclusive evidence on the topic in question Summary of CATs - Ans: CATs are quick, easy, and intuitive organizational tools for using EBP can serve as a pool of the EBP knowledge can be flawed because of the inherent speed of their creation Critically Appraised Papers (CAPs) - Ans: a CAP is very useful in helping practitioners quickly figure out the quality of a newly published research study and how to apply it similar to CATs, but specific to individual papers CAP characteristics: - Ans: -succinct appraisal of a single research study, comprised of a declarative title, a structured abstract, and a commentary -written by clinician or methodologist who describes the strengths and weaknesses of a study -places study in context of other research and discusses implications for practice, education, and future research Strengths of CAPs - Ans: cover many different types of evidence including RCTs, qualitative studies, systematic reviews, and metasyntheses of qualitative research easy to share among colleagues or at meetings Limitations of CAPs - Ans: have more of a medical than a rehabilitation focus not all are peer-reviewed CAPs are meant to provide a guide because they are based on someone else's interpretation of the methods, results, and statistics of a paper. These interpretations may not always be accurate and the suggestions on implications for practice might not apply to your own situation, setting, or specific client Searchable databases that are very useful in supporting EBP: - Ans: -OTSeeker: contains abstracts of systematic reviews and RCTs (critically appraised and asset in evaluating their validity and interpretability) -RehabT: provides links to research publications on topics such as SCI, TBI, and CVA -Physiotherapy Evidence Database: access to RCTs, systematic reviews, and clinical practice guidelines Clinical guidelines: -Clinical Guidelines: conduct a side-by-side comparison of two guidelines -Exter Health Library -The Ottawa Hospital Library Service -Orthopaedic Web Links -SUM Search: metasearch engine -TRIP Databse: allow for a search restricted to a certain level of evidence -Evidence-Based Medicine Guidelines: systematic reviews and trials include the following: --The Cochrane Library: systematic reviews, plain-language summaries with link to full review --National Health Service Center for Reviews and Dissemination --Clinical Evidence: systematic reviews for common clinical interventions --Getting Hooked on Evidence: evidence for physical therapy interventions Take Home Messages - Ans: EBP is not only about using research evidence, but about ______ - Ans: using it in partnership with excellent clinical reasoning and paying close attention to the client's stated goals, needs, and values use of a step-by-step model to gather and use evidence will improve the process of building evidence for your practice Critically Appraised Topics: CATs _______ - Ans: is a one or two page summary of a search and critical appraisal of the literature related to a focused clinical question are brief, informative, and useful 5 types: 1. diagnosis/screening nosis 3. evaluating risk and harm in a case-controlled study 4. evaluating risk and harm in a cohort study 5. intervention studies - treatment, prevention, and screening necessary elements: -date of completion -question -clinical bottom line -evidence -gold standard -notes are quick, easy, and an intuitive tool, but are also subject to error or bias should be seen as a starting point in a decision-making process rather than a final word APPENDIX C - Ans: Qualitative Review Critical Review components - Ans: 1. citation 2. study purpose 3. literature 4. study design 5. design types 6. appropriateness of study design 7. qualitative methods 8. sampling 9. data collection 10. data analyses 11. overall rigor 12. conclusions and implications Study purpose - Ans: -was the purpose and/or research question stated clearly? -helps determine if topic is important, relevant, and of interest to you literature - Ans: -was relevant background literature reviewed? -could include both qualitative and quantitative evidence -identifies gaps in current knowledge and research about the topic of interest -how it applies to OT Study design - Ans: -what was the study design? -essential features should be mentioned -numerous issues to be considered when determining which study design to use Design types - Ans: 1. Phenomenology: answers the question "what is it like to have a certain experience?", seeks to understand the phenomenon of a lived experience (emotion, relationship, being part of a group) 2. Ethnography: well-known and focuses on the question "what is the culture of a group of people, or people in a particular setting?" -goal is to tell the whole story of a group's daily life to identify the cultural meanings, beliefs, and social patterns of the group, and can include the description of material culture (buildings, tools, and other objects the have cultural meaning) 3. Grounded theory: focuses on the task of theory construction -indicative nature of qualitative research is considered essential for generating a theory -focus is on searching to identify the core social processes within a given social situation 4. Participatory action research (PAR): an approach to research and social change that can be considered a type of qualitative research. it involves individuals and groups researching their own personal beings, sociocultural settings, and experiences. -reflect on values, shared realities, collective meanings, needs, and goals. -can be time consuming, delays occur 5. Other designs: heuristics, ethnomethodology, institutional ethnography, hermeneutics, ecological psychology, feminism, and social interactionism Appropriateness of study design - Ans: choice of qualitative research design should be congruent with the following: -the beliefs and worldview of the researcher -the nature of the end results desired -the depth of understanding and description required from participants -the type of reasoning involved -was the theoretical perspective identified? - researcher should know something conceptually of the phenomenon of interest and state perspective upfront Qualitative methods - Ans: 1. Participant observation -uses observation to res