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Evidence Based Practice – An Overview

Evidence Based Practice – An Overview

Defining Evidence Based Practice:
Evidence Based Practice (EBP) is a process for making better clinical treatment decisions.  In EBP we consider relevant research about a condition and think about what might be useful based on clinical judgment and experience.  We then talk with families about the options and offer guidance of what we think makes sense.  Families then make the decisions about how to proceed based on their own values and culture.  EBP offers truly informed consent. We thus avoid recommending treatment based solely on a few studies, as it might not make sense clinically and it might not make sense for the family, nor do we recommend treatment that has no basis in science.  EBP was adopted in 2001 by the American Academy of Sciences Institute of Medicine (IOM) as the basis for informed consent.

Confusion in Terminology:

EBP is often confused with terms such as ‘evidence based research’ or ‘evidence based treatment’. These terms refer to research studies without taking into consideration clinical judgment or the needs of the family. On the other hand, clinical case reports of positive results for treatments may bring new ideas, however when a symptom improves it may have more to do with the natural ups and downs of a condition, or may be part of a placebo effect. It is the combination of supporting research and clinical judgment that offer families a better package of information on which to make decisions. Still, lack of research does not mean a treatment is not useful, and so we need to look at how to do better research.

The Limits of Randomized Controlled Trials (RCTs):
In RCTs a null hypothesis posits that there is no difference between treating and not treating a person.  When one group is treated and a control is not, if the outcomes are statistically different, the null hypothesis is disproved and the treatment is deemed effective.  RCT efficacy studies measure short- term outcomes to substitute for longer-term outcomes.  These outcomes may have little relevance to functional outcomes.  For example, an RCT may show that a child can be taught to answer questions correctly for an IQ test but this does not necessarily help the child relate and communicate.  Also, some researchers conduct experiments repeatedly until random data shows a good result, then report the positive outcome without reporting ineffective results.  Moreover, many treatments are difficult to research with RCTs, especially, as in Autism, when the subjects are all very different or receiving other treatments. If we use only RCTs to support treatment, we have a narrow view of what might work, study reports may be slanted toward predetermined outcomes, the outcomes we strive for may have little relevance to the outcomes we really want, and it may take far longer to establish new treatments.

Clinical Judgment and Experience:

Critical decision-making is now recognized as a process combining and balancing experience and intuition with methodical fact finding and analysis. We are naturally driven to seek patterns in information, and, over the course apprenticeship and then practice, helping professionals become able to recognize patterns of symptoms and circumstances, and to respond more flexibly to the individual needs of a real person, better than any specific guidelines can. Good clinicians also talk with colleagues to think through challenges and avoid narrow thinking. This reflective process is essential, allowing for effective problem solving. It involves stepping back from the immediate situation to clarify what is going well, define current challenges, and think about how to address those problems. This requires regular, protected time, yet this time is more than saved in better efficiency and outcomes.   Moreover, active, open, and observant problem solving fosters similar parallel processes at other levels of the system, e.g. between clinician and family, helping families in their own efforts to find their solutions to the challenges they face.

New Kinds of Relevant Research:

Everyday clinical decision-making is based on inadequate knowledge about disorders, and health care providers often apply treatments for one condition to a different condition.  Scientific thinking is catching up with clinical experience as the IOM describes research methods that reach beyond RCTs as part of EBP.  Single Subject Case reports can be studied using before and after changes in individual subjects receiving treatment, allowing us to see treatment effects with fewer subjects than RCTs require and enlisting clinicians in meaningful clinical research.   Survival Studies follow the clinical course of a population and help us to know whether what we did long ago was helpful.  We might look at functional outcomes in persons with developmental disorders, e.g., independent living, to see how to adjust our current interventions for people who are earlier in the process of intervention.  Efficiency Studies use the few subjects available in multiple clinics to create a much larger group of typical subjects than can be found in a traditional RCT. In efficiency studies there are so many subjects that confounding variables are cancelled out statistically.  Moreover, efficiency studies look at what clinicians do in real practice, using a variety of treatments for different symptoms in difference conditions, making it possible to understand whether these practices are helpful in real life settings.

Better Outcomes and Better Cost Effectiveness:
Health care costs are rising nationally while health care funds and resources are becoming more scare, particularly with the recent global economic downturn.  Many studies demonstrate that EBP, particularly with its attention to the central role of the family in decision-making, leads to better, more efficient care and better outcomes. The IOM makes clear that EBP is our best current hope for containing health care costs while simultaneously supporting both innovation and humane care.  EBP is the best process available for clinical decision making, allowing for thoughtful, responsible, and innovative treatment and better care and outcomes for our families.

Joshua Feder, M.D. Dr. Feder's Blog

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