A marriage made in heavenEvidence-based practice

Sue Jenkins APA Conference 2013

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

EBP – what it is

Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sackett 2000)

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

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

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

Physiotherapy evidence

PEDro

>25,000 randomised trials, systematic reviews and clinical practice guidelines

Absence of evidence ≠ evidence of absence (Altman & Bland 1995)

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)

Impact of research on clinical practice

Respiratory physiotherapy following cardiac surgery

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)

Did the research influence clinical practice?

Mx of patients post-CABG 19951 20102

Cardiothoracic units (Aus / NZ)

Clinical pathway

35 units 53 units

91% units

DBE or cough routinely used 89% patients 77% patients

IS routinely used 65% patients 40% patients

Factors influencing Rx

Personal experience

Literature

91%

63%

87%

75%

Why not?

17 year lag for uptake of research findings (Morris et al 2011)

(1Tucker et al 1995, 2Filbay et al 2012)

Barriers to the implementation of EBP

Barriers to the implementation

of EBP in healthcare

Awareness

Motivation

PracticalitiesAcceptance and beliefs

Skills

Knowledge

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, Jette et al 2003)

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

n of 1 trials!

Systematic reviews – strong conclusion often lacking

Recruitment to RCTs%

pa

tient

s re

cru

ited

PAH – pulmonary arterial hypertension, *ongoing trial, (#Calverley et al 2007)

*

#

My journey into EBP

1991 – King’s College London 1992 – Curtin University

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)

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)

Outcome-based program

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

Charlie's Easy Breathers

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

Program database

Report on program outcomes

Generate research questions

Output 24 conference abstracts 7 papers Pilot data – research, grant applications

Comparison of program outcomes with international data

Patients with COPD Jenkins & Cecins Puhan 2008*

Number of patients 150 460

Males 68% 71%

Age (yrs) 67±9 69±8

Lung function (%pred) 38±14 39±14

Baseline 6MWD (m) 424±110 361±112

Improvement in 6MWD (> MID) 63% 51%

Improvement in HRQoL (> MID) 69% 60%

mean ± SD, MID – minimal important difference *Data from 9 trials - North America, Europe

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

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 inHCU sustained (Cockram et al 2006, Cecins et al 2013)

Pulmonary rehabilitation and EBP =

A marriage made in heaven

Unlike this one!

Overcoming barriers to the implementation of EBP

“Change is not made without inconvenience, even from worse to better” Richard Hooker 1554-1600

Strategies/drivers for implementing EBP

The expert patient

Clinician-led research

NHMRC TRIP Fellowships

Clinicians

Evidence-based clinical pathways

Clinical guidelines / consensus statements

Support from managers, academics

Mentorship - QI, clinical audits, research

Education University courses PD, EBP sessions Journal clubs Professional

associations

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

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

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

Acknowledgements

Nola Cecins

Jeffrey Tapper & Ian Cooper, Physiotherapy Department, Sir Charles Gairdner Hospital

Research colleagues and students

Patients

Dr Kathy Stiller

Thank you for your attention

Sue JenkinsGradDipPhys, PhD Associate Professor & Pulmonary Rehabilitation PhysiotherapistSchool of Physiotherapy and Exercise ScienceEmail | S.Jenkins@curtin.edu.auPhone | +61 8 9266 3639

Citations for imagesSlide 4http://www.cancer-clinical-trials.com/p/clinical-trials-in-cartoons.html#.UljzXODcK5

. [accessed 11.10.2013]Slide 10http://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 27http://www.resources2.news.com.au/images/2011/10/12/1226164/643242.jpg.

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