Problems with implementing EBP

[Guest guest]

Hello all,

I am working on a plan to implement Evidence based practice in my facility. In

process I have hit some road blocks in forms of following objections/comments

1. It is NOT EBP unless until the reference used is a Meta analysis. Now I am

aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

I would really appreciate if someone can help me deal with these arguments and

if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

Thanks

Nat

MI

[Guest guest]

Hi Nat,

This is based in my opinion and experience so take it as that:

1) Any implementation of EBP must start with the accepted triangle of

EBP: what the research brings (of any type including good case studies),

what the therapist's experience brings and what the patient brings. True

EBP uses all sides of the triangle to determine the best practice to use.

This should address some of the objection and concern. Your department plan

should commit to the triangle as well. There are plenty of authors that

described the triangle but one for here is " Strauss SF, McAlister FA,

Evidenced-Based Medicine CMAJ 2000 "

2) Second is to have all the staff realize that no study is definitive

in every case. Even the best studies in terms of design, strength and

results are strong only for the population and crtiteria studied. We

constantly extrapolate these findings. If we did not our practice would be

very narrow and ineffective because the truth is that we do not have enough

research to support what we do in all situations. This is the main reason

that we cannot use " just what the research shows " .

3) Third is to present EBP as a pathway to improvement in outcomes,

patient and staff satisfaction and lay out how the department will gather

info on each. Also give the staff chance to make suggestions for

improvement.

4) Fourth, establish monthly journal clubs, post articles and use the

time to educate staff on the benefits of EBP. This addresses the barrier of

what was " learned in school " and moves it to what is taught here and now.

Journal clubs can be geared towards taking the research and applying it by

using EBP.

5) Fifth, phase it in over time in a professional and appropriate way.

6) Sixth, find examples of how EBP has benefitted patients and staff in

other facilities. Seeing real world examples helps win converts. It also

is good to show how healthcare in general is moving towards more EBP with

comparative effectiveness research, payment systems that reward outcomes.

Use the APTA, a search online or use the listserve to gather examples.

The resistance most always come when the powers that be try to narrow EBP to

just what the research shows. Therapists feel that their professional

experience is wasted. This experience should be valued and using the

triangle helps build that value. If you can create a positive atmosphere,

work into the guidelines slowly, have plenty of chance for input and

teaching, and plenty of ways to determine the success (or failure) of your

efforts, then you should win over the staff.

There are plenty of management techniques out there to use to effect change.

Always make it clear that change will happen no matter what but give staff a

plan that is positive, values their experience and skill, gives plenty of

chance for input and charts success. Make sure to give plenty of feedback

on the success as well. The obstructionists will either see the value and

commit or move on.

M. Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, Idaho

thowell@...

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From: PTManager [mailto:PTManager ] On Behalf

Of nits_physio

Sent: Thursday, April 14, 2011 3:23 PM

To: PTManager

Subject: Problems with implementing EBP

Hello all,

I am working on a plan to implement Evidence based practice in my facility.

In process I have hit some road blocks in forms of following

objections/comments

1. It is NOT EBP unless until the reference used is a Meta analysis. Now I

am aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

I would really appreciate if someone can help me deal with these arguments

and if possible provide quotes or references against the above objections

and in favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am

doing my bit at the grass root level. I will look forward to your comments.

Thanks

Nat

MI

[Guest guest]

Nat,

Hats off to you for trying to put EBP into practice.  Great topic in my

opinion.

 

First, a quote I heard a while back, although I cannot remember who to

appropriately give credit:  " Evidence based medicine is the conscientious,

explicit, and judicious use of current best evidence in making decisions about

the care of an individual patient.  It means integrating clinical expertise

with the best available evidence from systematic research. "

I have a few points on your questions.  First, while meta-analyses are the

" gold standard, " we cannot simply ignore the results from Level I randomized,

controlled trials.  Clinical studies are extremely difficult because there are

so many factors that need to be controlled.  Study design, cohorts, and a host

of other reasons make this is a tremendous challenge for PT's.  That said, I

think it's a mistake NOT to utilize the best available evidence until proven

otherwise.  For example, look at how often people were casted for joint

injuries " back in the day. "   From studies by Salter, Amiel, Woo, Tabary, Noyes

and a host of others, we know with a fair amount of certainty that

immobilization leads to deleterious effects on connective tissues.  We say this

even though those studies would all be " inconclusive " when it comes to

meta-analyses...

To your second point, I don't believe we should rely on what is taught in

schools.  I would argue that for the most part, students get the " nuts and

bolts " .  Further, I think the DPT programs, while a great step for us, has

caused so much more information to be crammed in a similar amount of time.  No

discredit to schools, but I have students on a regular basis in the clinic and

there are some things that I think are " common knowledge " at this point are

completely new information.  I imagine that this is not the best way to go...

 

I think the best way to do things (and someday when I have the opportunity to

make decisions like this) is to use things such as the DASH, LEFS, Penn Shoulder

Score, SF-36, etc for outcomes.  FOTO is another possiblity, but that is an

added cost to facilities.  Instead of having the added paperwork to PT's, I

find this is something that can easily be done by PTA's, ATC's, or even an

appropriately trained " tech " to follow patients and execute these studies for

us, then accumulate the data.  If anything, your " outcomes " can be shared at

conferences or colleagues on various listserves, even though your " study " might

not be " publishable. "   Bottom line is that if you have an approach that is

clearly working for patients with PFPS, your " clinical expertise " cannot be

ignored just because it didn't satisfy the PEDro Scale or an editorial review

board...this goes back to the article recently in in I believe PT Journal or

JOSPT - efficacious vs. effective. 

Ideally, we have treatments that are both efficacious and effective, but how

much do we do that is undeniable effective but studies say are completely not

efficacious? 

 

I'm not sure this has helped at all, but I think these are great questions and

something I have a considerable interest in...

 

Dan Lorenz, DPT, PT, LAT, CSCS

Olathe, KS

Subject: Problems with implementing EBP

To: PTManager

Date: Thursday, April 14, 2011, 4:22 PM

 

Hello all,

I am working on a plan to implement Evidence based practice in my facility. In

process I have hit some road blocks in forms of following objections/comments

1. It is NOT EBP unless until the reference used is a Meta analysis. Now I am

aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

I would really appreciate if someone can help me deal with these arguments and

if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

Thanks

Nat

MI

[Guest guest]

Hi Nat,

Promoting change is never easy. In your scenario, you will have huge obstacles

because you are indirectly conveying all the practitioners are making poor

decisions which could lead to suboptimal outcomes.

How do you know your facility needs evidence based practice? What evidence do

you have that can readily indicate change is required? I'm not trying to be

impossible, but the first step is to define the problem or the results of the

problem. Obviously, the practitioners are using " something " to make clinical

decisions. If you think their " something " isn't optimal, why do you think that?

Since you are in Michigan and I'll assume your facility participates with BCBSM

PPO, well, get a hold of the Landmark quarterly reports. What category are most

of the practitioners in your facility? In my opinion... I'd want everyone to be

a Category B provider. If you have a lot of C's and a lot of A's, dig deeper to

understand how those folks are making decisions. Look into the area of the

reports where the treatment interventions are shared. Do you see anything

glaring in that area that might indicate clinical decision-making issues that go

against evidence. (Basically, the passive modality bar should be really, really

low... there is hardly any evidence supporting the passive modalities.)

Truly measure status quo. In all seriousness, you first have to know where

practitioners are at before any change is implemented. (Because after your

implemented evidence, you have to somehow know what impact implementing evidence

had.) I'd recommend starting small. If you are in an outpatient facility...

choose low back pain. Just implement one new outcome tool to measure

function/disability. In other words, for now, don't argue with the

practitioners... instead, argue for measuring their current outcomes. Take the

stance they may be absolutely correct and how they make decisions might be

spot-on. No one knows anything until actual data is analyzed. Take 6 months to a

year to gather outcome data. You'll need to use the tools at bare minimum at the

initiation of the episode of care and at the end of the episode of care. Front

desk personnel could easily be responsible for providing the outcome tool to the

patients.

Your role... research general outcomes for an episode of low back pain for

acute, subacute and chronic situations. Research the general interventions to

obtain those outcomes. When you have your data... compare your results with

research. If you see glaring differences in the outcomes, then that needs to be

problem-solved. You could set quality standards... x amount of disability at the

end of the episode of care within y amount of time or visits. And you could

provide the evidence to help the practitioners achieve the quality standards.

Your goal isn't to push the evidence as much as it is to clarify performance and

help practitioners achieve the desired performance level. Once you define what

you want, chances are highly likely the practitioners will have a different

point of view on the evidence and literature that is out there. They will come

to value evidence because their performances are being measured.

Selena Horner, PT

ton, MI

>

> Hello all,

>

> I am working on a plan to implement Evidence based practice in my facility. In

process I have hit some road blocks in forms of following objections/comments

>

> 1. It is NOT EBP unless until the reference used is a Meta analysis. Now I am

aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

>

> 2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

>

> I would really appreciate if someone can help me deal with these arguments and

if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

>

> Thanks

> Nat

> MI

>

[Guest guest]

Hi Nat,

Promoting change is never easy. In your scenario, you will have huge obstacles

because you are indirectly conveying all the practitioners are making poor

decisions which could lead to suboptimal outcomes.

How do you know your facility needs evidence based practice? What evidence do

you have that can readily indicate change is required? I'm not trying to be

impossible, but the first step is to define the problem or the results of the

problem. Obviously, the practitioners are using " something " to make clinical

decisions. If you think their " something " isn't optimal, why do you think that?

Since you are in Michigan and I'll assume your facility participates with BCBSM

PPO, well, get a hold of the Landmark quarterly reports. What category are most

of the practitioners in your facility? In my opinion... I'd want everyone to be

a Category B provider. If you have a lot of C's and a lot of A's, dig deeper to

understand how those folks are making decisions. Look into the area of the

reports where the treatment interventions are shared. Do you see anything

glaring in that area that might indicate clinical decision-making issues that go

against evidence. (Basically, the passive modality bar should be really, really

low... there is hardly any evidence supporting the passive modalities.)

Truly measure status quo. In all seriousness, you first have to know where

practitioners are at before any change is implemented. (Because after your

implemented evidence, you have to somehow know what impact implementing evidence

had.) I'd recommend starting small. If you are in an outpatient facility...

choose low back pain. Just implement one new outcome tool to measure

function/disability. In other words, for now, don't argue with the

practitioners... instead, argue for measuring their current outcomes. Take the

stance they may be absolutely correct and how they make decisions might be

spot-on. No one knows anything until actual data is analyzed. Take 6 months to a

year to gather outcome data. You'll need to use the tools at bare minimum at the

initiation of the episode of care and at the end of the episode of care. Front

desk personnel could easily be responsible for providing the outcome tool to the

patients.

Your role... research general outcomes for an episode of low back pain for

acute, subacute and chronic situations. Research the general interventions to

obtain those outcomes. When you have your data... compare your results with

research. If you see glaring differences in the outcomes, then that needs to be

problem-solved. You could set quality standards... x amount of disability at the

end of the episode of care within y amount of time or visits. And you could

provide the evidence to help the practitioners achieve the quality standards.

Your goal isn't to push the evidence as much as it is to clarify performance and

help practitioners achieve the desired performance level. Once you define what

you want, chances are highly likely the practitioners will have a different

point of view on the evidence and literature that is out there. They will come

to value evidence because their performances are being measured.

Selena Horner, PT

ton, MI

>

> Hello all,

>

> I am working on a plan to implement Evidence based practice in my facility. In

process I have hit some road blocks in forms of following objections/comments

>

> 1. It is NOT EBP unless until the reference used is a Meta analysis. Now I am

aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

>

> 2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

>

> I would really appreciate if someone can help me deal with these arguments and

if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

>

> Thanks

> Nat

> MI

>

[Guest guest]

Hi Nat,

Promoting change is never easy. In your scenario, you will have huge obstacles

because you are indirectly conveying all the practitioners are making poor

decisions which could lead to suboptimal outcomes.

How do you know your facility needs evidence based practice? What evidence do

you have that can readily indicate change is required? I'm not trying to be

impossible, but the first step is to define the problem or the results of the

problem. Obviously, the practitioners are using " something " to make clinical

decisions. If you think their " something " isn't optimal, why do you think that?

Since you are in Michigan and I'll assume your facility participates with BCBSM

PPO, well, get a hold of the Landmark quarterly reports. What category are most

of the practitioners in your facility? In my opinion... I'd want everyone to be

a Category B provider. If you have a lot of C's and a lot of A's, dig deeper to

understand how those folks are making decisions. Look into the area of the

reports where the treatment interventions are shared. Do you see anything

glaring in that area that might indicate clinical decision-making issues that go

against evidence. (Basically, the passive modality bar should be really, really

low... there is hardly any evidence supporting the passive modalities.)

Truly measure status quo. In all seriousness, you first have to know where

practitioners are at before any change is implemented. (Because after your

implemented evidence, you have to somehow know what impact implementing evidence

had.) I'd recommend starting small. If you are in an outpatient facility...

choose low back pain. Just implement one new outcome tool to measure

function/disability. In other words, for now, don't argue with the

practitioners... instead, argue for measuring their current outcomes. Take the

stance they may be absolutely correct and how they make decisions might be

spot-on. No one knows anything until actual data is analyzed. Take 6 months to a

year to gather outcome data. You'll need to use the tools at bare minimum at the

initiation of the episode of care and at the end of the episode of care. Front

desk personnel could easily be responsible for providing the outcome tool to the

patients.

Your role... research general outcomes for an episode of low back pain for

acute, subacute and chronic situations. Research the general interventions to

obtain those outcomes. When you have your data... compare your results with

research. If you see glaring differences in the outcomes, then that needs to be

problem-solved. You could set quality standards... x amount of disability at the

end of the episode of care within y amount of time or visits. And you could

provide the evidence to help the practitioners achieve the quality standards.

Your goal isn't to push the evidence as much as it is to clarify performance and

help practitioners achieve the desired performance level. Once you define what

you want, chances are highly likely the practitioners will have a different

point of view on the evidence and literature that is out there. They will come

to value evidence because their performances are being measured.

Selena Horner, PT

ton, MI

>

> Hello all,

>

> I am working on a plan to implement Evidence based practice in my facility. In

process I have hit some road blocks in forms of following objections/comments

>

> 1. It is NOT EBP unless until the reference used is a Meta analysis. Now I am

aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

>

> 2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

>

> I would really appreciate if someone can help me deal with these arguments and

if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

>

> Thanks

> Nat

> MI

>

[Guest guest]

thanks to all who replied to my question. I appreciate all of your time and

expertise. I will update this message on how I proceed with implementing EBP.

Thanks

Nitin

> >

> > Hello all,

> >

> > I am working on a plan to implement Evidence based practice in my facility.

In process I have hit some road blocks in forms of following objections/comments

> >

> > 1. It is NOT EBP unless until the reference used is a Meta analysis. Now I

am aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

> >

> > 2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

> >

> > I would really appreciate if someone can help me deal with these arguments

and if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

> >

> > Thanks

> > Nat

> > MI

> >

>

[Guest guest]

thanks to all who replied to my question. I appreciate all of your time and

expertise. I will update this message on how I proceed with implementing EBP.

Thanks

Nitin

> >

> > Hello all,

> >

> > I am working on a plan to implement Evidence based practice in my facility.

In process I have hit some road blocks in forms of following objections/comments

> >

> > 1. It is NOT EBP unless until the reference used is a Meta analysis. Now I

am aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

> >

> > 2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

> >

> > I would really appreciate if someone can help me deal with these arguments

and if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

> >

> > Thanks

> > Nat

> > MI

> >

>

[Guest guest]

thanks to all who replied to my question. I appreciate all of your time and

expertise. I will update this message on how I proceed with implementing EBP.

Thanks

Nitin

> >

> > Hello all,

> >

> > I am working on a plan to implement Evidence based practice in my facility.

In process I have hit some road blocks in forms of following objections/comments

> >

> > 1. It is NOT EBP unless until the reference used is a Meta analysis. Now I

am aware that meta analysis or systemic reviews have the highest scientific

strength but there may not be a meta analysis or systemic review for every

clinical decision.... does that mean we should not honor other forms of

experimental designs which may be available ?

> >

> > 2. Instead of EBP, the best way to practice is to only follow what is being

taught in the PT/OT schools

> >

> > I would really appreciate if someone can help me deal with these arguments

and if possible provide quotes or references against the above objections and in

favor of EBP. Implementing EBP is APTA/AOTA vision 2020 and I am doing my bit at

the grass root level. I will look forward to your comments.

> >

> > Thanks

> > Nat

> > MI

> >

>