Research shows that patients’ outcomes are at least 28% better when clinical care is based on evidence rather than tradition or common sense (Heater, 1988). As we all want what is best for our patients, it is important that we incorporate research evidence into our practices.
Evidence based practice – what is it?
Evidence-based practice (EBP) can be an important change in the way we massage therapists practice and teach. Evidence-based practice, which is often referred to as evidence-based massage therapy or evidence-based medicine (EBM), is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." (Sackett, 2000)
The three cornerstones of evidence-based practice are:
1. Best available research evidence (as determined by critical appraisal)
2. Clinical experience, clinical reasoning
3. Practical, patient-centred application
Hicks (1997) states that evidence-based care “takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.”
EBP - what it is not
“Many of the arguments raised against EBP within the health care community are based on a caricature radically at odds with established, accepted and published principles of EBP practice. Contrary to what has sometimes been argued, EBP is not cookbook medicine that ignores individual needs. Neither does EBP mandate that only proven therapies should be used,” says Vickers in his 2001 article “Message to complementary and alternative medicine: evidence is a better friend that power.”
Historically, health care has been largely practitioner-centered (where the patient is a passive recipient of information), but health care practitioners have begun to incorporate patients' perspectives in ways that increasingly matter. Some call this shift "patient-centered" care (Laine, 1996).
The average health care consumer today has access to an unprecedented amount of health information through the Internet and local libraries. Increasingly research journals are directly targeting consumers with consumer friendly versions of their articles (Cochrane library).
There are however limitations to the patient-centered role. In a recent study Baldwin et. al. (2008) noted “patient-centered role orientation is associated with a less favorable clinical profile in some contexts”.
These facts highlight the need for us as RMTs to be interpreters and balancers of scientific information to help steer our patients through the labyrinth of health information.
As we are Primary Health Care Practitioners, there is a need for RMTs to be well informed about evidence-based health care. This is further emphacized in the government of BC’s proposed Primary Health Care Charter which states that “evidence-based best practices be the core process behind providing patients with accessible, appropriate, efficient, effective, safe quality care at the right time in the right setting by the right provider” (Primary Health Care Charter, retrieved February 2008).
Finding practical information
Among other things, providing true patient-centered care relies on our ability to supply patients with accurate, evidence-based information. As every clinician’s time is limited, our efforts should focus on identifying, validating, and applying common POEMs (Patient Oriented Evidence that Matters) to clinical practice. This refers to the kind of article that addresses a clinical problem or clinical question that we therapists encounter in our practices, uses patient-oriented outcomes, and has the potential to change practice if the results are valid and applicable. When reading research articles we have to look at the evidence in the context of the patient and make sure we are doing things that will make a difference to our patient.
EBP is not only about evaluating original research. Finding good secondary sources (systematic reviews) that summarize the literature available can also give us a useful, actionable bottom line based on the evidence.
Can I use this study?
In his article “Making EBM Doable in Every Day Practice”, White (2004) reports on PP-ICONS. Looking for the PP-ICONS in a research article help us decide quickly whether a study warrants our attention.
PP-ICONS stand for:
1.Problem - Is it a problem I see in my practice?
2.Patient population - Does the study’s patient population look like my patient population?
3.Intervention - What is the intervention, and is it realistic in my setting?
4.Comparison - What is the intervention being compared to, and is it a reasonable comparison?
5.Outcomes - Would the outcomes matter to my patients?
6.Number - How many patients were in the study? Studies with small numbers, generally less than 80, may be interesting, but the results may not be worth applying.
7.Statistics - How does the study present its findings? Most research papers use the relative risk reduction (see Glossary at the end of this article), which tends to emphasize small differences in the research findings. A better statistic is the number needed to treat (NNT), which is simply the reciprocal of the absolute risk reduction (see Glossary). It tells you how many patients you need to treat for one patient to benefit.
Therapists may be dimayed, after searching the literature for evidence of an intervention's efficacy, only to discover just how meagre that evidence is in many cases. Often when different sources of evidence conflict, it's important to bear in mind that building a collection of evidence for or against a given intervention is an ongoing process.
Evaluating scientific literature
We as therapists continually make decisions to determine how to proceed with our patients’ care. (Mattingly and Fleming, 1994). We make decisions using information from the patient, the patient’s response to treatment, our experiences with previous patients, research findings, and expert opinion from a variety of sources.
In evidence-based practices, epidemiologic (see Glossary) criteria are used to critically evaluate research evidence related to specific treatments.
You can rate the information you find as Level A, B or C. This will help you decide on which article to read.
* Level A (randomized controlled trials/meta-analyses – see Glossary): High-quality randomized controlled trials (RCT) consider all important outcomes. High-quality meta-analyses and systematic reviews use comprehensive search strategies to find all the relevant studies.
* Level B (other evidence): Well-designed, nonrandomized clinical trials. Includes non-quantitative systematic reviews (see Glossary) with appropriate search strategies and well-substantiated conclusions. Other examples include lower quality RCTs, clinical cohort studies, and case-controlled studies with nonbiased selection of study participants and consistent findings. Other evidence, such as high quality, historical, uncontrolled studies, or well-designed epidemiologic studies with compelling findings is also included in this level.
* Level C (consensus/expert opinion): Consensus viewpoint or expert opinion.
Competent practice includes reasonable efforts to base decisions on a critical review of the evidence, whether it is from the scientific literature, expert consensus or professional experience.
Remember, developing an evidence based practice is a process. EBP involves using the best available research evidence, clinical reasoning, and experience, and professional knowledge of the patient to provide the best in patient care.
* Absolute risk reduction – The absolute arithmetic difference in rates of bad outcomes between experimental and control participants in a trial.
* Critical appraisal - The process of assessing and interpreting evidence by systematically considering its validity, results and relevance.
* Epidemiology - The study of the distribution and determinants of health-related states or events in specified populations.
* Meta-analyses - A systematic review that uses quantitative methods to synthesize and summarize the results.
* Number needed to treat - The number of patients who need to be treated to achieve one additional favorable outcome.
* Relative risk reduction - The proportional reduction in rates of bad outcomes between experimental and control participants in a trial.
* Systematic review - A summary of the medical literature that uses explicit methods to perform a comprehensive literature search and critical appraisal of individual studies and that uses appropriate statistical techniques to combine these valid studies.
Baldwin AS, et al. 2008. Preferences for a patient-centered role orientation: association with patient information seeking behavior and clinical markers of health. Annals of Behavioral Medicine 35(1): 80-86
The Cochrane library, plain language summaries.
Accessed February 23, 2008
Fleming, M.H. and Mattingly, C. (1994) Action and inquiry: reasoned action and active reasoning. In Clinical reasoning: Forms of inquiry in a therapeutic Practice, pp. 316-342, Philadelphia: F.A. Davis Co
Heater, B., Becker, A, and Olsen, R. 1988. Nursing interventions and patient outcomes: a meta-analysis of studies. Nurse Res: 37:303–307.
Hicks, N. 1997. Evidence-based health care. Bandolier 4(39):8.
C. Laine, F. Davidoff. 1996. Patient-centered medicine. A professional evolution. JAMA, Vol. 275 No. 2.:152-156
Primary Health Care Charter: a collaborative approach, British Columbia Ministry of Health. http://www.health.gov.bc.ca/phc/. Accessed February 23, 2008
Sackett, DL. et al 2000. Evidence-Based Medicine: How to Practice and Teach EBM." 2nd edition, Churchill-Livingstone, New York.
Vickers, Andrew J. 2001. Message to complementary and alternative medicine: evidence is a better friend than power.
BMC Complementary and Alternative Medicine 2001,1(1):1.
White, B. 2004. Making evidence-based medicine doable in everyday practice family practice management. www.aafp.org/fpm. February 2004 issue