EvidenceBased Practice in Continence Care Assoc Prof Winsome

Evidence-Based Practice in Continence Care Assoc Prof Winsome St John RN Ph. D Research Centre for Clinical Practice Innovation School of Nursing and Midwifery, Griffith University, Gold Coast

Quick review of evidence based practice Debates in evidence based practice Overview of evidence for continence Resources Ways forward

History Critique of medical practice The Cochrane Collaboration Actually, we don’t really base all of the things we do on good scientific evidence Evidence shows that some things we have ‘always done’ can even cause harm.

Evidence-based medicine The conscientious, explicit and judicious use of current best evidence in making the decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett et al, 1996, p. 249 -254)

Evidence-based practice The systematic interconnecting of scientifically generated evidence with the tacit knowledge of the expert practitioner to achieve a change in a particular practice for the benefit of a well defined client / patient group. French, 1999, p. 74

Evidence-Based Practice Centres Cochrane Collaboration Joanna Briggs Institute (JBI) Campbell Collaboration Universities Hospitals Evidence-Based Journals

Why should clinicians think about EBP? Providing care based on research / evidence will enable us to: l l l l Keep up to date – accurate information Develop our body of knowledge Provide a basis for clinical judgments & practice guidelines Provide high quality, cost effective care Eliminate worst practice Remain accountable Validate and justify care, Lobby for resources

What is evidence? How do you know what you know? Types of information in the literature Texts, secondary sources l Descriptions l Theoretical literature l Single research studies l Reviews of the literature l Systematic reviews l Meta-analyses l

Weighing the Evidence Not all research is well designed, valid, generalisable The evidence must be appropriate to The question l Practice issue l Client group l Not all evidence is equal

Level Intervention 1 I A systematic review of level II studies II A randomised controlled trial III-1 A pseudorandomised controlled trial (i. e. alternate allocation or some other method) III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial ▪ Cohort study ▪ Case-control study ▪ Interrupted time series with a control group III-3 A comparative study without concurrent controls: ▪ Historical control study ▪ Two or more single arm study ▪ Interrupted time series without a parallel control group IV Case series with either post-test or pre-test/post-test outcomes NHMRC 2008 Evidence Hierarchy: designations of ‘levels of evidence’ according to type of research question

Key Questions 1. 2. 3. 4. 5. 6. Evidence base Consistency Clinical impact Generalisability Applicability Other factors NHMRC 2008

Critique of this Approach to Weighing Evidence RCT – effectiveness Does not necessarily provide answers for l l l Diagnosis, prognosis, harm Patient decision-making, health behaviours, daily-living management Economic costs Discounts other forms of evidence How and why Tightly controlled studies may not be widely generalisable Study results may not take account of patient context Judgments about when the evidence is relevant

JBI Applicability FAME Scale Feasibility evidence about the extent to which an activity or intervention is practical. Appropriateness evidence about the extent to which an activity or intervention is Ethical or culturally apt. Meaningfulness evidence about the personal opinions, experiences, values, thoughts, beliefs or interpretations of clients and their families or significant others. Effectiveness evidence about the effects of a specific intervention on specific outcomes. (JBI, 2008)

JBI Model of Evidence-Based Health Care 2008

JBI Levels of Evidence (2008)

Making Evidence Accessible to Busy Clinicians Systematic reviews Summaries Abstracts Practice sheets Evidence-based clinical guidelines

A Systematic Review is: “… a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research” (Cochrane, 2005).

How are they done? A systematic review Has a focused clinical question, protocol Based on research evidence – not authority, opinion Focuses on a client group, intervention, risk factor Examines benefits, harm, cost effectiveness The search is exhaustive Examines rigour of research Includes consultations with clinicians Weighs levels of evidence

When should a systematic review be carried out? The problem requires a response from health professionals There is a recurring practice problem To investigate a common therapeutic practice or approach To develop standards or protocols Recent research generates questions about practice

Cochrane Library: Systematic Reviews Exercises, Biofeedback & Electrical Stimulation Physical therapies for prevention of urinary and faecal incontinence in adults J Hay-Smith, P Herbison, S Mørkved 2007 Pelvic floor muscle training for urinary incontinence in women Jean Hay-Smith, Kari Bo, Bary Berghmans, Erik Hendriks, Rob de Bie, Ernst van Waalwijk van Doorn 2008 Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women EJC Hay-Smith, C Dumoulin 2006 Weighted vaginal cones for urinary incontinence P Herbison, N Dean 2002 Pelvic floor muscle training for urinary incontinence in women Jean Hay-Smith, Kari Bo, Bary Berghmans, Erik Hendriks, Rob de Bie, Ernst van Waalwijk van Doorn 2008 Electrical stimulation with non-implanted electrodes for urinary incontinence in adults Berghmans, K Bo, E Hendriks, M van Kampen, R de Bie 2004 Neuromodulation with implanted electrodes for urinary storage and voiding dysfunction in adults P Herbison, E Arnold 2003

Cochrane Library: Systematic Reviews Bladder retraining & Voiding Timed voiding for the management of urinary incontinence in adults J Ostaszkiewicz, L Johnston, B Roe 2004 Habit retraining for the management of urinary incontinence in adults J Ostaszkiewicz, T Chestney, B Roe 2004 Bladder training for urinary incontinence in adults SA Wallace, B Roe, K Williams, M Palmer 2004 Pharmacological Intervention Oestrogens for urinary incontinence in women B Moehrer, A Hextall, S Jackson 2003 Adrenergic drugs for urinary incontinence in adults A Alhasso, CMA Glazener, R Pickard, J N'Dow 2005 Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults P Mariappan, AA Alhasso, A Grant, JMO N'Dow 2005 Management Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders J Jamison, S Maguire, J Mc. Cann 2004 Absorbent products for light urinary incontinence in women M Fader, AM Cottenden, K Getliffe 2007

Cochrane Library: Systematic Reviews Client groups Treatment of urinary incontinence after stroke in adults LH Thomas, S Cross, J Barrett, B French, M Leathley, CJ Sutton, C Watkins 2008 Conservative management for postprostatectomy urinary incontinence KF Hunter, KN Moore, CMA Glazener 2007 Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children M Brazzelli, P Griffiths 2006 Faecal Incontinence & Constipation Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children M Brazzelli, P Griffiths 2006 Plugs for containing faecal incontinence M Deutekom, A Dobben 2005 Sacral nerve stimulation for faecal incontinence and constipation in adults G Mowatt, C Glazener, M Jarrett 2007 Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults C Norton, JD Cody, G Hosker 2006 Drug treatment for faecal incontinence in adults Mark J Cheetham, Miriam Brazzelli, Christine C Norton, Cathryn MA Glazener 2002 Electrical stimulation for faecal incontinence in adults G Hosker, JD Cody, CC Norton 2007

Cochrane Library: Systematic Reviews Investigations Urodynamic investigations for management of urinary incontinence in children and adults CMA Glazener, MC Lapitan 2002 Surgical Intervention Surgical management of pelvic organ prolapse in women C Maher, K Baessler, CMA Glazener, EJ Adams, S Hagen 2007 Open retropubic colposuspension for urinary incontinence in women MC Lapitan, DJ Cody, AM Grant 2005 Surgery for faecal incontinence in adults SR Brown, RL Nelson 2007 Traditional suburethral sling operations for urinary incontinence in women CA Bezerra, H Bruschini, DJ Cody 2005 Minimally invasive sling operations for stress urinary incontinence in women CCB Bezerra, MS Plata 2007 Anterior vaginal repair for urinary incontinence in women CMA Glazener, K Cooper 2001 Bladder neck needle suspension for urinary incontinence in women Cathryn MA Glazener, Kevin Cooper 2004

JBI: Systematic Reviews Haddow, G. , Watts, R. , Robertson, J. (2005). The effectiveness of a pelvic floor muscle exercise program on urinary incontinence following childbirth (Technical Report) The Australian Centre for Rural and Remote Evidence Based Practice. (Completed). Instruments for the Assessment of Faecal Incontinence for Community-dwelling Older Persons. Toowoomba Health Service District, Toowoomba, Queensland, Australia A systematic review of psychometric evidence and expert opinion regarding the assessment of faecal incontinence in older communitydwelling adults. The University of Queensland/Blue Care Research and Practice Development Centre. Hodgkinson, B. Hegney, D. Josephs, K. and Leira, E. A (Review in progress). Systematic review of the effect of educational interventions of urinary and faecal incontinence for health care staff/carers/clients on level of knowledge, frequency of incontinence episodes and hours spent on the management of incontinence episodes. The University of Queensland/Blue Care Research and Practice Development Centre.

Evidence-Based Clinical Guidelines Multi-Disciplinary, Allied Health, Nursing New Zealand Continence Association Guidelines http: //www. continence. org. nz/guidelines. html l Nocturia, Enuresis, Constipation New Zealand Guidelines Group http: //www. nzgg. org. nz/index. cfm Auckland District Health Board Jean Hay Referral guidelines: Female Urinary Incontinence NMAP: The UK’s gateway to high quality resources in nursing, midwifery and allied health. <http: //www. nmap. ac. uk> Royal College of Nursing (United Kingdom). Clinical guidelines. http: //www. rcn. org. uk/resources/guidelines. php

General & Medical Guidelines International Network http: //www. g-i-n. net/ National Institute of Clinical Studies (NICS) (NHMRC) http: //www. nhmrc. gov. au/nics/asp/index. asp Medical Journal of Australia Clinical Guidelines http: //www. mja. com. au/public/guides. html National Guideline Clearinghouse in the United States of America found at http: //www. guideline. gov/

Journals International Journal of Evidence Based Healthcare The Journal of Evaluation in Clinical Practice Worldviews on Evidence-based Nursing Bandolier Evidence-Based Nursing

What information should I be keeping up with? Usefulness = Relevance X Validity Work it takes to find out J of Fam Pract 1994 38, 505 -513

Relevance of Information Is this research client/practice focused? Will it change my practice / affect clinical decision making? Are these findings applicable to my clients / practice? Was the setting for this research similar to my clients’ setting / practice setting? Is the research valid? Are the results significant?

What does experience and expertise contribute? Assessment skills Judgment Efficiency and effectiveness More thoughtful, compassionate care An ability to apply the appropriate knowledge to the right situation

Knowledge that would contribute to improving continence practice: Effectiveness of continence treatments, therapy and care Experience of and responses to incontinence, therapy, treatment, advertising, product use, etc. Processes for providing continence care, purchasing, etc. Inequities in continence care provision / service provision Socio-cultural impacts of incontinence, buying patterns, etc. Issues generating conflicting perspectives

The Challenge for Continence Care Basic research to generate new knowledge about continence treatment & care Get continence issues on the EBP agenda Undertake systematic reviews in relation to core practices in continence care Make this information accessible to practitioners Provide organisational support for EBP and research Fund research / access funding

Changes to Practice Question practice decisions based on authority alone Reflect on practice Look for evidence as a basis for decisionmaking Use clinical guidelines based on evidence that have been developed by others Ongoing review of clinical guidelines, based on evidence Evaluate the outcomes of practice Generate questions that need answering

Developing EBP Approaches Develop and lobby for clinically-relevant questions for systematic reviews Learn how to apply the results of studies done by others Share knowledge / expertise with others eg. attend conferences Learn to read research articles and systematic reviews critically eg. Start a journal club Resources l l l Use the library / databases Develop a library of CATS (critically appraised topics) Subscribe to the JBI, Cochrane Develop research skills / team up with someone who has research skills

Barriers to EBP Attitudes l Most clinicians do not read research literature, use research findings (eg. Nagy, et al, 1992) Resources l Access to libraries, journals, systematic reviews, research expertise, etc. Support Time, financial support to conduct research and disseminate findings l Organisational culture / structure l Knowledge

Sources of Information Different sources are required for different types of evidence Guidelines – professional organisations l Systematic reviews - Evidence based practice centres l National or local data - grey literature, organisational material l

Websites Cochrane Collaboration http: //www. cochrane. org Joanna Briggs Institute http: //www. joannabriggs. edu. au/about/home. php NHS Centre for Reviews and Dissemination The Database of Abstracts of Reviews of Effectiveness (DARE) Campbell Collaboration http: //www. campbellcollaboration. org The US Centre for Disease Control http: //www. cdc. gov/eval/resources. htm National Institute for Clinical (NICS) New Zealand Guideline Group http: //www. continence. org. nz/guidelines. html

JBI Resources Systematic reviews Best practice sheets Evidence utilisation Technical reports COn. NECT: Clinical Online Network of Evidence for Care and Therapeutics l Online facility providing resources and tools to search, appraise, summarise, embed, utilise and evaluate evidence-based information PACES program: Practical Application of Clinical Evidence System l An on-line tool for health professionals to conduct an audit in a large or small health care setting

The Future Clinically-focused research Clinicians developing and shaping their own practice area through research, publication Collaboration between clinicians and academics to develop knowledge to support evidence based practice eg. Research positions in health agencies More research into clinical practice undertaken by/in collaboration with clinicians Strategic planning for research activity in clinical practice Development of a library of evidence-based knowledge

Clinically-focused, rigorous research can be used to develop knowledge, enhance practice, and validate the value of practice in continence care. The outcome of refining and applying knowledge better care is for people with incontinence

Thankyou

References Sackett DC, Rosenberg WMC, Gray JAM, Haynes RB & Richsrdson WS. (1996) Evidence-based medicine: What it is and What isn’t it. British Journal of Medicine, 312, 71 -2. Popay J, Rogers A, Williams G. (1998). Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res, 8(3), 341 -351.

EBP - the next phase? Effectiveness: RCT, cohort studies etc. Appropriateness: meta-analysis / synthesis of interpretive research Feasibility: action research, critical approaches Basic research required to generate new knowledge Develop rigorous ways of evaluating the findings from non-RCT research

Questions and Critique of EBP in Continence Care Don’t we do this now? Could become a straight jacket for practice Could be used as a cost cutting measure What counts as evidence? Focuses on the measurable, values outcomes, not processes Limited research evidence in continence care Insufficient research skills We have to implement practices right now Where does experience and expertise fit?

NHMRC: Levels of Evidence 1995 I Evidence obtained from a systematic review of all relevant randomised controlled (RCT) trials II Evidence obtained from at least one properly designed randomised controlled trial III. 1 Evidence obtained from well-designed controlled trials without randomisation III. 2 Evidence obtained from well-designed cohort or case-control analytic studies preferably from more than one centre or research group III. 3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments IV Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Key Questions 1. Evidence base A Several Level I or II studies with low risk of bias B one or two Level II studies with low risk of bias or SR/multiple Level III studies with low risk of bias C Level III studies with low risk of bias or Level I or II studies with moderate risk of bias D Level IV studies or Level I to III studies with high risk of bias 2. Consistency A All studies consistent B Most studies consistent and inconsistency can be explained C Some inconsistency, reflecting genuine uncertainty around question D Evidence is inconsistent NA Not applicable (one study only) 3. Clinical impact A Very large B Moderate C Slight D Restricted 4. Generalisability A Evidence directly generalisable to target population B Evidence directly generalisable to target population with some caveats C Evidence not directly generalisable to the target population but could be sensibly applied D Evidence not directly generalisable to target population and hard to judge whether it is sensible to apply 5. Applicability A Evidence directly applicable to Australian healthcare context B Evidence applicable to Australian healthcare context with few caveats C Evidence probably applicable to Australian healthcare context with some caveats D Evidence not applicable to Australian healthcare context