Evidence-based practice and Cochrane Systematic Reviews as a tool for research, learning and making things better Professor Maritta Välimäki University of Turku, Dept of Nursing Science and Soutwest hospital district
Background Healthcare today is a complex system Increasing needs of specific knowledge of evaluation of research and implementation into clinical practice
Vision Evidence-based health care = The use of current best evidence in making decisions about the care of individual patients or the delivery of health services
Evidence-based practice (EBP) EBP is an approach to decisionmaking in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best Gray JAM. 1997. Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone.
Hierarchy of evaluative studies Objective Randomised trials Cohort studies Case control Subjective Case series
Randomized Controlled Studies
Large knowledge base A high number of published trials (about 200 new trials registered per a week) The number of people being enrolled in trials is likely to be more than 2,000,000 per year (Chan & Altman 2005)
Question to be answered: The challenges related to designing and preparing systematic reviews and their dissemination, implementation and evaluation How the Cochrane systematic reviews could be used in health and social care sectors as a tool for research, learning and practice development?
Structure of the presentation History Current situation Future
History
History Publication of Archie Cochrane's 'Effectiveness and Efficiency: random reflections on health services' (1972) Attention to our collective ignorance about the effects of health care
The Cochrane Centre 'The Cochrane Centre' opens in 1992 in Oxford, UK Development of Cochrane Collaboration Handbook begins with arrival of 1st Cochrane Visiting Fellow at the UK Cochrane Centre in 1993
Cochrane Network In the network, people work together to help health care providers, policymakers, patients, their advocates and carers make well-informed decisions about health care with the best available research evidence. www.cochrane.org
The Cochrane Collaboration Established in 1993 An international network: more than 28,000 people from over 100 countries 14 Centres Over 50 groups with different topics
Key Points 1. Seek to collate all evidence that fits pre-specified eligibility criteria in order to address a specific research question 2. Aim to minimise bias by using explicit, systematic methods 3. Prepares, maintains and promotes systematic reviews to inform healthcare decisions: Cochrane Reviews
What is a systematic review? A high-level overview of primary research on a particular research question It aims to identify, select, synthesize and appraise all high quality research evidence relevant to a specific question in order to answer it
Current situation
The Cochrane Library 5,000 reviews have been published online in The Cochrane Library In 2010 3,957,567 full-text downloads of Cochrane Reviews
The Cochrane Schizophrenia Group's Register, Nottingham, UK May 2011 the Group's Register contains: 16156 references and 13542 studies The Editors are based in Brazil, China, Finland, Germany, India, the USA, as well as the UK
Challenges
System reviews A rapid crow in non-systematic ( narrative ) reviews and case reports
Other challenges We still do not know exactly how many trials have been done How to access? A length of the systematic review reports 10 to several hundreds of pages Difficult writing style About half of systematic reviews are not updated and therefore includes unrelevant information for readers (Shojania et al. 2007) Publication bias Bastian et al. 2007
Factors associated with published articles (Lee ym. 2005) BMJ, Lancet, Annals of Internal Medicine 1,107 manuscripts between years 2003-2004; 6 % accepted a hight quality research methods used RCT studies funding body identified the authors lived in the same country as a publisher a large research data
The challenges in designing and preparing systematic reviews
Number of trial reports over time 100 90 80 70 Number of trials 60 50 40 30 20 10 0 R 2 = 0.59
A huge number of published abstracts.
A huge number of existing publications
Low number of existing studies..
Source of trials Africa-Asia 5% Australia 2% South & Central America 1% Europe 37% North America 54%
Frequency of trial size 500 400 Number of studies 300 200 100 0 Number of participants
Outcomes 640 different scales in first 2000 trials...and who uses rating scales in clinical practice?
Use of Cochrane Systematic Reviews
The scientific evidence for healthcare is not used sufficiently for decisions in daily practice as well as for changing practice
In Sweden (N = 5787; n = 1445) Areskoug Josefsson K et al. 2012 Knowledge used in daily clinical practice based on information about the patient personal experience local guidelines 20 % worked 'in the way they always had 11% used evidence from research as a basis for change The results are more prominent among assistant staff
Obstacles to the implementation of evidence-based physiotherapy in practice (Karin et al. 2009) Lack of autonomy and authority to decide on patients' treatments or to negotiate with government in Belgium The lack of evidence Inapplicability of scientific evidence The expectations from patients A lack of motivation hamper the implementation of EBP
Difficulties to understand the results
Dissemination, implementation and evaluation of systematic reviews
Inaccessibility (Karin et al. 2009)
Who and how the Cochrane systematic reviews could be used in health and social care sectors as a tool for research, learning and practice development?
The collaboration between clinical practice, education and research Research (researchers) Education (doctoral and master students) Practice (nurses, nursing directors, patients) Professor Maritta Välimäki
There is not one truth
The Evidence-based Medicine Triad Source: Florida State University, College of Medicine. Retrieved 08.07.11.
The role of health professionals in evidence-based practice A consumer of research A research subject A research facilitatior A research assistant A researcher preparing Cochrane systematic reviews