Evidence Based Practice
What is Evidence-Based Medicine?
"Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making 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 DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-72.
EBM Venn Diagram Five A's of the Decision Making Cycle |
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Image source: https://health.ucdavis.edu/cnr/evidence_based_practice.html |
Image source: https://www.library.ucdavis.edu/guide/ebp-resources/ |
What is PICO?
Practitioners of EBP Research often use the PICO format to help define and answer your research question.
By organizing a research question using PICO, a researcher can determine specific terms that will help find relevant evidence in professional literature.
PICO Tools
- 7 Steps to the Perfect PICO Search - from EBSCO
- The Underappreciated and Misunderstood PICOT Question: A Critical Step in the EBP Process. [Article]
- How to Create a Well-Built Clinical Question - from NLM
- PICO Worksheet [pdf]
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PICO and Search Query Worksheet [pdf] from Ebling Library - University of Wisconsin-Madison
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PICO Center - from Ovid
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PICO Linguist / Babel MeSH - Multilanguage search for Medline/PubMed from NLM
Types of Possible Questions in Relation to PICO
https://s3.amazonaws.com/libapps/accounts/43254/images/PICO_Questions_.png
PICOT Search
AJN's Evidence-Based Practice Series: Step by Step
This series was published in the American Journal of Nursing, 2009-2011. It came from The Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice.
"Evidence-Based Practice (EBP) is a problem solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.
The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time." - from "Igniting a Spirit of Inquiry," the first article in the series.
AJN's Evidence-based Practice Step-by-Step (Updated with EBP 2.0)
Evidence-Based Practice Part 1 : Developing and Searching the Clinical Question
Evidence-Based Practice, Part 2 : Critical Appraisal of the Evidence
Evidence-Based Practice Part 3 : Implementation
Evidence-Based Practice Part 4 : Disseminating the Evidence and Sustaining the Change
- EBP 2.0: From Strategy to Implementation
- EBP 2.0: Promoting Nurse Retention through Career Development Planning
- EBP 2.0: Data-Driven Precision Implementation Approach
- EBP 2.0: Implementing and Sustaining Change: The STAND Skin Bundle
- EBP 2.0: Implementing and Sustaining Change: The Malnutrition Readmission Prevention Protocol
- EBP 2.0: Implementing and Sustaining Change: The Evidence-Based Practice and Research Fellowship Program
- EBP 2.0: Implementing and Sustaining Change: Implementing Improved Central Line Flushing Practices
Evidence Pyramid
An evidence pyramid visually depicts the evidential strength of different research designs. The image below is one of several available renderings of an evidence pyramid.
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- Studies with the highest internal validity, characterized by a high degree of quantitative analysis, review, analysis, and stringent scientific methodology, are at the top of the pyramid.
- Observational research and expert opinion reside at the bottom of the pyramid.
Levels of Evidence |
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Level I |
Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or 3 or more RCTs of good quality that have similar results. |
Level II |
Evidence obtained from at least one well designed RCT (eg large multi-site RCT). |
Level III |
Evidence obtained from well-designed controlled trials without randomization (ie quasi-experimental). |
Level IV |
Evidence from well-designed case-control or cohort studies. |
Level V |
Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis). |
Level VI |
Evidence from a single descriptive or qualitative study. |
Level VII |
Evidence from the opinion of authorities and/or reports of expert committees. |
Types of Study Designs
Systematic Review
A summary of the clinical literature. A systematic review is a critical assessment and evaluation of all research studies that address a particular clinical issue. The researchers use an organized method of locating, assembling, and evaluating a body of literature on a particular topic using a set of specific criteria. A systematic review typically includes a description of the findings of the collection of research studies. (AHRQ Glossary of Terms)
Meta-Analysis
A work consisting of studies using a quantitative method of combining the results of independent studies (usually drawn from the published literature) and synthesizing summaries and conclusions which may be used to evaluate therapeutic effectiveness, plan new studies, etc. It is often an overview of clinical trials. It is usually called a meta-analysis by the author or sponsoring body and should be differentiated from reviews of literature. (PubMed)
Randomized Controlled Trial
A controlled clinical trial that randomly (by chance) assigns participants to two or more groups. There are various methods to randomize study participants to their groups. (AHRQ Glossary of Terms)
Controlled Clinical Trial
A type of clinical trial comparing the effectiveness of one medication or treatment with the effectiveness of another medication or treatment. In many controlled trials, the other treatment is a placebo (inactive substance) and is considered the "control." (AHRQ Glossary of Terms)
Cohort Study
A clinical research study in which people who presently have a certain condition or receive a particular treatment are followed over time and compared with another group of people who are not affected by the condition. (AHRQ Glossary of Terms)
Case Control Study
The observational epidemiologic study of persons with the disease (or other outcome variable) of interest and a suitable control (comparison, reference) group of persons without the disease. The relationship of an attribute to the disease is examined by comparing the diseased and non-diseased with regard to how frequently the attribute is present or, if quantitative, the levels of the attribute, in each of the groups. (OCEBM Table of Evidence Glossary)
Case Series
A group or series of case reports involving patients who were given similar treatment. Reports of case series usually contain detailed information about the individual patients. This includes demographic information (for example, age, gender, ethnic origin) and information on diagnosis, treatment, response to treatment, and follow-up after treatment. (OCEBM Table of Evidence Glossary)
Case Study
An investigation of a single subject or a single unit, which could be a small number of individuals who seem to be representative of a larger group or very different from it. (Dictionary of Nursing Theory and Research, Fourth Edition)
Editorial
Work consisting of a statement of the opinions, beliefs, and policy of the editor or publisher of a journal, usually on current matters of medical or scientific significance to the medical community or society at large. The editorials published by editors of journals representing the official organ of a society or organization are generally substantive. (PubMed)
Opinion
A belief or conclusion held with confidence but not substantiated by positive knowledge or proof. (The Free Dictionary)
Animal Research
A laboratory experiment using animals to study the development and progression of diseases. Animal studies also test how safe and effective new treatments are before they are tested in people.(NCI Dictionary of Cancer Terms)
In Vitro Research
In the laboratory (outside the body). The opposite of in vivo (in the body). (NCI Dictionary of Cancer Terms)
Centre of Evidence Based Medicine: Study Designs
According to the Centre of Evidence Based Medicine, study designs include:
- A defined population (P) from which groups of subjects are studied
- Outcomes (O) that are measured
Experimental and analytic observational studies also include
- Interventions (I) or exposures (E) that are applied to different groups of subjects
Click here: CEBM to go to a description of each research study type, their strengths and weaknesses
https://www.cebm.ox.ac.uk/images/resources/263_study-design.jpg
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