Royal College of Surgeons in Ireland Finding & Using Evidence Prof. Seamus Cowman Royal College of Surgeons in Ireland December 2005 Finding and Using

Royal College of Surgeons in IrelandFinding & Using Evidence

Prof. Seamus CowmanRoyal College of Surgeons in Ireland

December 2005

Finding and Using Evidence: The Healthcare Experience

Irish Evaluation NetworkIrish Evaluation Network


Central thesis of the paper

How do we know what we do and the decisions we make are derived from best practice?

The importance of evidence in making decisions Determine a process of finding and validating

knowledge for use in day to day activities Research based knowledge is fundamental to

effectiveness and valid and reliable outcomes


Evaluation finding and using evidence – the links Evaluation: what is said

A means of systematically collecting and analysing of information.

Purpose of evaluation is to improve effectiveness – activities and outcomes

Necessary not only to improve practice but prove it

Inevitably concerned with decision making


• Decision making often based on values and opinion:

• Confusion about best practice

The Importance of Evidence


Public Expectation & Consumerist ethos

Quality Assurance, User Satisfaction

Accountability and efficient use of available resources



Patients as informed consumers want more, expect more and complain more



Research utilisation is a ‘systematic method of implementing sound, research based innovations in clinical practice, evaluating the outcomes and sharing the knowledge through the process of research dissemination.’

(LoBiondo-Wood & Haber, 1994)

Research Utilisation


Unsatisfactory Why?

Lack of focus on outcomes research Inadequate dissemination of research findings Failure to maximise potential avenues for

dissemination eg; on line, Internet, Intranet



Policy makers rarely signal a demand for research, many appear allergic to research and pay lip service to evidence based policy; even when there is an appetite for change

Pestieau 2003



It has proved difficult to uncover many instances where social sciences research has had a clear and direct influence on policy even when it has been specifically commissioned by government

Quinn Patton 1997



Communication gap between researcher and practitioner

Findings communicated primarily to other researchers

Practitioner may not value research findings

Barriers to Research Utilisation


Researcher originated studies

Policy making perceived exclusively as an art rather than a science.

Practitioners and decision makers do not know how to apply research findings

Barriers to Research Utilisation


In a study with medical doctors, therapy issues and critical appraisal of literature on appropriate clinical practice only 5 out of 36 searched the Cochrane library, appraisals were sometimes inaccurate.

When article was retrieved for appraisal usability was found to be high www.jrsm.org/cgi/content/full/94/11/573

Information Retrieval


In a nursing study it was reported that it is not the research knowledge per se that carries little weight in the clinical decision making process but rather the medium through which it is delivered and the process of retrieval (Thompson et al 2001)

Information Retrieval


The average time span between discovery and utilisation is 20 years

Decrease in time for utilisation of discoveries 1185 - 1919 30 years 1945 – 1965 17 years

The Time Lag

(Glaser et al 1983) Putting knowledge to use Jossey Bass.


The Time Lag

Innovation Conception Realisation

Pacemaker 1928 1960

ECG 1937 1959

Oral Contraceptive 1951 1960

Insecticides 1934 1947

In/output Econ analysis

1936 1964

Video Recorder 1950 1956


Collaborate with Practitioners Disseminate Research Findings

Aggressively Communicate in a way comprehensible to

non researchers Suggest practical implications, how can

findings be utilised

Message for Researchers


Read widely and critically online searching of www and data bases – Start up a Journal Club: Create a learning culture

Attend professional conferences/seminars Learn to expect evidence that a procedure is

effective Collaborate with researcher Participate/initiate institutional projects

Message for Practitioners/decision makers


Foster a climate of intellectual curiosity Offer support and facilitation to researchers Offer financial support and resource support

for utilisation Reward efforts of research utilisation Support an Evidence Based Practice culture

Message for Administrators


• Too much information available• Literature reviews can be biased

Cochrane Collaboration (2003)

Finding Best Evidence


Publication Bias• Time lag bias• Multiple (duplicate) publication bias• Citation bias• Language bias• Outcome reporting bias

• Systematic reviews attempt to minimise bias and provides confidence with the use of knowledge.

Egger et al, (2001)



Case Study

A Practical Problem becomes a Cochrane Review .

Egger et al, (2001)



Pressure Ulcer


Pressure Ulcer

Royal College of Surgeons in IrelandFinding & Using Evidence Pressure UlcerPressure Ulcer


An EU study found that 18% of hospital patients had a pressure ulcer (EPUAP 2002)

Cost of Pressure Ulcer management in the UK estimated to be £1.4 - 2.1 billon

(4% total healthcare budget).

The Importance of Research Evidence


To assess the effects of wound cleansing solutions and techniques on

the healing rates of pressure ulcers

Objective of Systematic Review


The Cochrane library contains 2,500 reviews. – Randomised Control trials (RCTs)

A data base of evidence about different interventions It assess intervention across all areas of healthcare and brings together sufficient research evidence to draw conclusions about the effects of an intervention.

Cochrane Database


A Systematic Review

A way of Finding, Assessing, and Using evidence from studies (usually RCTs) to obtain a reliable overview

Cochrane Collaboration (2003)

Finding the Evidence


• RCT's comparing wound cleansing with no wound cleansing

• RCT's comparing different wound cleansing solutions

• RCT's comparing different wound cleansing techniques

• No restrictions regarding year or language of publication

Types of Study included in Review


Studies involving people of any age, in any health care setting, with existing

pressure ulcers

(defined as a break in the continuity of the skin caused by pressure with or without shearing/friction forces)

Type of Participant


• An objective measure of pressure ulcer healing• Time to complete healing • Rate of change in pressure ulcer area or volume • Proportion of pressure ulcers healed

Type of Outcome Measure - Primary


• Pain, using validated scales where reported• Ease of use of the method of cleansing• Secondary outcomes only reported from studies

which also report primary outcomes

Type of Outcome Measure - Secondary


• Cochrane Central Register of Controlled Trials (CENTRAL)

• Specialised Trials Register of the Cochrane Wounds Group (up to August 2005)

• Hand search of relevant bibliographies• Contacted experts and researchers in the field

Search Strategy


• 2 authors extracted data independently • Structured narrative summary initially• Data entered into Cochrane RevMan 4.2 and

analysed with Cochrane MetaView. • For dichotomous outcomes RR & 95% CI

calculated• For continuous outcomes WMD & 95% CI

calculated• Meta analysis not conducted due to small number

of diverse RCT’s

Data Extraction & Analysis


• Were the eligibility criteria clearly specified• Was the generation of the randomisation truly random• Was the allocation to treatment group concealed• Were the groups similar at base line in term of prognostic

factors• Were outcome assessors blinded to treatment allocation• Were measures of variability for each group presented for

the primary outcome measure• Were participants analysed in groups in which originally

allocated.

Data Extraction Criteria


Initial search

111111 titles

3333 letters written

1313 replies received

no new studies

Abstracts reviewed

1212 papers

possibly eligible

Inclusion

Criteria applied

33 papers

eligible


Results

Study Bellingeri(2004)

Griffiths(2001)

Burke(1998)

Setting Hospital Community Hospital

Treatment Saline solution versus isotonic

saline

Water versus Saline

Whirlpool versus no whirlpool

Outcome Measure

PSST Wound Size Length X Width

Number 126 patients 8 patients 42 ulcers

Result P = 0.025 NS NS


StudyBellingeri

(2004)Griffiths

(2001)Burke(1998)

Eligibility Criteria

Described Described Described

RandomAllocation

Yes Yes Yes

ConcealedAllocation

No No No

Blinded Assessment

No information

Yes Yes

ITT No Yes Yes

Methodological Quality


Conclusion

Overall, there is no good trial evidence to support use of any

particular wound cleansing solution or technique for pressure ulcers


Reflections

• 19 months work• Greatest challenge lay in the lack of

clarity in publications• Lack of data a disappointment


Moore Z., Cowman S. Wound cleansing for pressure ulcers. The Cochrane

Database of Systematic Reviews 2004, Issue 4, Art, No.: CD004983. DO1:

10.1002/14651858.CD004983.

Cochrane Review

Documents

Royal College of Surgeons in Ireland Finding & Using Evidence Prof. Seamus Cowman Royal College of Surgeons in Ireland December 2005 Finding and Using