Presentation NVAO Evidence Based Practice

Evidence-Based Practice

Lunchbijeenkomst

14 maart 2013

HBO Universiteit

Post Grad

(E)MBA

Business Schools

1. Wat moet een student in de praktijk straks kunnen:

- zelf onderzoek doen?

- onderzoek kunnen beoordelen + toepassen?

2. Wat betekent dat voor het curriculum?

3. Wat betekent dat voor de accreditatie?

Aanleiding

“In onze moderne samenleving is het cruciaal dat hbo-

bachelors over een onderzoekend vermogen beschikken

dat leidt tot reflectie, tot evidence-based practice, en tot

innovatie.”

HBO standaard (2009)

Evidence-Based Practice ?

Wat is het?

Waar komt het vandaan?

Hoe ziet het er uit in een opleiding?

Hoe zit dat bij 4e jaars studenten?

Evidence based practice:

Wat is het?

Uitgangspunt bij evidence-based practice is dat beslissingen gebaseerd dienen te zijn op een combinatie van wetenschappelijk denken en de best beschikbare 'evidence'.

Evidence-based practice

Met het begrip 'evidence' wordt niet meer bedoeld dan 'informatie'.

Dit kan informatie zijn afkomstig uit wetenschappelijk onderzoek, maar ook interne bedrijfsinformatie en zelfs persoonlijke ervaring geldt als 'evidence’.

Evidence based practice

In principe neemt iedere manager dus beslissingen op basis van 'evidence'.

De meeste managers besteden echter nauwelijks aandacht aan de kwaliteit van de 'evidence' waarop ze hun beslissingen baseren.


Evidence-based practice:

kritisch en wetenschappelijk denken

van verschillende informatiebronnen gebruik maken

de beschikbare evidence kritisch tegen het licht houden

denken in termen van waarschijnlijkheid in plaats van 'golden bullets'.

Professional expertise and judgement

Best available organizational

evidence

Stakeholders’ values and concerns

Best available scientific evidence

Evidence-based decision



Waar komt het vandaan?

“there is a large research-user gap”

“practitioners do not read academic journals”

“the findings of research into what is an effective intervention

are not being translated into actual practice”

“academics not practitioners are driving the research agenda”

“the relevance, quality and applicability of research is

questionable”

“practice is being driven more by fads and fashions than

research”

“many practices are doing more harm than good”

What field is this?

McMaster University Medical School, Canada

Medicine: Founding fathers

David Sackett Gordon Guyatt

How it all started

if you’re hyperventilating

breathe into a bag

Problem I: persistent convictions

elderly people who have an irregular heartbeat are much more likely to die of

coronary disease

give them a drug that reduces the number of

irregular beats

Problem I: persistent convictions

How 40,000 cardiologists can be wrong

In the early 1980s newly introduced anti-arrhythmic drugs were found to be

highly successful at suppressing arrhythmias.

Not until a RCT was performed was it realized that, although these drugs suppressed arrhythmias, they actually increased mortality.

By the time the results of this trial were published, at least 100,000 such patients had been taking these drugs.

David Sackett

Half of what you learn in medical school will be

shown to be either dead wrong or out-of-date

within 5 years of your graduation; the trouble is that

nobody can tell you which half.

The most important thing to learn is how to learn

on your own: search for the evidence!

(Remember that your teachers are as full of bullshit

as your parents)

More than 1 million articles in 40,000 medical journals per

year (= 1995; now probably more than 2 million). For a

specialist to keep up this means reading 25 articles every

day (for a GP more than 100!)

Problem II: too much information

Problem II: too much information

HRM: 1,350 articles in 2010 (ABI/INFORM). For an HR

manager to keep up this means reading 3 to 4 articles

every day (for a ‘general’ manager more than 50!)

BTW: most of the research is seriously

flawed or irrelevant for practice

The 5 steps EBP

1. Formulate a focused question (Ask)

2. Search for the best available evidence (Acquire)

3. Critically appraise the evidence (Appraise)

4. Integrate the evidence with your professional

expertise and apply (Apply)

5. Monitor the outcome (Assess)

Zelf onderzoek doen?

Evidence-Based Practice

1991Medicine

1998Education

1999Social care, public policy

2000Nursing

2000Criminal justice

????Management?


Hoe ziet het er uit in de opleiding?

Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken

Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek.

Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal)

Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)


Professional expertise and judgment

Best available organizational

evidence

Stakeholders’ values and concerns

Best available scientific evidence

Evidence-based decision


Waarom (wetenschappelijk) onderzoek?

Trust me, 20 years of experience

Bounded rationality

“The first principle is that you must not fool yourself - and you are the easiest person to fool”.

Richard Feynman

Bounded rationality

Het feilbare brein

System 1

Snel, actie Intuitief, associatief shortcuts & biasses

System 2

Langzaam (lui!) Rationeel Nadenken

Systeem 1

Seeing order in randomness Mental corner cutting Misinterpretation of incomplete data Halo effect False consensus effect Group think Self serving bias Sunk cost fallacy Cognitive dissonance reduction

Confirmation bias Authority bias Small numbers fallacy In-group bias Recall bias Anchoring bias Inaccurate covariation detection Distortions due to plausibility

Systeem 1: het feilbare brein

Het feilbare brein- Meningen

- Assumpties (aannames)

- Overtuigingen

- Persoonlijke ervaringen

Wetenschappelijk onderzoek- Feiten

- Evidence: bewijs / aanwijzingen

Waarom onderzoek?

BIAS

1. Denkfouten

2. Informatiebronnen

3. Mythbusting

4. Assumpties

Fase 1: Kritisch & wetenschappelijk denken

1. Seeing order in randomness

2. Confirmation bias

3. Small numbers fallacy

4. Outcome bias

5. Halo effect

6. Authority bias

7. Group think

7 Denkfouten (die u beter aan anderen kunt overlaten)

Een Type I fout of een vals positief: denken dat er een patroon / verband is terwijl dat er in het echt niet is.

Een Type II fout of een vals negatief: denken dat er geen patroon / verband is terwijl dat er in het echt wel is

Dr. Michael Shermer (Director of the Skeptics Society)

Seeing order in randomness

Een Type I fout of een vals positief: denken dat het geritsel in de bosjes een gevaarlijk roofdier is, terwijl het gewoon de wind is (goedkoop foutje)

Het feilbare brein: patern recognition

Een Type II fout of een vals negatief: denken dat het geritsel in de bosjes gewoon de wind is, terwijl het een gevaarlijk roofdier is (duur foutje)


Het probleem met patroon herkenning:

Het kritisch beoordelen of er sprake is van een

Type I of een Type II fout is best moeilijk,

(vooral in ‘split second life and death’ situaties),

dus de default positie is om aan te nemen dat

alle patronen echt zijn.


Een Type I fout of een vals positief: denken dat het geritsel in de bosjes een gevaarlijk roofdier is, terwijl het gewoon de wind is (goedkoop foutje)

DEFAULT

Een Type II fout of een vals negatief: denken dat het geritsel in de bosjes gewoon de wind is, terwijl het een gevaarlijk roofdier is (duur foutje)


Ook ervaren mensen en experts zien patronen en verbanden waar ze niet zijn.

stress & lifestyle peptic ulcer


Peptic ulcer – an infectious disease!

This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.

In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now

firmly established that Helicobacter pylori causes more then 90% of duodenal ulcers. The link between Helicobacter pylori infection and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.

Oct 2005

Ook slimme mensen houden er verkeerde ideeën op

na, niet omdat ze dom of eigenwijs zijn, maar omdat het

de meest logische conclusie is op basis van hun eigen

ervaringen.


(systeem 1 doet altijd mee!)






5-step approach

EBMgt is a 5-step approach

1. Formulate an answerable question (PICOC)

2. Search for the best available evidence

3. Critically appraise the quality of the found

evidence

4. Integrate the evidence with managerial

expertise and organizational concerns and apply

5. Monitor and evaluate the results

Formulate a focused question

Focused question?

Does team-building work?

What are the costs and benefits of self-steering teams?

What are the success factors for culture change?

Does management development improve the

performance of managers?

Does employee participation prevent resistance to

change?

How do employees feel about 360 degree feedback?

What is a ‘team’?

What kind of teams?

In what contexts/settings?

What counts as ‘team-building’?

What does ‘work’ mean?

What outcomes are relevant?

Over what time periods?

Foreground question?

Does team-building work?

P = Population

I = Intervention or success factor

C = Comparison

O = Outcome

C = Context

Answerable question: PICOC

2. Finding the best available evidence

Searching evidence

What do we search?

Current Information

Overview of a subject

General background

Academic Information

Statistical Information

Theories about a subject

What do we search?

Company information

Peer reviewed journals

Searching evidence

Where do we search?

Searching for evidence

Databases

ABI/INFORM

Business Source Elite

PsycINFO

Web of Knowledge

ERIC

Google Scholar

Searching for evidence

Searching evidence

How do we search?

Search Strategy

Two types of search strategies

Search strategy

Building blocks methodSnowball method

Search strategy

Search in ABI/Inform:

1. How many articles has Stephen Covey published in peer reviewed journals?

2. How many of these articles are based on scientific research?

3. Are there articles (by other authors) that are critical of Covey’s 7 Habits?

4. How many of these critical articles are based on scientific research?

Exercise: Search for evidence

Search in ABI/Inform or BSE:

Search for peer reviewed research articles to answer the following question: What is the long term effect of a hostile take-over on the financial performance of the acquired organization? Use the following search terms:

“hostile takeovers”, “financial performance”, “long term”

How many studies did you find?

Exercise: Search for evidence






Which design for which question?

Research designs

Randomized controlled study? Grounded theory approach? Cohort / panel study? Qualitative field research? Longitudinal study? Post-test only study? Survey? Action research? Case study?

What is the best design?

What is the BEST car?

What is the best design?

quants vs quallies, positivists vs post structuralist, etc

on the research question

Effect vs Non-effect

Types of questions

Does it work?

Does it work better than ....?

Does it have an effect on ....?

What is the success factor for ....?

What is required to make it work ...?

Will it do more good than harm?

Effect

Types of questions: non-effect

Needs: What do people want or need?

Attitude: What do people think or feel?

Experience: What are peoples’ experiences?

Prevalence: How many / often do people / organizations ...?

Procedure: How can we implement ...?

Process: How does it work?

Explanation: Why does it work?

Economics: How much does it cost?

Internal validity

internal validity = indicates to what extent the

results of the research may be biased and is thus

a comment on the degree to which alternative

explanations for the outcome found are possible.

Internal validity

We are pattern seeking primates:

we are predisposed to see order

and causal relations in the world

Causal relations

1. Are the "cause" and the "effect” related?

2. Does the "cause" precede the "effect" in time?

3. Are there no plausible alternative explanations for the

observed effect?

effect size

before and after measurement

randomization, blinding, control group, measurements

Considerations for research:

Causality

Bias & Confounding

Research shows:

Shoe size > quality of handwriting

Smoking youngsters > better lung function

Levels of internal validity

Explanation

Which design for which question?

Different types of research questions

require different types of research designs,

but ...

Best research design?

But 1: feasibility

But 1: feasibility

Step 3: Critical appraisal of studies

Intermezzo

How to read a research article?

Critical appraisal: quick and dirty

Is the study design appropriate to the stated aims?

Are the measurements likely to be valid and reliable?

Was there a relevant effect size?

Is the outcome (population, type of organization)

generalizable to your situation?

Levels of internal validity

1. Were there enough subjects in the study?

2. Was a control group used?

3. Were the subjects randomly assigned?

4. Was a pretest used?

5. Was the study started prior to the intervention or event?

6. Was the outcome measured in an objective and reliable way?

6x yes = very high (A)

5x yes = high (A)

4-3x yes = limited (B)

2x yes = low (C)

1-0x yes = very low (D)

Appraisal

Critical appraisal questionnaires

www.cebma.org/ebp-tools

CAT: Critically Appraised Topic

CAT: Critically Appraised Topic

A critically appraised topic (or CAT) is a structured, short (3

pages max) summary of evidence on a topic of interest,

usually focused around a practical problem or question. A CAT

is like a “quick and dirty” version of a systematic review,

summarizing the best available research evidence on a topic.

Usually more than one study is included in a CAT.

CAT: structure

1) Background / context

2) Question (PICOC)

3) Search strategy

4) Results / evidence summary

5) Findings

6) Limitations

7) Recommendation

CAT-walk