From Concept to Implementation: The Challenges Facing Evidence- Based Social Work Faculty Research & Insights: A Series Featuring CUSSW Faculty Research.
Slide 1From Concept to Implementation: The Challenges Facing Evidence- Based Social Work Faculty Research & Insights: A Series Featuring CUSSW Faculty Research Edward Mullen & Aron Shlonsky September 22, 2004 Slide 2 Evidence-Based Social Work Is A Concept Awaiting Implementation Much discussed Required in EPAS Not clearly Defined Not yet implemented in pure form --- the conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of service-users and carers (Sheldon, 2003, p. 1). Placing the clients benefits first, evidence-based practitioners adopt a process of lifelong learning that involves continually posing specific questions of direct practical importance to clients, searching objectively and efficiently for the current best evidence relative to each question, and taking appropriate action guided by evidence (Gibbs et al., 2003, p. 6). Evidence-based medicine has been defined as --- the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (Sackett, et al., 1996, p. 71); and the "integration of best research evidence with clinical expertise and patient values" (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000, p. 1). Slide 3 Origin of Evidence-Based Social Work Adaptation of evidence-based approaches found in medicine and healthcare Evolution from earlier attempts to join policy-practice- research Effectiveness research Eclecticism Empiricism & the scientist-practitioner model Social intervention research Outcomes measurement Systematic review methodologies meta-analysis Eileen Gambrill early translator (1999) Leonard Gibbs first workbook-text (2003) Aaron Rosen & Enola Proctor on guidelines (2003) Slide 4 EBP The EBP Model Best Evidence Client Values and Expectations Practitioners Individual Expertise Sackett et al., 1997 Slide 5 Newest EBP Model Clinical state and circumstances Clinical Expertise Client Preferences and actions Research Evidence Haynes, Devereaux, and Guyatt, 2002 Slide 6 Steps of EBP Become Motivated to Apply EBP Step 1Convert information need (prevention, assessment, treatment, risk) into an answerable question. Step 2Track down current best evidence. Step 3Critically appraise the evidence. Step 4Integrate critical appraisal with practice experience, clients strengths, values, and circumstances. Step 5Evaluate effectiveness and efficiency in exercising steps 1-4 and seek ways to improve them next time. Step 6Teach others to follow the same process Gibbs, 2003 Slide 7 The Cycle of EBP Clinical state and circumstances Client Preferences and actions Current Best Evidence Clinical Expertise Actuarial risk assessment Contextual assessment Other valid assessment measures? Effective services Appropriate for this client? Barriers (e.g., cultural conflict Clients preferred course or at least willing to try? Adapated from Haynes, Devereaux, and Guyatt, 2002; as presented in Shlonsky and Wagner, in press. Slide 8 Hallmarks of EBP Individualized assessment (strengths, needs, values, preferences of client) Well-formulated question (database query) Well-executed search of research literature Deciding its applicability to clients Considering the evidence together with the values and preferences of the client. Sackett et al., 1997; Gibbs, 2003 Slide 9 Origins of Evidence-Based Healthcare & Public Policy Used to inform health care policy at hospital, regional, & national levels (Davies & Boruch, 2001; Romanow, 2002; Gray, 2001; Davies, Nutley, & Smith, 2000) Became component of New Labours modernizing government strategy - extended to other sectors including social care (Davies, 2004; Walker, 2001) Facilitated by: Cochrane & Campbell Collaborations UK ESRCs evidence-based practice & policy centres UK Social Care Institute for Excellence Sweden Institute for Evidence-Based Social Work Publications e.g., Evidence-based Policy: A Journal of Research, Debate and Practice Slide 10 Policy Applications An approach to policy that: helps people make well informed decisions about policies, programs & projects EBPolicy contrasts with opinion-based policy which relies heavily on either the selective use of evidence (single studies irrespective of quality) untested views of individuals or groups Philip Davies (2004), Director of Policy Evaluation in the Cabinet Office of the UK Prime Ministers Strategy Unit Slide 11 What is evidence-based healthcare? Discipline centered on evidence-based decision-making about: -Groups of patients -Populations Evidence from wide range of disciplines Use of scientific research findings and logic Healthcare problems Health improvement Decision-making in healthcare Gray 2001 Slide 12 Evidence-Based Policy Definition Decision-making process in which policy-makers, purchasers, managers, or practitioners together with key stakeholders make decisions about problem or need assessment, goals & objectives, interventions & outcomes Slide 13 EBPolicy Process (Gray, 2001) Slide 14 Sources of Evidence in EBP Slide 15 EBPolicy Steps Finding and appraising evidence pertaining to the decision at hand: Assessment or intervention options Intended outcomes Research method Developing organizational capacity Getting the evidence into practice Preparing a policy Making cultural changes Designing systems for implementation Implementation Monitoring Audit Slide 16 Examples of Evidence-based Policy Initiatives EVIDENCE AND POLICY: A JOURNAL OF RESEARCH, DEBATE AND PRACTICE ESRC Evidence Network - UK Centre for Evidence Based Policy & Practice U.K. Cabinet Office University of St. Andrews Romanow Commission Canada U.S. Implementing Evidence-based Practices Project Slide 17 Arguments For Evidence-Based Social Work (EBSW) Enhances decision quality Fosters learning of assessment skills Incorporates client values and expectations Fosters evidence search and appraisal skills Makes best use of best evidence Framework for self-directed, life-long learning Identifies gaps in knowledge Common interdisciplinary language Sackett et al, 2000 Slide 18 Arguments For Evidence-Based Social Work (EBSW) Eschews authoritarian practices and policies Promotes SW ethics through: Informed consent Using effective services Wisely allocating scarce resources Involving clients in practice process Individualizing & personalizing decisions Gambrill, 2003 Slide 19 Arguments For Evidence-Based Social Work (EBSW) Helping clients develop critical appraisal skills Involving clients in design and critique of practice and policy related research Involving clients as informed participants who share in decision making Recognizing clients unique knowledge in terms of application concerns Promoting transparency and honesty Encouraging a systemic approach for integrating practical, ethical and evidentiary issues Maximizing the flow of knowledge and information about knowledge gaps Gambrill, 2003 Slide 20 Challenges Facing EBSW Evidence-of-effectiveness Authority Conflicting hierarchy Definition of evidence Shortage of evidence Variation by field of practice Inflation of evidence Small & transient effects Assessment validity Nomothetic versus ideographic knowledge Efficacy versus effectiveness Diffusion, adoption and implementation Policy & system level issues Training & sustaining Slide 21 Evidence-of-effectiveness Challenge A key assumption of EBP is that it results in better outcomes than other forms of practice Yet, this assumption is not empirically testable: This proof is no more achievable for the new paradigm (EBM) than it is for the old, for no long-term randomized trials of traditional and evidence-based medicine are likely to be carried out. (Evidence-Based Medicine Working Group, 1992, 2424) Slide 22 Authority Challenge As originally conceived the founders of evidence-based medicine envisioned that medical practitioners would seek out evidence & appraise the quality of that evidence, alone or in teams of practitioners The new paradigm puts a much lower value on authority. The underlying belief is that physicians can gain the skills to make independent assessment of evidence and thus evaluate the credibility of opinions being offered by experts (Evidence-Based Medicine Working Group, 1992) Slide 23 Authority Challenge Lack of evidence that EBM can be transmitted into practice Medical students have not shown an interest in becoming evidence-based practitioners only evidence users As evidence users rather than independent appraisers, practitioners are simply replacing one authority with another researchers are the new authorities! Slide 24 Authority Challenge To date it has not been shown that average practitioners can gain the skills needed to conduct independent assessments of the evidence Practitioners can become evidence-users not evidence-based practitioners say Upshur & Tracy Evidence-users accept evidence that has been vetted by others thus replacing one authority for another! But what is the basis for the authority of the evidence appraisers? Slide 25 Conflicting Hierarchy Challenge Hierarchy of Evidence Ranked by Quality N of 1 randomized trials Systematic reviews/Meta-analysis of randomized trials Randomized Controlled Trials Systematic review of observational studies addressing patient-important outcomes Physiological/Laboratory experiments Unsystematic clinical observation Slide 26 Conflicting Hierarchy Challenge Practice recommendations (e.g., practice guidelines) are to be based on the soundness of the evidence Many evidence hierarchies have been published & these hierarchies are not commensurable (e.g., randomized, controlled trials and meta-analysis versus well designed epidemiological studies) Fundamentally these hierarchies do not rest on evidence but rather on the consensus of experts the beliefs of the few! Slide 27 Definition of Evidence Challenge Because contemporary health care and human services are multidisciplinary there are many differing perspectives that require consideration Accordingly, the concept of a univocal understanding of evidence is not sustainable A restrictive view of evidence is not sustainable Slide 28 Shortage of Evidence Challenge The question that faces proponents of EBP is whether there are enough high-quality studies so that evidence- based decisions can be made. Surprisingly for a field that places a high premium on research, few studies have examined this. The conclusion at this point, based on just a few studies, is that there are still many decisions that are made that are not based on good evidence, but the picture is not nearly as bleak as opponents to EBP would have us believe. Professionals must remember, though, that when they make decisions for which little or no evidence exists, that they should exercise caution and perhaps be even more vigilant in monitoring outcomes. Slide 29 Shortage of Evidence Varies by field of practice Confounded by inflation of evidence by proponents and users Clouded by dominance of small and transient effects Applies to assessment evidence as well as intervention evidence Slide 30 Shortage of Evidence Varies by Field of Practice Adequacy varies considerably by field of practice Most robust is mental health In other fields of practice much more of a patchwork Unevenness of the research base across fields of practice looms as a major challenge Slide 31 Inflation of Evidence Challenge Bias in reported research due to: Tendency for investigators or assistants to give a leg up to interventions they favour - expectation for improvement Dependence on client self-report to measure intervention outcomes which may reflect social desirability, expectancy, & cognitive dissonance effects Slide 32 Small & Transient Effect Size Challenge The rule is small effect sizes which may not be clinically or social important Gains frequently do not persist, especially for complex and chronic problems such as addressed by social workers Slide 33 Assessment Challenge Reliable, valid, & relevant assessment tools are needed to support evidence-based social work practice Rapid assessment measures have contributed greatly (Corcoran & Fisher, 2000) Social work practitioners generally do not use any standardized assessment procedures to guide their practice (Mullen & Bacon, 2004) Slide 34 Shortage of Evidence Challenge Evidence-based social workers must remember that when they make decisions for which little or no evidence exists, that they should exercise caution and perhaps be even more vigilant in monitoring outcomes Knowledge gaps point the way to needed research Methodological corrections should be instituted to deal with the inflation of evidence issue Where interventions are found to have small with transient effects of limited importance this should be acknowledged and addressed The underutilization of assessment instruments should be corrected by enhance training in the use of appropriate instruments & dissemination of information about available instruments. Slide 35 Challenge of Applying Results to Individuals Results of RCTs are analyzed by comparing the mean score of the experimental group against that of the placebo or control group (or some comparable summary statistic). This masks the fact that there is always individual variability around the means, & overlap in the distributions of scores for the two groups. The result of this is that a proportion of people in the experimental group actually do worse than some in the control group and, conversely, some in the comparison group improve more than some people in the active treatment group. Practitioners cannot blindly apply a proven procedure and assume that a particular individual receiving that procedure will benefit Slide 36 Challenge of Applying Results to Individuals We are at least able to quantify the probability with which an individual person will respond to a given procedure (Number Needed to Treat) Alternative to using evidence-based interventions with their known rate of failure is to use unproven procedures, based only on the hope that they may work Practitioners can and should view each case or situation as an N = 1 study and collect data Slide 37 Efficacy Versus Effectiveness Challenge The efficacy versus effectiveness challenge requires a careful consideration of the trade off between internal and external validity Claims to evidence-based practice typically must be grounded in random, controlled trials which usually translate into efficacy studies Such studies do not address how effective such interventions would be in real world contexts At the present time there is a paucity of evidence of relevance to social work based on effectiveness studies conducted in real world contexts it may be more efficient to begin with studies based on conditions as realistic as possible so as to avoid the misinformation that too frequently comes from misinterpretations of efficacy studies Slide 38 Adoption & Implementation Challenge Two major challenges: (1) adoption & effective implementation of evidence-based practice in social agencies (2) educating for evidence-based practice Sisyphus Slide 39 Training, Time, Resources Challenges EBP requires: Training in search techniques Training in critical appraisal Computer resources Electronic resources Slide 40 Killer Bs Low BASE rate Incompatible client or community BELIEFS BAD BARGAIN in terms of scarce resources BARRIERS too high Slide 41 Adoption & Implementation Challenge Motivate core group Acceptance of EBP Facilitate adoption Implementation of effective services Evaluate outcomes 2.5%13.5%34% 16% InnovatorsEarly Adopters Early Majority Late Majority Laggards Slide 42 Gira, Kessler and Poertner (2004) Survey of reviews of adoption of research evidence medical practice Educational outreach visits and audit and feedback showed weak to moderate effects Certain types of continuing education and the use of computers as decision aids showed moderate effects There are no magic bullets (Oxman et al., 1995) The literature from health care suggests that disseminating information alone is insufficient. Many interventions have been designed to improve practitioners adherence to EBP guidelines and are differentially effective. To date, no intervention has demonstrated powerful effects (p. 77-78). Slide 43 Adoption & Implementation Challenge Can social agencies adopt EBP approach? Can social workers become EB practitioners? What are the barriers? Facilitators? What resources are needed? What training is required? What systems need to be established? How will EBP change client experience? What outcomes will be achieved? Slide 44 Challenges in Teaching Evidence-based Social Work Fear of Loss of Human Context Disconnect between classroom and field Overwhelmed by new skills and knowledge needed (Bilsker & Goldner, 2004) Slide 45 A Challenge to Critics Knowledge and information revolution Valuable resource Cannot be ignored Must be harnessed Slide 46 A Measured Optimism Real world constraints -limitation of approach -social and political realities Great promise, but need for caution -harnessing knowledge and information -management of scarce resources -unknowns abound Hold EBP to its own evidentiary standards -the jury is still out Slide 47 Knowledge needs to be managed much more effectively than it has been in the past The challenge is to rethink our view of what knowledge is & how best to facilitate its rapid generation, sharing, and application in a manner that closes the policy- research-practice gap