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What is E3BP?
How do you integrate the findings from
CAPs/CATs into everyday clinical practice?
NSW SPEECH PATHOLOGY EBP NETWORK
EBP EXTRAVAGANZA, 9th December 2009
Sydney Children’s Hospital, Randwick, Lecturer Theatre
Elise Baker, Ph.D.
The University of Sydney
Outline
What is EBP?
Is EBP really a regular part of clinical
practice?
What is E3BP?
Guidelines for conducting E3BP
What is evidence-based practice (EBP)?
Current best evidence
Clinical expertise
Client’s values
From: http://www.asha.org/members/ebp/default 10/23/08
However, EBP “has not become a
regular part of clinical practice”.
Brackenbury, Burroughs and Hewitt (2008, p. 78)
Why?

Lack of time to search for, read and critique published
evidence relevant to every clinical decision

Too much information
 Aphasia therapy – 220,000 hits
 Dysphagia treatment – 3,290 000
 Voice therapy – 2,760 000
 Phonology therapy – 1,050 000

Too little information - how many systematic reviews have
you come across in your search for evidence?
Why?

Need time and resources to develop efficient
searching skills

Even then….Brackenbury et al. , (2008) reported that
“it is doubtful that most SLPs can afford to take 3 to
7 (or more) to provide evidence for each of the
clinical decisions that must be made” (p. 85).
Why?

Have found, read, critiqued the research ... the findings
may not be easily applied to clinical practice

O’Conner and Pettigrew (2009) reported that half their
participants did not feel that research results were
generalizable to their own setting.
Why?

EBP has been thought of as simply using research to
justify an intervention approach.

Sense that ….“until EBP came along, clinicians were
basing their clinical decisions on something other than
evidence, which is simply not true” (Dollaghan, 2007, p. 1)
Why?

How many clients/patients in the past week have you...

Searched for and answered a clinical question (or
known the answer to a clinical question based on
work you have done on a CAP or CAT?)

Provided the client / patient with the information
necessary to make an informed choice
Outline
What is EBP?
Is EBP really a regular part of clinical
practice? No….not completely.
What is E3BP?
Guidelines for conducting E3BP
What is E3BP?
“the conscientious, explicit, and judicious
integration of
1. best available external evidence from
systematic research,
2. best available evidence internal to clinical
practice, and
3. best available evidence concerning the
preferences of a fully informed patient”
(Dollaghan, 2007, p. 2)
What is E3BP?
Best external evidence
Best internal evidence
Best internal evidence
(from clinical practice)
(from client factors & preferences)
External published evidence
To date, our CAPS seem to focus primarily on the level of
identified evidence
To facilitate the integration of difference sources of
evidence we need to:
 Consider the validity of the evidence
and...
 Consider the importance of the evidence
 Effect size
 Precision
 Practical significance
(Based on Dollaghan, 2007)
Yeah but..... I can’t exactly
replicate that in my service
Gap between what is possible and what is practical
Internal evidence from clinical practice
Internal evidence about what is possible in
your clinical practice
However....determining what is possible in clinical
practice is a challenging task, as, “our strong
preferences for what we already believe to be
true makes us poor judges of whether it is
actually true” (Dollaghan, 2007, p. 3).
Internal evidence from clinical practice
It is perhaps, best derived from the systematic
and regular collection and analysis of clinical
case-based outcome data.
How are you currently doing this?
Could you compare your outcomes with another colleague?
Internal “client” evidence:
client factors, values and preferences

Client factors

ICF / ICF-CY frameworks (integrated impairment and sociallybased perspective)
Consider –
structure,
Is there any external
published evidence
 function
on client factors?
 activity and participation
 environmental factors and Personal factors – that
could act as barriers or facilitators


Client values and preferences
Outline
What is EBP?
Is EBP really a regular part of clinical
practice? No….not really.
What is E3BP?
How to conduct E3BP
How can individual clinicians
incorporate EBP in a meaningful and
realistic manner?
(Brackenbury, Burroughs, & Hewitt, 2008)
7-Step process for engaging in E3BP
(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)
STEP 1. Pose a “PICO” question
(Patient, Intervention, Comparison, Outcome)
“In children with a phonological impairment and no other concomitant
conditions, does the Hodson (2007) cycles approach lead to
significantly greater gains in percent consonants correct as compared
with the Williams (2010) multiple opposition approach?”
STEP 2. Search for external evidence
Use electronic databases – SpeechBITE; HighWire Press via
ASHA membership, ERIC, Medline, Cochrane….
(Based on Baker & McLeod, 2008)
7-Step process for engaging in
E3BP
(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)
STEP 3. Evaluate the external evidence
Consider the validity and importance of the evidence
(Based on Baker & McLeod, 2008)
7-Step process for engaging in
E3BP
(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)
STEP 4. Evaluate the internal client evidence
Use the ICF and/or ICF-CY framework
Consider your client / patient’s activity and participation
Consider the family beliefs and cultural values, financial resources,
and informed preferences
International Classification of Functioning Disability
and Health – Children and Youth (WHO, 2007)
(Based on Baker & McLeod, 2008)
7-Step process for engaging in
E3BP
(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)
STEP 5. Evaluate your internal clinical
evidence
Think about what you currently do and why
Think about the efficiency of your intervention
How do your outcomes compare with the research?
How do your outcomes compare with your colleagues
or other similar departments?
(Based on Baker & McLeod, 2008)
Remember….
“our strong preference for what we already believe to be true
makes us poor judges of whether it is actually true…
…E3BP requires honest doubt about a clinical issue, awareness of
one’s own biases, a respect for other positions, a willingness to let
strong evidence alter what is already known, and constant
mindfulness of ethical responsibilities to patients”
(Dollaghan, 2007, p. 3).
(Based on Baker & McLeod, 2008)
7-Step process for engaging in
E3BP
(Based on Baker & McLeod, 2008 adapted from Gillam & Gillam, 2006)
STEP 6. Make a decision by integrating your three
sources of evidence
STEP 7. Evaluate the outcome of your decision
Did it work? What is efficient?
(This adds to your own internal clinical evidence)
(Based on Baker & McLeod, 2008)
Where to from here?

E3BP and the NSW EBP Network

Implications –



Focus of current CAP is on external evidence
Could we develop “CAPs” for internal clinical and client
evidence?
How might they be used within clinical groups?
QUESTIONS AND DISCUSSION
Elise: e.baker@usyd.edu.au