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Background01 Introduction01 Background02 Evidence-basedpracticeintheAODsector04 AODEvidence-BasedPracticeModel06 References

Research tools08 RecommendedDatabasesforAODResource10 LevelsofEvidence11 AODEvidenceChecklist12 FindingoutmoreaboutEvidence-BasedMedicine14 GlossaryofEvidence-Basedterms

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AcknowledgementsThisresourcewaspreparedonbehalfoftheAlcoholandotherDrugsCouncilofAustralia(ADCA)byJaneShellingandKimberleyClarke.

FeedbackandassistancefromADCA’smembers,ADCA’sNationalResourceCentreAdvisoryCommitteeandthoseinvolvedinourevidence-basedpracticeworkshopsoverthepastyearisgratefullyacknowledged.

©2007AlcoholandotherDrugsCouncilofAustralia(ADCA)17NapierCloseDeakinACT2600POBox269WodenACT2606www.adca.org.au

ISBN978-1-876837-12-9

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Introduction

Ashealthprofessionals,thereisaresponsibilityforthealcoholandotherdrug(AOD)workforcetoensureourpracticewillachievethebestpossibleoutcomeforourtargetgrouporclient.Bestpracticeisoftendefinedbycurrentevidence;howevertherearemanybarrierspreventingalcoholandotherdrugworkersfromapplyingestablishedmodelsofevidence-basedpracticetotheirwork.Theaimofthisprojectistoassistthealcoholandotherdrugsectorinapracticalwaytomorerigorouslyresearchandfindevidencetohelpguidetheirpractice.Drawinguponprinciplesofevidence-basedpractice,andtheneedsofthebroaderAODsector,thispaperwillprovideanevidence-basedprotocolapplicabletothoseworkingtoreducedrugrelatedharm.

Background

Centraltotheprinciplesofevidence-basedpracticeisthenotionofwhatisregardedas“soundevidence”.Duetothesheernumberofresearchprojectsconductedandpublishedannually,itisoftendifficultforpractitionerstodeterminewhatevidencetheyshouldbasetheirpracticeon.Forthisreason,frameworkssuchasevidence-basedmedicinerequiretheapplicationofthehierarchyofevidenceinordertodeterminewhatevidencecanbeusedtoinformpractice(Reimer,Sawker&James2005).

Therelianceonthehierarchyofevidenceisthecauseformuchdebateregardingthevalidityofevidence-basedmedicineandevidence-basedpractice(Reimeretal2005).Thehierarchyofevidenceregardssystematicreviewsofrandomisedcontroltrials(RCT)asthe‘goldstandard’ofevidence(Sackett,Rosenberg,Gray,Haynes&Richardson,1996).Asascale,thehierarchyofevidenceusesstudydesigntorankthequalityofevidence,andaccordinglythosestudydesignswhichcarrytheleastriskofbiasandconfoundingareseentobethemostreliable(Reimer2003).

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Criticsarguethatrelyingsolelyonstudydesignasamarkerforqualitymayleadtotheexclusionofsomeformsofevidencethatmayproveuseful(Rychetnik,Frommer,Hawe&Shiell2006).Itissuggestedbyeliminatinganypossiblebiasfromastudyoneisactuallyremovingoralteringthecontextinwhichthebehaviourorinterventionisoccurring(Rychetnik&Frommer2000).Itissuggestedthatlowerlevelsofevidence,suchasthatderivedfromstudiesofacohortorlongitudinaldesign,maybemoreappropriateforinvestigatingresearchquestionsthatexplorebehavioursorinterventionsthatoccurinsocialsettings(Gowing2001).Asimilarargumentexistsconcerningtheapplicabilityoftraditionalevidenceappraisalcriteriawithinthepublichealtharenawheretheliteraturearguesthat“Goodinformationontheeffectsofthecontextandofinteractionsbetweenthecontextandtheinterventionrequiresacombinationofdifferenttypesofresearch,includingexperimental,observational,multi-levelandqualitativeapproaches”,(Rychetnik&Frommer,2000,p11).

Inrecenttimes,therehasbeenanincreasedemphasisontheimportanceoffactorssuchasclinicaljudgementandclientorpopulationgrouppreferenceinguidingpractice.Thishasledtotherecognitionofevidence-informedpracticeasanalternativetootherapproachessuchasevidence-basedmedicine,orevidence-basedpractice.Supportersoftheevidence-informedapproacharguethatthetermevidence-basedpracticediminishestheimportanceofclinicaljudgementandclientpreferences,andimpliesevidenceistheonlycontributingfactorinfluencingdecisionmaking(Nutley,Davies&Walter,2003).Evidence-informedpracticerecognisestheroleofprofessionalismindetermininghowevidenceisappliedtoparticularcircumstances(Phillips2004).

Evidence-based practice in the AOD sector

TherearemanybarrierspreventingmembersoftheAODsectorfromtransferringevidenceintopractice(RocheinRoche&McDonald2001).TheAODsectorischaracterisedasbeingunder-resourcedandoverworked,anditisoftendifficultforworkerstofindthetimeororganisationalsupporttoundergotheseeminglyvigorousprocessesneededtoapplyevidenceintopractice.

Reimeretal2005highlightsthepracticallimitationstoapplyingevidenceintopracticewithintheAODsectoraccordingtothefollowinggroups:

>> IndividualFactors.Thisincludesfactorssuchasbeliefs,attitudesandvalues,professionaldevelopment,skillsandinterests.

>> Organisationalfactors.Includesfactorssuchasjobburnout,poorleadership,achange-adversecultureandlackoforganisationalsupportforapplyingevidenceintopractice.

>> Communityfactors.Thesefactorsareapplicabletocommunity-levelinterventionsandprograms.Factorsincludedifferingbackgroundsandtraining,differingperspectivesonprevention,lackofcommunityreadiness,andcompetingpoliticalinterests.

ConsideringthemanybarrierstoapplyingevidenceintopracticeasoutlinedbyReimeretal2005,itisarguedthatcurrentprotocolssuchasevidence-basedmedicineandevidence-basedpracticearenotentirelysuitedtotheAODsectorinAustralia.Thereisaneedforanapproachwhichisconsiderateofthemanybarriersfacedbythesector,andaimtoovercomethesebarriers.

Inaddition,oneshouldalsorecognisethattheAODsectorisbroadanddiverse.Interventionsoccurringwithinthesectorrangefromclinicallybasedtreatmentinterventionsinahospitalsetting,throughtopopulationbasedpreventativeinterventionswhichoccurinacommunitysetting.Certainquestionswithinthesectorrequireanapproachwhichincorporatesprinciplesfromanevidence-basedmedicineapproach,whileothersshouldacknowledgetheinfluencesocialandpsychologicalfactorshaveontheinterventionandadoptamoreevidence-basedpublichealthapproach.ProfessionalismandclinicaljudgementareoftenstronglyrelieduponintheAODsectorandshouldplayastrongroleindetermininghowevidenceisappliedintopractice.This‘horsesforcourses”approachiswellidentifiedwithintheliterature(Nutleyetal2003),andshouldbeonethatisadoptedintheAODsector.

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AOD Evidence-Based Practice Model

How to use the modelADCA’smodelsuggestsaprocessthatAODworkerscanapplytoassistinaddingrigourtotheirpractice,andtoprogressa“researchintopractice”paradigm.ThemostimportantaspecttorememberwhenworkingwiththeADCAmodelforevidence-basedpracticeistoadopta‘horsesforcourses’approachtoapplyingevidenceintopracticeintheAODfield.AODworkersarefacedwithmanyproblemsintheirdaytodaywork,andthetypeofproblemidentifiedcangreatlydeterminewhattypeofevidencetousetoinformyourpractice.

Ifyourproblemisonethatisrelatedtotherapy,harm,prognosis,diagnosisorintervention,ADCAstronglyrecommendsthatyouapplyanevidence-basedmedicineapproachtoansweringyourquery.Ampleinformationonevidence-basedmedicinecanbefoundintheliterature,andwehaveprovidedsomereferencestosourcesinthiskit.Thepurposeofthiskithoweverisnottoguideyouthroughaprocessofevidencebasedmedicine,butratherhelpyoufollowarigorousevidence-basedapproachtoaddressingpopulationbasedproblemswhicharemorecommontothealcoholandotherdrugfield.

Whenaproblemdoesnotfitwithinanevidencebasedmedicineapproach,itisstillimportanttoensurethatyouareapplyingfundamentalprinciplesofevidence-basedpracticeinyourwork.Thiskitoutlinesamodelforpractitionerstofollowwhenproblemsoccurwithinthescopeofprevention,healthpromotion,policyandpublichealth.Themodelfollowstheidealsoftheevidence-basedmedicinemodelbuttriestoincorporaterigourinamannermorerealistictotheAODsetting.Asdiscussedpreviously,manyAODworkersarelimitedinthetimeandresourcestheycanspendonactivitiesneededtoapplyevidenceintopractice.Inresponsetothis,ADCAsuggeststhatworkersusethismodeltoguidetheirpracticewithintheresourcestheyhaveavailable.Notallworkerswillbe

abletospendexhaustiveamountsoftimeoneachoftheindividualsteps,howeveritisimportanttorememberthatevenapplyingpartofthemodelwillbebetterthannotapplyinganyatall.

BeforeusingthemodelItisimportanttospendsometimeonpreparationpriortoapplyingthemodeltoaprobleminyourworkplace.

Identifytheproblem.Itisimportanttoaccuratelydefinetheproblembeforeyouattempttoaddressit.Often,doingsomepreliminarydatabasesearchingcanensureyoufullyunderstandthedimensionsoftheproblem.Also,makesurethatyoudiscusstheproblemwithyourcolleaguestodetermineiftheyareexperiencingsimilarproblems.

TimeandresourceallocationYoushouldalsoconsidertheamountoftimeandresourcesthatyoucancomfortablyallocatetotheresearchprocess.Itmayalsoproveusefultodiscusstheevidence-basedpracticeprocesswithyourmanagerandimmediatecolleagues–orevengettheminvolved.Thisway,theyareawareofwhatyouaredoing,andaremorelikelytosupportyouthroughtheprocess.

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References

GowingL.2001.“Evidence-BasedPractice:FromConceptstoReality”,inRoche&McDonald,Systems,Settings,People:WorkforceDevelopmentChallengesfortheAlcoholandotherDrugsField,NationalCentreforEducationandTrainingonAddictions,Adelaide.

NutleyS,DaviesH&WalterI.2003.EvidenceBasedPolicyandPractice:CrossSectorLessonsfromtheUK.KeynotePaperfortheSocialPolicyResearchandEvaluationConference,WellingtonNZ.

PhillipsM.2004.ContinuingProfessionalDevelopmentandEvidence-InformedPractice:WorkingPaperSeriesvol.1.UniversityofBristol,DepartmentofManagement,Bristol.

ReimerB.2003.StrengtheningEvidence-BasedAddictionPrograms:Apolicydiscussionpaper.AlbertaAlcoholandDrugAbuseCommission,CanadianCentreonSubstanceAbuse,andtheNationalPolicyWorkingGroup,Canada.

ReimerB,SawkaE&JamesD.2005.“ImprovingResearchTransferintheAddictionsField:APerspectivefromCanada”,SubstanceMisuseandUse,vol40,pp1707-1720.

RocheA,2001,“WhatIsThisThingCalledWorkforceDevelopment”,inRoche&McDonald,Systems,Settings,People:WorkforceDevelopmentChallengesfortheAlcoholandotherDrugsField,NationalCentreforEducationandTrainingonAddictions,Adelaide.

RychetnikL&FrommerM.2000.AProposedSchemaforEvaluatingEvidenceonPublicHealthInterventions:AdiscussionpaperpreparedfortheNationalPublicHealthPartnership.NationalPublicHealthPartnership,VictoriaAustralia.

RychetnikL,FrommerM,HallP&Shiell.2002.“Criteriaforevaluatingevidenceonpublichealthinterventions”,JournalofEpidemiologyandPublicHealth,vol56,pp119-127.

SackettD,RosenbergW,GrayJ,HaynesR&RichardsonW.1996.“Evidencebasedmedicine:whatitisandwhatitisn’t”,BritishMedicalJournal,vol312,pp71-72.

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Recommended Databases for AOD Resources

FRee Access dAtABAsesAOd guidelines and protocols - www.adca.org.au/resource/LinkstoAODguidelinesandprotocols,availablefromADCA’sNationalResourceCentre(NRC)webpage.

drug database - www.adca.org.au/drugDrugistheonlinedatabaseofADCA’sNationalResourceCentre.Itcurrentlycontainsover63,000referencestobooks,videos,journalarticles,conferencepapers,researchreportsandunpublishedmaterialsonthehealth,socialandeconomicaspectsofalcohol,tobaccoandotherdruguse.EachmonthDrugisupdatedaddinganadditional300referencesallofwhichareavailablefromtheNRC.

cochrane Library - www.thecochranelibrary.comTheCochraneLibrarycontainshigh-quality,independentevidencetoinformhealthcaredecision-making.ItincludesreliableevidencefromCochraneandothersystematicreviews,clinicaltrials,andmore.Cochranereviewsbringyouthecombinedresultsoftheworld’sbestmedicalresearchstudies,andarerecognisedasthegoldstandardinevidence-basedhealthcare.

cork - www.projectcork.org/database_search/TheCorkdatabaseincludesover69,000itemsonsubstanceabuse,indexedbyover400terms.Itemsareprimarilyfromtheprofessionalliteratureandincludejournalarticles,books,bookchapters,andreports.Thedatabaseisupdatedquarterly. PubMed (Medline) - www.pubmed.govPubMedisaserviceoftheU.S.NationalLibraryofMedicinethatincludesover16millioncitationsfromMEDLINEandlifesciencejournalsforbiomedicalarticlesbacktothe1950s.PubMedincludeslinkstofulltextarticlesandotherrelatedresources.

Fee-BAsed dAtABAsescINAHL - www.cinahl.com/CINAHLisamultidisciplinarydatabasecoveringthenursing,alliedhealth,biomedicine,andconsumerhealthliteraturefrom1982topresent.

Informit - www.informit.com.au/InformitisasuiteofdatabasesfromAustralasia’sleadingagenciesandinstitutionsthatindexandabstractavastrangeofAustralasiansourcesofinformation,includingtheDrugdatabase,butalsosourcesforrural,aboriginalandcrimeissues.TheNRCprovidesADCAmemberswithaccesstoRMITInformitdatbases.

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Levels of Evidence

Thereareseveraltablesshowingthehierarchyofevidencewhichcanbehelpfulindetermininghigherlevelsofevidence.Thispyramiddemonstratestheevidence-basedmedicinehierarchyofevidence.

evidence Pyramid

SunyDownstateMedicalCentre2007,Aguidetoresearchmethods,availableat:http://library.downstate.edu/ebm/2toc.htm

Cohort Studies

Case Control Studies

Case Series

Case Reports

Ideas, Editorials, Opinions

Animal Research

In vitro (‘test tube’) research

Systematic Reviewsand Meta-analyses

Randomised Controlled Double Blind Studies

AOD Evidence Checklist

Key CheCKs Considerationsyes/no/

Can’t tell

the topic

Clarity Is the purpose/query/objective/intervention clearly stated?

Relevancy – Accurate reflection of my scenario/situation.

Is my specific query/situation addressed? Consider client/population’s age, sex, race, social background/situation.

Size Significant number of participants in study.

SettingAccurate reflection of my setting.

Rural/MetroIs the setting Australian or a country with a similar social setting?

Trustworthiness Is the study design used appropriate?

the recommendation

Results Were the results clearly stated? Were full explanations given?

Ability to Replicate Has the study already been replicated or could it be replicated in my own situation? Consider costs, appropriateness and additional resources required.

Credibility Is the action or recommendation in line with your current practice? Is it logical and reasonable?

Impact Were the negative and/or positive impacts and/or unexpected outcomes of following this course fully explained?

General Considerations

Currency Is the date when the evidence was produced relevant?Is currency an impact factor?

Organisation associated with evidence

Is this a known organisation? Do they have a particular bias or affiliation?

Author Is the author known? Does he/she have a particular bias or affiliation?

Journal Is this a well known and respected journal? Consider criteria for article inclusion.

Ethics Was any ethics approval sought or is there an ethics statement made?

Funding Has the source of funding been disclosed?

Levels of Evidence

Thereareseveraltablesshowingthehierarchyofevidencewhichcanbehelpfulindetermininghigherlevelsofevidence.Thispyramiddemonstratestheevidence-basedmedicinehierarchyofevidence.

evidence Pyramid

SunyDownstateMedicalCentre2007,Aguidetoresearchmethods,availableat:http://library.downstate.edu/ebm/2toc.htm

Cohort Studies

Case Control Studies

Case Series

Case Reports

Ideas, Editorials, Opinions

Animal Research

In vitro (‘test tube’) research

Systematic Reviewsand Meta-analyses

Randomised Controlled Double Blind Studies

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Finding out more about Evidence-Based Medicine

Forthosenewtoevidence-basedmedicinethereareawidevarietyofresourcesavailabletohelpwithunderstandingconcepts.Listedbelowareonlyafewofthemanysiteswhichareeasilyaccessible.Universities,hospitalsandhealthservicelibrariesrunevidence-basedmedicineclassesfornurses,medicalstudentsandotherhealthpersonnel-theremaybeopportunitiesforyoutoparticipatetoo.

Online ArticlesCraig,JC,Irwig,LM,&StocklerMR.2001,Evidence-basedmedicine:usefultoolsfordecisionmaking.MJA,174:248-253.www.mja.com.au/public/issues/174_05_050301/craig/craig.html

Sackett,D,1996,Evidencebasedmedicine:whatitisandwhatitisn’t.BMJ,71-72.www.bmj.com/cgi/content/full/312/7023/71

‘Howtoreadapaper’isanexcellentseriesofBMJarticlesbyTrishaGreenhalgh(alsoavailableasabook).www.bmj.com/collections/read.dtl

terminologyGlossaryofterms:astudentsguide-DenisonLibrary,UniversityofColoradodenison.uchsc.edu/SG/glossary.html

tutorialsIntroductiontoEvidence-BasedMedicine:aselfpacedtutorial-DukeUniversityMedicalCenterLibraryandHealthSciencesLibrary,UniversityofNorthCarolina.www.hsl.unc.edu/services/tutorials/EBM/index.htm

Evidence-basedmedicinetutorial–UniversityofMassachusettsMedicalSchoollibrary.umassmed.edu/EBM/index.cfm

Web sitesCentreforEvidence-BasedMedicine–Oxfordwww.cebm.net/

EvidenceBasedMedicineToolkit–UniversityofAlberta,Canadawww.med.ualberta.ca/ebm/ebm.htm

Evidence-BasedPractice–UniversityofWesternAustraliaLibrary,seeunderEducation,training&support.www.library.uwa.edu.au

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Glossary of Evidence-Based terms Thisglossaryincludesdefinitionsfrom:OxfordCentreforEvidence-BasedMedicine2007,Glossaryoftermsinevidence-basedmedicine,availablefrom:http://www.cebm.net/glossary.asp,andRychetnik,L,Hawe,P,Waters,E,Barratt,A,&Frommer,M2004‘Aglossaryforevidence-basedpublichealth’.JEpidemiolCommunityHealth,vol.58,pp.538-545.BlindedAstudyisblindedifanyoralloftheclinicians,patients,participants,outcomeassessors,orstatisticianswereunawareofwhoreceivedwhichstudyintervention.Thedoubledouble-blindusuallyreferstopatientandclinicianbeingblinded,butisambiguoussoitisbettertostatewhoisblinded.

clinical Practice Guidelineisasystematicallydevelopedstatementdesignedtoassistpractitionerandpatientmakedecisionsaboutappropriatehealthcareforspecificclinicalcircumstances.

cohort studyinvolvesidentificationoftwogroups(cohorts)ofpatients,onewhichdidreceivetheexposureofinterest,andonewhichdidnot,andfollowingthesecohortsforwardfortheoutcomeofinterest.

cost-Benefit Analysisconvertseffectsintothesamemonetarytermsasthecostsandcomparesthem.

cost-effectiveness Analysisconvertseffectsintohealthtermsanddescribesthecostsforsomeadditionalhealthgain(e.g.costperadditionalMIprevented).

evidenceInthebroadestsense,evidencecanbedefinedas“factsortestimonyinsupportofaconclusion,statementorbelief”and

“somethingservingasproof”.Suchagenericdefinitionisausefulstartingpoint,butitisdevoidofcontextanddoesnotspecifywhatcountsasevidence,when,andforwhom.

evidence-Based Health careextendstheapplicationoftheprinciplesofEvidence-BasedMedicine(seebelow)toallprofessionsassociatedwithhealthcare,includingpurchasingandmanagement.

evidence-Based Medicineistheconscientious,explicitandjudicioususeofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualpatients.Thepracticeofevidence-basedmedicinemeansintegratingindividualclinicalexpertisewiththebestavailableexternalclinicalevidencefromsystematicresearch.

expert Opinion usuallyreferstotheviewsofprofessionalswhohaveexpertiseinaparticularformofpracticeorfieldofinquiry,suchasclinicalpracticeorresearchmethodology.Expertopinionmayrefertooneperson’sviewsortotheconsensusviewofagroupofexperts.Whentheconceptofevidence-basedpracticewasfirstintroduced,expertopinionwasidentifiedastheleastreliableformofevidenceontheeffectivenessofinterventions,andpositionedatthelowestlevelin“levelsofevidence”hierarchies.Otherdevelopmentshavedeterminedthatrankingexpertopinionwithlevelsofevidenceisnotusefulorappropriatebecauseexpertopinionisqualitativelydifferenttotheformsofevidencethatarederivedfromresearch.Opinioncanbeidentifiedasameansbywhichresearchisjudgedandinterpretedratherthanasaweakerformofevidence.

Lay Knowledgereferstotheunderstandingthatmembersofthelaypublicbringtoanissueorproblem.Layknowledgeencompasses“themeaningsthathealth,illness,disabilityandriskhaveforpeople.”Formalidentificationandexaminationoflayknowledgeismostlyconductedthroughqualitativeformsofinquiry.Adequateattentiontolayknowledgehasbeenproposedasacriterionforcriticallyappraisingqualitativeresearch.Concernsthatsomehealthprofessionalsmaynotadequatelyvaluelayknowledgehavebeenexpressed.Layknowledgecanbedifficulttoaccessandsynthesise,andfocusonquantitativeformsofevidence

canleaddecisionmakerstoundervaluethelayknowledgethatisderivedfromnarrativesandstories.

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Meta-analysisisasystematicrevieworoverviewwhichusesquantitativemethodstosummarisetheresults.

Peer reviewisareviewofjournalarticlesbyothersinthesamefield.Peerreviewistheprimarymethodforqualitycontrolinmedicalpublishing.

Randomised controlled clinical trialiswhenagroupofpatientsisrandomisedintoanexperimentalgroupandacontrolgroup.Thesegroupsarefollowedupforthevariables/outcomesofinterest.

sensitivityistheproportionofpeoplewithdiseasewhohaveapositivetest.

specificityistheproportionofpeoplefreeofadiseasewhohaveanegativetest.

systematic Reviewisaliteraturereviewfocusedonasinglequestionwhichtriestoidentify,appraise,selectandsynthesisallhighqualityresearchevidencerelevanttothatquestion.