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    There are several steps in doing EBP, but the number varies a bit by author.

    First Step. Social worker Len Gibbs points out that the first step is to becomemotivated to do EBP. One's introduction might be based on a carrot or a stick or

    a hammer! If shown the utility of EBP to real world practice, professionals and

    students would begin with a positive orientation and motives. On the other handbeing forced to do EBP by managed care could create considerable resentment.

    Most authors don't mention this step as part of EBP.

    Core Steps:

    Step 1.Develop a clear and answerable question derived from the client's

    problem or need. Such questions may be about diagnosis, treatment, side

    effects, prognosis as well as costs and benefits or efficiency of care (though nowthe concern shifts to overall benefit, not just to the client.)

    Step 2. Search the literature for relevant research that could help answer thisquestion. The EBP model places greatest credibility in results of randomized

    controlled trails [RCTs] or meta-analyses of experimental studies. (See Rating

    the Evidence.)

    Step 3. Conduct a critical appraisal of this information and rank the evidence

    for its validity and applicability to the client's need and situation. The client's

    wishes and needs (stated and implicit) must also be considered, along with theprofessional's competencies.

    Step 4.Formulate and apply an intervention based on the most relevant and

    applicable findings which we can call the "best available evidence." Theassumption is that the evidence will clearly point to a best intervention. In many

    situations the model may point to a "best intervention." However, in many

    situations the evidence will be lacking, of variable quality or irrelevant, making

    the yield of this step a bit more ambiguous than the model suggests.

    Additional Steps:

    Step 5. A few authors (Gibbs, for one) appear to make practice evaluation anaspect of EBP. That is, the professional should audit the intervention (to verify it

    was done appropriately) and evaluate its yield. This makes some sense, but note

    that the practice evaluation of the single case would be done using methodsquite different from those used in EBP. Single case or single system designs can

    help identify progress, but are based on replication logic rather than the

    sampling logic underlying experimental research. That is, the case studies onewould use in practice evaluation are not highly valued in EBP research

    summaries.Step 6. A few authors also add sharing your results with others and work towardimproving the quality of available evidence (Gibbs). This would be useful but

    again does not necessarily draw on the same core logic of experimental research

    EBP emphasizes. In fact, case studies are often viewed as the leastuseful sourceof evidence in many EBP "evidence hierarchies". Note, however, that such work

    may be very helpful in identifying to whom and in what circumstances the best

    research evidence does not work or is not appropriate. Ironically, very small

    http://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htm
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    scale research may be very useful in shaping how and when and where to use

    large scale experimental evidence to best advantage.

    The University of Michigan's Social Work Library offers a fine page on the

    steps of EBP (but also a disclaimer that the pages are not intended as a course

    for beginners.)

    Note that all steps are meant to be transparent and replicable by others. That is,

    the steps should be so clear you could re-do them yourself with enough time and

    access. It also means many things are accepted at face value (or as face valid)such as definitions of mental and social disorders (usually defined via DSM or

    ICD) though these categories do change over time. Measures of treatments are

    assumed to be adequate, valid, reliable and complete. Treatments though oftenonly broadly described, as assumed to be replicable by others in different

    settings, with different training and with different backgrounds.

    Note, too, that EBP focuses on the outcome of treatment, not the processes bywhich change occurs. Understanding both outcome and change process is the

    cornerstone of science.

    to Social Work Resources Home Page

    text copyright J. Drisko page begun 3/17/04; last update 06/8/08

    There are several steps in doing EBP, but the number varies a bit by author.

    First Step. Social worker Len Gibbs points out that the first step is to become

    motivated to do EBP. One's introduction might be based on a carrot or a stick or

    a hammer! If shown the utility of EBP to real world practice, professionals and

    students would begin with a positive orientation and motives. On the other handbeing forced to do EBP by managed care could create considerable resentment.

    Most authors don't mention this step as part of EBP.

    Core Steps:

    Step 1.Develop a clear and answerable question derived from the client's

    problem or need. Such questions may be about diagnosis, treatment, sideeffects, prognosis as well as costs and benefits or efficiency of care (though now

    the concern shifts to overall benefit, not just to the client.)

    Step 2. Search the literature for relevant research that could help answer thisquestion. The EBP model places greatest credibility in results of randomized

    controlled trails [RCTs] or meta-analyses of experimental studies. (See Rating

    the Evidence.)

    Step 3. Conduct a critical appraisal of this information and rank the evidence

    for its validity and applicability to the client's need and situation. The client's

    wishes and needs (stated and implicit) must also be considered, along with theprofessional's competencies.

    Step 4.Formulate and apply an intervention based on the most relevant and

    applicable findings which we can call the "best available evidence." The

    http://www.lib.umich.edu/socwork/rescue/ebsw.htmlhttp://www.lib.umich.edu/socwork/rescue/ebsw.htmlhttp://var/www/apps/conversion/tmp/scratch_3/index.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htmhttp://www.lib.umich.edu/socwork/rescue/ebsw.htmlhttp://www.lib.umich.edu/socwork/rescue/ebsw.htmlhttp://var/www/apps/conversion/tmp/scratch_3/index.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htmhttp://var/www/apps/conversion/tmp/scratch_3/rating_the_evidence.htm
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    assumption is that the evidence will clearly point to a best intervention. In many

    situations the model may point to a "best intervention." However, in manysituations the evidence will be lacking, of variable quality or irrelevant, making

    the yield of this step a bit more ambiguous than the model suggests.

    Additional Steps:

    Step 5. A few authors (Gibbs, for one) appear to make practice evaluation an

    aspect of EBP. That is, the professional should audit the intervention (to verify it

    was done appropriately) and evaluate its yield. This makes some sense, but notethat the practice evaluation of the single case would be done using methods

    quite different from those used in EBP. Single case or single system designs can

    help identify progress, but are based on replication logic rather than thesampling logic underlying experimental research. That is, the case studies one

    would use in practice evaluation are not highly valued in EBP research

    summaries.

    Step 6. A few authors also add sharing your results with others and work toward

    improving the quality of available evidence (Gibbs). This would be useful butagain does not necessarily draw on the same core logic of experimental researchEBP emphasizes. In fact, case studies are often viewed as the leastuseful source

    of evidence in many EBP "evidence hierarchies". Note, however, that such work

    may be very helpful in identifying to whom and in what circumstances the bestresearch evidence does not work or is not appropriate. Ironically, very small

    scale research may be very useful in shaping how and when and where to use

    large scale experimental evidence to best advantage.

    The University of Michigan's Social Work Library offers a fine page on the

    steps of EBP (but also a disclaimer that the pages are not intended as a course

    for beginners.)

    Note that all steps are meant to be transparent and replicable by others. That is,

    the steps should be so clear you could re-do them yourself with enough time and

    access. It also means many things are accepted at face value (or as face valid)such as definitions of mental and social disorders (usually defined via DSM or

    ICD) though these categories do change over time. Measures of treatments are

    assumed to be adequate, valid, reliable and complete. Treatments though often

    only broadly described, as assumed to be replicable by others in differentsettings, with different training and with different backgrounds.

    Note, too, that EBP focuses on the outcome of treatment, not the processes bywhich change occurs. Understanding both outcome and change process is the

    cornerstone of science.

    to Social Work Resources Home Page

    text copyright J. Drisko page begun 3/17/04; last update 06/8/08

    Steps in the Process of Evidence-Based Practice

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    Step 1: Framing the Clinical QuestionThe first step in applying evidence to a clinical decision is framing the specific question

    about which evidence will be sought. One widely-used approach to framing these

    questions is known as PICO, forPopulation,Intervention, Comparison, Outcome.

    Ensuring that the clinical question addresses all four of these areas will help to ensurethat the evidence will be relevant to the particular circumstance faced by the clinician.

    Population Intervention Comparison Outcome

    Stroke patients Early initiation of

    aphasia treatment

    Aphasia treatment after

    initial/spontaneous recoverytime

    Functional

    communicationabilities

    Kindergarteners witharticulation disorders

    Individual pull-outtreatment

    Group pull-out treatment Ability toconsistently

    produce /s/

    17-year-old malewith a severe head

    injury

    Cognitive rehab No cognitive rehab Return towork/school

    The first question, then, could be written as, "Are patients with aphasia who received SLP

    services shortly after their stroke more or less likely to achieve functional communication

    abilities than stroke patients who received such treatments later?".

    The most difficult aspect of framing appropriate clinical questions is determining the

    level of specificity of what goes into each of these categories. To some, it is difficult

    because it is an art, rather than a science, and usually requires a fair amount of trial and

    error before the question is in its final form.

    PopulationThe second example was Kindergarteners with articulation disorders. Here, the clinician

    will need to decide whether he or she wants evidence drawn only from Kindergarteners,

    or would studies including children one or two years younger or older also be of interest.What about a study of sixth graders?

    Let's say the specific circumstance that prompted this clinician's search for evidence was

    the arrival on his/her caseload of a girl who just arrived in the U.S., from China, and haslimited English proficiency. Should the evidence that is sought be limited to English-

    language learners, or should children whose first language is English also be included?

    Intervention and Comparison

    The intervention of interest is specified as individual pull-out treatment, and the

    comparison group pull-out treatment. Here the decision has to be made whether that isspecific enough, i.e., whether more information is needed about what actually transpires

    during those sessions, or perhaps whether it is too specific, and the real issue is whether

    the child should be treated using a pull-out model (whether individual or group) as

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    opposed to a classroom-based or collaborative consultation approach.

    OutcomeFinally, the outcome of interest as written here is the child's ability to pronounce /s/.

    Another approach would be to look at more functional outcomes such as the extent to

    which the teacher felt that the child was better able to participate in classroom activitiesrequiring speech. The two different types of outcomes would likely involve very different

    types of evidence (for more on this topic, see Robey R (2004).A five-phase model for

    clinical-outcome research.Journal of Communication Disorders, 37, 401-411).

    How to make these choices? There are two factors that will influence the final question.

    The first is the theoretical model that informs the clinician's thinking about this disorder.

    It is the clinician's expertise that will dictate whether he or she thinks it is important todifferentiate between left- and right-hemisphere strokes for a particular question, or to

    what extent the age of a patient should be considered a factor. This is one important

    reason that true EBP mustinvolve the expertise and experience of the clinician.

    Once these initial decisions are made, the second factor comes into play, and that is theavailability of evidence. This serves as a reality check on the feasibility of garnering

    sufficient evidence to address the question as posed. Perhaps, the question was originallyposed as elementary-school students with articulation disorders, but it turns out that there

    is a large body of evidence specific to Kindergartners and/or specific to English-language

    learners, so that the question can be more focused, and thus more directly relevant to theparticular clinical circumstance that prompted it. More common, however, is a dearth of

    evidence, and the clinician is faced with using his or her own expertise to decide to what

    extent the criteria can be relaxed (e.g., going from evidence on "left-hemisphere strokepatients" to just stroke patients) while still maintaining relevance.

    For more on framing clinical questions, see The University of Washington's web-based

    tutorial, Constructing Well-built Clinical Questions using PICO.

    Step 2: Finding the EvidenceIdeally, evidence-based clinical practice guidelines relevant to your clinical question will

    already exist (see Making the Decision). When that is not the case, however, the clinicianneeds to seek out scientific evidence to help inform the treatment decision. Two major

    types of evidence may be useful:

    Systematic Reviews

    Individual Studies

    Systematic ReviewsSystematic reviews form the basis for evidence-based clinical practice guidelines. They

    are formal assessments of the body of scientific evidence related to a clinical question,

    and describe the extent to which various diagnostic or treatment approaches are supportedby the evidence, but stop short of making specific recommendations for clinical practice.

    http://www.ncbi.nlm.nih.gov/pubmed/15231420?dopt=Abstracthttp://www.ncbi.nlm.nih.gov/pubmed/15231420?dopt=Abstracthttp://www.ncbi.nlm.nih.gov/pubmed/15231420?dopt=Abstracthttp://healthlinks.washington.edu/ebp/pico.htmlhttp://healthlinks.washington.edu/ebp/pico.htmlhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2FMaking.htmhttp://var/www/apps/conversion/tmp/scratch_3/%5Clsystematic%22http://var/www/apps/conversion/tmp/scratch_3/%5Clindividual%22http://www.ncbi.nlm.nih.gov/pubmed/15231420?dopt=Abstracthttp://www.ncbi.nlm.nih.gov/pubmed/15231420?dopt=Abstracthttp://healthlinks.washington.edu/ebp/pico.htmlhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2FMaking.htmhttp://var/www/apps/conversion/tmp/scratch_3/%5Clsystematic%22http://var/www/apps/conversion/tmp/scratch_3/%5Clindividual%22
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    They are useful in helping clinicians make treatment decisions in that, when done

    properly, they have pulled together and in a systematic way characterized the available

    evidence on a clinical question.

    Where to Find Systematic Reviews

    ASHA's Evidence Maps ASHA/N-CEP's Compendium of Guidelines and Systematic Reviews

    Cochrane Collaboration

    Campbell Collaboration

    What Works Clearinghouse (U.S. Department of Education)

    Psychological Database for Brain Impairment Treatment Efficacy

    speechBITE: Speech Pathology Database for Best Interventions and Treatment

    Efficacy

    Evidence-based Communication Assessment and Intervention (EBCAI) Journal

    Individual StudiesWhen clinical practice guidelines or systematic reviews are not available, not current, not

    trustworthy, and/or not relevant, one can turn to individual studies to seek evidence tohelp make treatment decisions. The first place to find individual studies would be an

    online bibliographic database. For health care studies, the best place to start would be

    MEDLINE, the world's largest online bibliographic database of health related studies.

    MEDLINE cites over 12 million articles from 4,000 peer-reviewed journals.

    Unfortunately, publication in a peer-reviewed journal is not a guarantee ofscientific

    quality. It is also important to keep in mind that studies published in English langauge,and particularly American journals, are less likely to include studies with negativefindings than are European and other non-English journals. In order to get a

    comprehensive view of the evidence, both positive and negative, searching a European

    database such as CINAHL, the Cumulative Index to Nursing and Allied HealthLiterature, is valuable. Although CINAHL is more likely than MEDLINE to contain

    studies with negative findings, it is still more likely to publish a study with a positive than

    a negative finding. To find studies with negative findings, and indeed some with positivefindings, one can look to the "gray" literature. The gray literature is the term given to the

    body of research that is not published in peer-reviewed literature. This can take the form

    of technical reports, conference proceedings, testimony and other unpublished evidence.

    Finding the gray literature is a difficult task and is typically done through conversationswith content experts, relevant professional groups/organizations, and internet search

    engines.

    Step 3: Assessing the EvidenceSystematic Reviews

    There are at least two important factors to keep in mind when assessing a systematic

    http://www.ncepmaps.org/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fcompendium%2Fhttp://www.thecochranelibrary.com/http://www.campbellcollaboration.org/library.phphttp://ies.ed.gov/ncee/wwchttp://www.psycbite.com/http://www.speechbite.com/http://www.speechbite.com/http://www.informaworld.com/EBCAIhttp://www.nlm.nih.gov/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fassessing.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fassessing.htmhttp://www.ebscohost.com/cinahl/http://www.ncepmaps.org/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fcompendium%2Fhttp://www.thecochranelibrary.com/http://www.campbellcollaboration.org/library.phphttp://ies.ed.gov/ncee/wwchttp://www.psycbite.com/http://www.speechbite.com/http://www.speechbite.com/http://www.informaworld.com/EBCAIhttp://www.nlm.nih.gov/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fassessing.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fassessing.htmhttp://www.ebscohost.com/cinahl/
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    review.

    The first is relevance of the review to your specific clinical question (see framing theclinical question). If the brain-injured patient whose care prompted your question is a

    member of a cultural or linguistic minority, for example, how useful is a brain-injury

    review that excludes or makes no specific mention of culturally or linguistically diverse

    populations? If you are treating an autistic teenager, of what relevance are reviews basedprimarily on studies of younger children? Once again, the expertise and experience of the

    individual clinician is an absolutely essential part of evidence-based practice.

    The second factor to consider is who wrote and published the review. While many

    reviews are produced by academic institutions and interdisciplinary collaborations, others

    are produced by advocacy groups or payors. It is important to consider who produced the

    reviews and to what extent they would likely be affected by positive or negative findings.However, reviews eminating from a "trusted" source are no more guaranteed to be of

    high quality than are reviews coming from a less objective source guaranteed to be

    flawed.

    Individual StudiesAs noted elsewhere, publication of a study in a peer-review scientific journal is not aguarantee of quality. Individual studies are generally assessed along two dimensions:

    level of evidence and study quality. Level of evidence refers to the establishment of a

    hierarchy of study designs based on the ability of the design to protect against bias. Whilethere is no one universally accepted hierarchy, randomized controlled trials (RCTs) are

    considered to be the design least susceptible to bias, and various hierarchies follow from

    there through observational studies and non-experimental designs. The table below is oneexample of a hierarchy of levels of evidence.

    Leve

    l Description

    Ia Well-designed meta-analysis of >1 randomized controlled trial

    Ib Well-designed randomized controlled study

    IIa Well-designed controlled study without randomization

    IIb Well-designed quasi-experimental study

    III Well-designed non-experimental studies, i.e., correlational and case studies

    IV Expert committee report, consensus conference, clinical experience ofrespected authorities

    Adapted from theScottish Intercollegiate Guidelines Network

    Study quality is an assessment of the extent to which a study, of whatever design, wasdesigned and implemented appropriately. Again, there is no single universally accepted

    set of criteria for what constitutes a high quality study. For examples of study quality

    criteria, see the Scottish Intercollegiate Guidelines Network.

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    Step 4: Making the DecisionFinally, the time will come to combine clinical expertise, the patient's perspective, and

    the available scientific evidence in making a specific clinical decision with a specific

    patient. In some instances, evidence-based clinical guidelines will already have been

    developed on topics related to your particular question. There are at least three importantfactors to keep in mind when considering whether and to what extent to follow the

    guidance contained in such documents.

    The first is relevance of the guideline to your specific clinical question (see framing the

    clinical question and EBP Compendium). If the brain-injured patient whose care

    prompted your question is a member of a cultural or linguistic minority, for example,

    how useful are brain-injury guidelines that exclude or make no specific mention ofculturally or linguistically diverse populations? If you are treating an autistic teenager, of

    what relevance are guidelines developed primarily on the basis of evidence from younger

    children? Once again, the expertise and experience of the individual clinician is anabsolutely essential part of evidence-based practice.

    The second consideration is the extent to which clinical practice guidelines are truly

    evidenced-based. Many guidelines are produced via an expert consensus process or othernon-systematic approaches. While expert consensus can certainly be a valuable source of

    information, the conclusions are particularly vulnerable to the biases held by the

    "experts", and history is full of examples of such conclusions being simply wrong.

    If a guideline is truly evidence-based, the methodology by which evidence was identified

    and evaluated should be transparent. Unfortunately, transparency in itself is not a

    guarantee of quality. It can be a challenge for clinicians to determine what is and is not ahigh quality evidence-based practice guideline. Systems for evaluating practice

    guidelines have been developed and can be useful tools to help determine whether a

    guideline should be applied. The most prominent of these tools is the Appraisal ofGuidelines Research and Evaluation(AGREE) framework. AGREE was developed by

    the European Union and has subsequently been endorsed by the US Agency for Health

    Research and Quality (AHRQ).

    The third factor to consider is who wrote and published the guideline. While many

    guidelines are produced by academic institutions and interdisciplinary collaborations,

    others are produced by advocacy groups or payors. It is important to consider whoproduced the guidelines and to what extent they would likely be affected by positive or

    negative recommendations. However, guidleines eminating from a "trusted" source are

    no more guaranteed to be of high quality than are guidelines coming from a less objectivesource guaranteed to be flawed. Application of the AGREE or other objective criteria

    should be the final determinant of the guideline's quality.

    Where to Find Evidence-Based Practice Guidelines

    N-CEP's Compendium of Guidelines and Systematic Reviews (ASHA)

    Scottish Intercollegiate Guidelines Network(SIGN)

    The National Guideline Clearinghouse

    http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fframing.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fframing.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fcompendium%2FN-CEP-background.htmhttp://www.agreecollaboration.org/instrument/http://www.agreecollaboration.org/instrument/http://www.agreecollaboration.org/instrument/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fcompendium%2Fhttp://www.sign.ac.uk/guidelines/index.htmlhttp://www.guideline.gov/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fframing.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fframing.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fcompendium%2FN-CEP-background.htmhttp://www.agreecollaboration.org/instrument/http://www.agreecollaboration.org/instrument/http://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fcompendium%2Fhttp://www.sign.ac.uk/guidelines/index.htmlhttp://www.guideline.gov/
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    American Academy of Pediatrics

    U.S. Department of Veterans Affairs

    Academy of Neurologic Communication Disorders and Sciences (ANCDS)

    National Electronic Library for Health (National Health Service of the UK)

    Royal College of Speech-Language Therapists

    When guidelines are either inapplicable or non-existent, then the clinician must rely on

    the evidence identified and assessed in the previous steps (Finding the Evidenceand

    Assessing the Evidence). There typically is no magic formula for determing how much

    evidence is "enough." Factors such as patient preference, cost effectiveness, potential forharm and availability of alternative treatments all come into play in ultimately making the

    treatment decision

    http://aappolicy.aappublications.org/http://www.ciebp.research.va.gov/http://www.ancds.org/http://www.evidence.nhs.uk/nhs-evidence-content/journals-and-databaseshttp://www.rcslt.org/members/publications/clinicalguidelineshttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Ffinding.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Ffinding.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fassessing.htmhttp://aappolicy.aappublications.org/http://www.ciebp.research.va.gov/http://www.ancds.org/http://www.evidence.nhs.uk/nhs-evidence-content/journals-and-databaseshttp://www.rcslt.org/members/publications/clinicalguidelineshttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Ffinding.htmhttp://var/www/apps/conversion/tmp/scratch_3/%2Fmembers%2Febp%2Fassessing.htm