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Evidence Based Practice in Nutrition and Dietetics

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Brandis Roman

on 17 October 2012

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Transcript of Evidence Based Practice in Nutrition and Dietetics

Evidence-Based Practice in
Nutrition and Dietetics What is evidence-based nutrition/dietetics practice? Use of systematically reviewed scientific evidence...
In making food and nutrition practice decisions...
By integrating best available evidence with professional expertise and client values...
To improve health outcomes. Hasn't our profession always done this? In the past, dietitians made decisions based on: Evidence Based Practice Academic knowledge and practical experience Info from those we perceive to have more authority/ knowledge Intermittent reviews of the literature Sales reps, trade journals, advertisements Now add: Methodological evaluation of research (ours or others) Critical and thoughtful application of best evidence to our practice EBDP Clinical Management Public Health Does EBDP only apply to the clinical setting? Education What is the best evidence on the use of an enteral formula with arginine, glutamine, n-3 fatty acids, and RNA? What is the evidence that patients and clients are dissatisfied with food and nutrition services? Is a nutrition intervention in a community program effective for patients with HIV? What is the evidence that dietetics practitioners of the future need Master's degrees at entry-level? What is the impetus for EBDP? Maximize outcomes with limited resources = best possible value
Patients/clients have access to more and more health information
HCPs have access to more evidence now than previously
RDs need EBDP for empowerment and credibility
Reimbursement for MNT Evidence Based Decisions Current Best
Evidence Patient, Client, or Customer
Preferences and Needs Available
Resources Practitioner’s Knowledge and Skills Considerations for Decision-Making How Do RDs Feel About EBP? Last time read research*
Frequency of professional reading
Advanced level board certifications
Level of education*
Taken a research course
Work status* (working vs. unemployed)
Association membership* (>2 organizations) Predictors of Higher PAK Scores Lack of resources (time, money, staffing)
Poor organizational culture
Unsupportive health care team members
Provider skill
Lack of relevant research
Applicability of RCT results to real-world clinical settings
Guidelines need to be continually updated as new evidence becomes available Barriers to EBDP 1. Cultivate a spirit of inquiry 2. Formulate a clinical (or other) question. 3. Search for answers. 4. Critically appraise the evidence. 5. Apply the results = evidence + expertise + patient values 6. Assess the outcome. 7. Disseminate the EBP results. What are the 7 steps of EBP? Spirit of Inquiry Usually involves a clinical practice area where controversy exists about a given intervention
Examples:
Fruit and vegetable consumption and incidence of stroke
Effect of breastfeeding on risk of celiac disease
Prenatal intake of omega-3 PUFAs and cognitive development Where might your spirit of inquiry lie? P = Patient population of concern I = Intervention C = Comparison intervention (or control) O = Outcome of Interest T = Time it takes to achieve the outcome How do you write a good clinical question? P = In infants 0-12 months of age fed infant formula I = does feeding with infant formula with added DHA and ARA C = as compared to feeding with infant formula without added DHA/ARA O = improve Wechsler Preschool and Primary Scale of Intelligence T = at 4 years of age? What's your question?
Where do we find evidence to solve our problems and practice in the field of dietetics? Research Questions and Findings Dietetics Practice Is a double-blind, randomized, placebo-controlled clinical trial always the best way to answer a clinical question? PICOT 5+7= (cc) image by anemoneprojectors on Flickr Type of Question Type of Study Diagnosis

Treatment

Prognosis

Etiology or
harm Cross-sectional

RCT

Cohort

Cohort or case-control (cc) photo by theaucitron on Flickr Consider the quality of the evidence 1a - Systematic review of RCT
1b - RCTs
1c - All or none case series
2a - Systematic review of cohort studies
2b - Individual cohort study or RCT with <80% follow-up
2c - Outcomes research
3a - Systematic review of case-control study
3b - Individual case-control study
4 - Case series
5 - Expert opinion Search Strategy: 4S (for Efficiency) Systems Synopses Syntheses Studies Covers a variety of diagnoses
Provides a summary of results of high quality systematic reviews
Frequently updated
Examples
Clinical Evidence (www.clinicalevidence.com) – requires a subscription
ADA Evidence Analysis Library (www.adaevidencelibrary.com)
Up-to-Date Systems Structured abstracts of high-quality systematic reviews or original articles.
Examples:
ACP Journal Club (www.acpjc.org)
Best Evidence (http://gateway.ovid.com)
Evidence-Based Medicine (http://ebm.bmjjournals.com) Synopses High quality systematic reviews (and/or meta-analysis)
Examples:
Cochrane Database of Systematic Reviews (www.cochrane.org)
Database of Abstracts of Reviews of Effectiveness (http://www.ovid.com/site/products/ovidguide/daredb.htm) Syntheses What is the difference between a review of the literature and a systematic review of the literature? The Systematic Review is much more formal than the traditional review of the literature
Formal search strategy
Formal method of evaluating the research reports
Formal methods of grading the research and making recommendations Review of the Literature vs. Systematic Review
What is meta-analysis? A formal, defined data system to combine results of numerous small independent studies
Merges the results of similar research studies as if one large study was done
Meta-analysis can be part of a systematic review. Definition of Meta-Analysis Original research articles
Identified by searching MEDLINE, PubMed, CINAHL, etc.
Use key phrases from the PICO(T) question to narrow down your search
Use advanced search functions to further limit studies retrieved Studies What are some things you would consider in appraising evidence, particularly individual studies? Is the study valid?
Randomized, blinded?
Were there differences between study groups at the start of the trial?
Are the results important?
How large was the treatment effect?
How precise are the results?
Can I apply the results to my patient?
Is my patient too different from those in the study?
Is the treatment feasible in my setting? Appraising the Evidence
What is bias? “Any tendency that prevents unprejudiced consideration of a question.” (Pannucci and Wilkins, 2010)
Bias is almost always a part of studies and exists on a spectrum
Can be present at any point in the research process
Bias is a type of systematic error and is different from random error
Random error = False positive – can happen 5% of the time with p<0.05 Bias and How It Impacts Study Validity Flawed study design, ie Non randomization, non-blinding
Selection bias
Interviewer/examiner bias
Chronology Bias
Recall bias
Exposure or outcome misclassification
False negative – may show a negative result if not enough “n” Bias in Individual Studies Search bias
Selection bias
Reporting/citation/publication bias - studies with positive results are published more frequently than studies showing negative or neutral results Evaluating Study Bias in Systematic Reviews Consider:
Research evidence
Clinical expertise
Patient assessment
Patients’ preferences and values
Resources available Implementing the Evidence Evidence based guidelines (cc) photo by medhead on Flickr Evidence-based individual decision making Evidence Based Medicine Effects in a RCT do not always equal effects in the clinical setting.

Why? Assessing the Outcome How could you disseminate and share your research findings? So... how can you become more comfortable with EBP? Practice-based research networks EBP has the potential to improve patient outcomes and further the profession.
EBP involves integration of evidence with clinical experience and patient values.
EBG can be a springboard for EBM, but EBID is also important for the individual patient.
To overcome barriers to EBP:
Use efficient search strategies
Use strategies to become more comfortable with EBP Conclusion
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