"Effective evidence-based occupational therapy - PowerPoint"
Effective evidence-based occupational therapy An inspiring implementation challenge Dr. Esther Steultjens Where systematic reviews lead me Systematic reviews by Steultjens et al. • Efficacy of OT for RA • Efficacy of OT for stroke • Efficacy of OT for MS • Efficacy of OT for children with CP • Efficacy of OT for community dwelling elderly • Overview of systematic reviews Steultjens E, 2002, 2003, 2004, 2005 indexed in Pubmed Conclusions PhD thesis • Evidence in OT exists! • High methodological quality studies show efficacy of OT interventions • There are evidence gaps • Systematic (Cochrane) reviews can be performed in OT • Methodological challenges occur Steultjens E, 2005. NIVEL VU University Amsterdam NL OT practice High quality OT is: • Effective • Client centred • Evidence based • Occupation based • Efficient Content • From systematic review to evidence- based guideline • Into systematic reviews • Best Practice Guidelines level 1 • Using meaningful activities as tool in OT treatment leads to higher functional abilities and participation. • Training self-maintenance activities does not lead to better performance in leisure activities • Leisure activities need to be trained to raise satisfaction with performing leisure activities Themes • Client centeredness • Occupational performance • Multi-disciplinary collaboration • Caregivers and social context • Organisation of healthcare Changes in OT practice One year after dissemination • 60% active implementation of client centeredness • 70% active implementation of occupation based treatment • Focus on caregiver, multi-disciplinary collaboration, organisation of care need more attention Implementation Stroke OT guideline, 2006, HVA, Amsterdam Changes in OT practice 3 years after dissemination • 70% implemented guideline • 90% changed practice • 98% use meaningful activities as treatment tool • 90% collaborates with client and caregiver in treatment goal decision Evaluating the stroke OT guideline, 2008, HVA, Amsterdam Conclusion • Systematic reviews change practice • OT becomes more – Client centred – Evidence-based – Occupation-based • Efforts in developing and implementing guidelines are necessary. Into systematic reviews From chaos to confidence Experienced difficulties with Evidence-based Practice • 53% perceive using evidence as requiring too much effort • 70% reported difficulty in evaluating quality of evidence as greatest barrier • 60% did not think research is written in an understandable manner C. Döpp et al, 2008 Systematic review • Research question relevant to practice • Inclusion criteria stated – Patient characteristics – Intervention or situation characteristics – Comparison intervention or situation – Outcome • Search strategy replicable – Databases searched – Keywords used – Dates of search Systematic review • Inclusion process reliable – Transparent – Independent • Data extraction process reliable – Presentation of key characteristics • Synthesis process transparent – Description of statistical analyses and best evidence syntheses • Implications for practice An example • Steultjens et al. Efficacy of OT for MS (Cochrane review). first published 2003, issue 3 • Baker et al. The effectiveness of physical, psychological and functional interventions in treating clients with multiple sclerosis: a meta-analyses. Am J Occup Ther. 2001;55:324-331 An example • Efficacy of OT treatment vs efficacy of OT related treatment • Inclusion criteria: – Clear definition of OT vs multidisciplinary, physical, psychological and social work interventions – Searches till December 2002 vs searches till 2000 • Inclusion of: – 3 studies (1 RCT, 1CCT, 1 not controlled design) vs 23 studies (RCT and CCT only) Conclusion inclusion of literature • Big differences between reviews • Results based on 3 studies evaluating specific OT interventions • Results based on 23 non-specific OT related interventions An example 2 • Qualitative best-evidence synthesis for 3 studies incorporating heterogeneity • Meta-analyses of 23 studies without addressing issue of heterogeneity An example 2 • No conclusions can be stated whether occupational therapy improves outcome in multi-sclerosis patients • Overall medium effect size of 0.52 Implications for practice? Best Practice A professional reasoning perspective Implementation phases • Acquiring new knowledge • Knowing acquired change • Positive attitude to change • Changing process • Established new care Professional reasoning • Process of OT treatment • Content of OT treatment • Decision making process Explicit Professional reasoning Explicit reasoning model Thinking: When What HOW CCEBE-Model Client Evidence- based decision Bio-psychosocial state Scientific evidence society Logister, 2007 Who is the OT? Self-esteem