Meeting the Evidence-Based Standard

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Meeting the Evidence-Based Standard Powered By Docstoc
					One Sky Center
R. Dale Walker, MD, Director
Michelle Singer, Communications Coordinator, ICMI Project Director
Doug Bigelow, PhD, Deputy Director

MEETING THE EVIDENCE-BASED
STANDARD
“THE LEARNING HEALTHCARE SYSTEM”
OUTLINE

   Evidence-Based vs Culture-Based Dilemma
   What is “Evidence”?
   Multiple Streams of Evidence
   The Learning Healthcare System
   Description: A Scientific Framework
   Some Culture-Based Interventions
EBI – CBI DILEMMA
   Epistemological gulf
       Western
       Traditional AI/AN

   Epistemological debate
       Validity of traditional world view
       Freedom to live by a traditional world view

   Practical debate
       Controlling by purse strings
  BRIDGING EBI – CBI


     Bridging
          Evidence is?
          Status of evidence for EBI
          How to meet reasonable standards of evidence

     Practice Improvement
          Multiple Streams of Evidence
          Learning Healthcare System
http://coce.samhsa.gov/cod_resources/PDF/OP5-Practices-8-13-07.pdf
http://www.iom.edu/CMS/28312/RT-EBM/41894.aspx
SOURCES OF EVIDENCE

1.    Intervention/program research
          Randomized Controlled Trials (RCT)
          Nonrandomized, uncontrolled
          Evaluation



    Adaptation of Proven Intervention
    Like a Proven Intervention
    Basis in Proven Theory, Principles, Facts
EVIDENCE-BASED INTERVENTIONS
PROCESS AND CRITERIA

   Criteria:
       Fidelity
       Internal Validity (vs confounding variables)
       External validity
       Reliability—repeatability.

   Process:
       Scientific experts
       Independent judging and rating
       Compilation and Summary
NATURE OF BEHAVIORAL INTERVENTION

   Therapeutic power of Choice

   Self-healing guided by expert healers

   Uniqueness of interpersonal relationships

   Complexity of factors
STATUS OF “EVIDENCE” IN EBI

1.   Individual studies

2.   Reviewed collections

3.   Lists of model, best, promising, alternative

4.   Survivors of meta-analyses
THE BUFFALO JUMP FOR EBI
REASONABLE STANDARDS OF EVIDENCE
FOR IMPROVED PRACTICES


   “Best Practices” = highest scientific standards
   Balance point
   Reasonable standards are:
       Repeatability
       Achievable within resources and constraints
       Allow conclusions without intolerable doubt
       Low risk of harm, if conclusions are wrong
ADAPTATION-ADOPTION



Adoption requires buy-in

   Acceptance
   Implementation
ADAPTATION-ADOPTION

Adaptation to unique local culture and context

   Players
   Rules, expectations, traditions

   Resources/collaborations

   Opportunity to contribute to strategic plan
ADAPTATION-ADOPTION


   MI, CBT, SFP, Project Venture, Canoe Journey
    implementations
       are unique in every setting


   Every replication is an Adaptation
EBI OUT OF THE BOX

   The EBI idea is changing

   SAMHSA: “multiple streams of evidence”

   IOM: “Learning Healthcare System”
OTHER SOURCES OF EVIDENCE
    Intervention/program RTC; Evaluation




1.    Adaptation of Proven Intervention

2.    Analogous to a Proven Intervention

3.    Basis in Proven Theory, Principles, Facts
DESCRIPTION

                                                          1.
                                                     Causes



                       8.
                    Long term



                                                                                             2.
                                                    Domains:                            Target
           7.                                        Individual
      Medium term               Outcome             Relationship                      Population
                                                    Community                         For intervention
                                                      Culture


                  6.
               Short term




                                                   Intervention

                                                                            3.
                                            5.
                                                                       Intervention
                                          Manual
                                                                         strategy

                                                          4.
                                                    Theory of Action
IMPORTANCE OF PROGRAM MANUALS

   “Operationalization” a way of knowing/believing
       From black box to detail


   Consistency with body of knowledge

   Who, what, when, where, how, decisions
   Repeatability
PROVEN THEORY, PRINCIPLES & FACTS

   Social ecology (influences)             Modeling (observational learning)
   Prevention                              Instrumental learning
        Universal/ selected/ indicated
    
                                            Group dynamics
   Risk and Resilience                     Conformity, altruism
   Readiness to Change                     Listening and support
   Risk taking/seeking                     Catharsis
   Stress vulnerability                    Psychopharmacology
KINDS OF INTERVENTION STRATEGY
•   Screening                  •   School/institution-based
•   Gatekeeping                •   Education/skills
•   Diagnosis                  •   Experiential
•   Treatment                  •   Socialization/acculturation
•   Traditional healing        •   Public Health (risk/resilience)
•   Traditional ritual/ceremony•   Services develop/coord
•   Postvention                •   L E/justice/corrections
•   Parent/family training     •   Community competency
•   Group work                 •   Community change
                               •   Culture
AI/AN PREVENTION, TX, REHAB INTERVENTIONS

   Story telling           Vision Quest
   Talking circles
   Sweat Lodge             Flute playing/meditation
   Ceremonies and Ritual   Reconciliation
       Purification
       Passages            Mentoring
       Naming
       Grieving            Service learning
   Drumming, singing,
    dancing                 GONA
“BEST PRACTICES”

   Cultural Enhancement Through Story Telling
    (Tohono O’odham Res)

   AI Strengthening Families Program (U UT)
   Across Ages (Mentoring) (Temple U)
   Creating Lasting Family Connections
   Dare to Be You (Ute Res)
   With Eagles Wings (N. Arapaho Nat)
   Families That Care—Guiding Good Choices
“BEST PRACTICES”

    Families and Schools Together (Rural Wisconsin Res)
    Parenting Wisely
    Preparing for Drug Free Years
    Project Alert
    Project Venture (NIYLP)
    Promoting Alternative Thinking Strategies
    Zuni Life Skills (Zuni Pueblo)

    http://www.spokane.wsu.edu/ResearchOutreach/wimhrt/research2.asp
BOTTOM LINE

 Deal with Epistemological Gulf
 Know limitations of Evidence in EBI

 Agree upon “Practice Improvement” Goal

 Make credibility gains with “Scientific
  Framework” for Description
 Use existing practices and knowledge as
  evidence for similar CBI
Feel Free To Contact Us At:

One Sky Center
(o) 503-494-3703
onesky@ohsu.edu

www.oneskycenter.org