...the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients. (Sackett 1996)
Optimal use of EBP involves carefully balancing: clinical expertise, the best evidence available, and patient values + circumstances.
Why do we need EBP?
Consider the following graph:
In just 18 years' time, the number of studies available in the NIH database of clinical trials has increased by more than 23,000%.
And that is only studies in Clinicaltrials.gov. Think for a moment about all of the other databases where you can find health-based information. In fact, try searching "cancer diagnosis" using Google...how many results does that deliver? On the day this was written (12/14/2018), that search query returned 842,000,000 search results! How do you think information seekers pick from all of those links?
According to a recent survey from dotHealth, 31% will opt for the very first result. Why do you think that is?
Check out this video from WNYC to get a better idea:
EBP helps us make sense of it all
There is an enormous amount of information out there, and it isn't going to get smaller anytime soon.
EBP can help practitioners siphon out the information that doesn't work. Doing so takes practice. We have to learn how to balance efficiency with precision. This means:
Knowing where to look for information
Weeding out unnecessary information
Successfully accessing and storing information
Analyzing the validity of information
Sharing information and putting it into practice
In EBP, we label this process: ASK --- ALIGN --- ACQUIRE --- APPRAISE --- APPLY
Please keep in mind that this is not always a linear process. Instead, learning how to get the best information using the most efficient methods takes time and is often iterative. Sometimes, you will know where you want to look for information before you know what type of keywords to use. In those cases, you'll spend time going back and forth between asking, aligning, and acquiring as you work out your research needs.
For now, focus on understanding why this process is important...
As you read through the following tabs, consider each of these three components. Ask yourself:
How do I define my own expertise, and can that change, expand, or even become more narrow?
How do I decide what qualifies as the "best" evidence? And how do I find it?
How do I ensure that my patients are treated equitably and given agency to make their own informed decisions?
i also recommend working through this checklist for conducting evidence-based research, as it can be used anytime one is looking for evidence:
Based on systematic reviews conducted by content experts, AOTA’s Evidence-based Practice (EBP) tools and resources provide members with comprehensive information to: Guide and inform clinical decision making; share with clients who want to participate in the clinical decision making process; discuss the distinct value of occupational therapy interventions with external audiences, such as regulatory agencies, third-party payers, referral sources, and program managers; stimulate academic and continuing education, in-service programs, or journal clubs; guide the development of clinical research projects
Abstract: Clinicians are encouraged to practice evidence-based medicine (EBM) as well as patient-centered medicine. At times, these paradigms seem to be mutually exclusive and difficult to reconcile. It can become even more challenging when trying to include the preferences of the patient’s family members. This paper discusses the basis for this quandary, providing examples of the real-world impact it has on diagnosis-seeking and treatment decision-making behaviors and how it might inform implementation of EBM practices.
helps decision makers identify the best available evidence by providing guides to the systematic consideration of the validity, importance, and applicability of claims about the assessment of health problems and the outcomes of health care.
The first step in EBP is to write a focused clinical question. That question will be translated into a database query in step two. Best practice is to define your research question and identify which types of studies or publications would be best suited to that question before searching the literature. You should also be aware of the patient, if you are seeing one, and how their needs are informing your research.
Once you've considered the foundational components of your research, the next step involves constructing a question relevant to your needs and your patient's needs. It should be framed using the PICOT acronym:
Patient / Population:
What kind of person is the patient? What is their diagnosis? What is their particular situational need?
Example: pre-adolescent children with cerebral palsy
How would you describe the specific intervention you are considering?
Example: whole body vibration
Comparison / Control:
Is there a control group? Is there are an alternative intervention? (Keep in mind: not all questions have a "comparison" component)
Example: conventional physical therapy
What is the desired outcome? Does it involve reduction, relief, or elimination of symptoms? Can it be measured with a test?
Example: increased balance
(OPTIONAL) Time / Type:
What time periods should be considered? What study types are most likely to have the information you seek? What clinical domain does your question fall under?
Example: randomized controlled trials
Now, we string our PICO components together:
Does whole body vibration increase balance in comparison to standard physical therapy in children with cerebral palsy?
It can be helpful to classify your question based on the clinical domain it falls under. A clinical domain refers to the type of study you wish to locate. For instance, a question involving therapy (such as whole body vibration) falls under the the clinical domain, therapy. Knowing this, you can filter your search results to return randomized controlled trials, which are the "gold standard" for studies involving therapeutic interventions.
See the examples below for more clinical domains and corresponding PICO templates:
Questions addressing the treatment of an illness or disability.
In _________ (P), how does _________ (I) compared to _________(C) affect _______(O) within _______ (T)?
In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?
In African American female adolescents with hepatitis B (P), how does acetaminophen (I) compared to ibuprofen (C) affect liver function (O)? (Time is optional).
Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation.
Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)?
In ________ (P) are/is ________(I) compared with ________(C) more accurate in diagnosing ________(O)?
Is a PKU test (I) done on two week old infants (P) more accurate in diagnosis inborn errors in metabolism (O) compared with PKU tests done at 24 hours of age (C)? Time is implied in two weeks and 24 hours old.
In middle-aged men with suspected myocardial infarction (P), are serial 12-lead ECGs (I) compared with one initial 12-lead ECG (C) more accurate in diagnosing an acute myocardial infarction (O)?
Questions on how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.
For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)?
In OR nurses doing a five minute scrub (P) what are the differences in the presence and types of microbes (O) found on natural polished nails and nail beds (I) and artificial nails (C) at the time of surgery (T)?
Questions around how to select treatments to offer our patients that do more good than harm and that are worth the efforts and costs of using them.
In _______(P), what is the effect of _______(I) on ______(O) compared with _______(C) within ________ (T)?
What is the duration of recovery (O) for patients with total hip replacement (P) who developed a post-operative infection (I) as opposed to those who did not (C) within the first six weeks of recovery (T)?
Questions addressing the causes or origin of disease, the factors that produce or predispose toward a certain disease or disorder.
Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared with ______ (P) with/without ______ (C) over _____ (T)?
Are ______(P) who have ______(I) compared with those without _______(C) at ________ risk for/of _______ (O) over ________(T)?
Are kids (P) who have obese adoptive parents (I) at Increased risk for obesity (O) compared with kids (P) without obese adoptive parents (C) during the ages of five and 18 (T)?
Are 30- to 50- year old women (P) who have high blood pressure (I) compared with those without high blood pressure (C)at increased risk for an acute myocardial infarction (O) during the first year after hysterectomy (T)?
The Levels of Evidence are often represented by a pyramid, with the highest levels of evidence (least common) near the top, and the lowest levels of evidence (most common) near the bottom. The pyramid above is based on the TRIP rating system for therapeutic studies, but a variety of rating systems exist.
Review-type papers summarize, analyze, and synthesize published research. The most common type is the systematic review, which involves an exhaustive literature search followed by unbiased, expert appraisal of research evidence. In addition to systematic reviews, there are many other types of review papers, some of which exhibit higher levels of evidence than others. The most common are:
Systematic review: an exhaustive literature search followed by unbiased, expert appraisal of research evidence.
Meta-analysis: a systematic review with an additional quantitative component, involving statistical combination of study results to provide a more accurate understanding of the research.
Critical review: an extensive literature search followed by theoretical and critical analysis of, not only of findings, but of concepts and systems involved in research.
Mapping review: a systematic literature search culminating in a "map" of findings, which categorizes research into groups to be reviewed in further study.
Mixed methods review: a systematic review which allows for appraisals of mixed study types, typically quantitative and qualitative.
Scoping review: a preliminary review designed to asses the scope of the research available in a particular field of study. It is designed to set parameters for future systematic reviews.
Experimental studies involve the manipulation of populations and treatments in order to reduce opportunities for bias. This involves the use of controls, randomization, and blinding. Typically, experimental studies exhibit higher levels of evidence by virtue of their providing empirical, quantitative data. Different types include:
Double-blind Randomized Controlled Trials: prospective study that involves collection of data in a clinical setting. Includes double blinding, in which neither the patient-participants nor the researchers know which groups or patients are receiving treatment. Double-blinding is more common in pharmacological studies.
Randomized Controlled Trial (RCT): prospective study that involves collection of data in a clinical setting. Includes randomization, in which members in the control and variable groups are selected and placed at random without influence by the research team. RCTs are the premiere study type for researching therapeutic interventions.
Randomized Cross-Over Clinical Trial: prospective study that involves collection of data in a clinical setting. Involves the "crossing-over" of participants from one treatment to another after a determined period of time. This type of study is prone to bias, as multiple treatments can overlap.
Observational studies typically provide lower levels of evidence than experimental studies, because they do not involve strict manipulation of controls. However, they may offer valuable insight, especially if the application of control factors would lead to undue harm for the patient/s. They may also serve as preliminary studies with the goal of conducting an experimental study later in the future.
Cohort study: a prospective study that analyzes data collected from groups designated for observation. These studies are prone to bias because there are limited control factors involved in selection, treatment, or follow-up.
Case-control study:a retrospective study that is useful for epidemiological and diagnostic observation. Case-controls measure the similarities and differences between "cohorts" of patients with a common outcome alongside another, similar cohort expressing different outcomes. These types of studies require follow-up and recall, and as such, are prone to biased interpretations and memory.
Case series and case reports: retrospective, anecdotal studies that rely upon descriptive interpretations of outcomes based on a series(a group of similar "cases"), or a single "case". These are not necessarily generalizable, as they focus on single patients or small groups of patients, prone to bias. Researchers may also fall victim to over representation of "absurd" or "bizarre" cases
Question Type & Study Design
Some study designs are better suited to answer certain types of questions. Identifying the clinical domain your question falls under can help determine what study designs to look for in order to find the best, most suitable evidence. Systematic Reviews and Meta-Analyses are always preferred.
Preferred Study Design (after systematic reviews and meta-analyses)
Once you have compiled at least one promising study or review, you should consider a citation management platform like RefWorks. This will help you keep your research organized, which is particularly helpful if you're writing a literature review or annotated bibliography!
If you ever need help with RefWorks, visit the Library's Research Support Servicespage, and click on Citation Management Apps.
Foreground vs. Background information
Foreground information is the complex, precise information often needed in order to answer a PICO question. Before searching for foreground information, however, make sure you have a good understanding of each of the PICO concepts. If you don't have adequate knowledge about one of your PICO concepts, you will need to pursue background information in order to fully understand the foreground information you find.
Following from the levels of evidence pyramid described on the Ask tab, information resources can be collapsed into three broad categories: summaries and guidelines, pre-appraised research, and non-appraised primary studies. See below for descriptions and examples of each.
Summaries and guidelines
summarizes the evidence from a topical level, can be used as practice guidelines
For practitioners who need immediate, credible information, appraised resources are highly preferred. BMJ Best Practices and UpToDate are two specific resources that can be leveraged at or around point-of-care. Keep in mind that PubMed also indexes appraised information; however, it is more difficult to parse due to PubMed's scope.
Appraised resources can be found across most scholarly journals, although it is important to remember: 1) editorials, opinions, and responses should not count as critically appraised sources 2) appraised resources exist on a spectrum from most heavily appraised (review-type papers) to randomized-controlled trials, non-randomized trials, and qualitative studies.
After constructing your PICO question and finding the resource that best suits your needs, it's time to build and conduct a search. Listed below are strategies and tools that will make it easier to find information that is most applicable to you and your patients.
Your PICO question should help you identify specific search terms that you can use to search the databases. This, combined with what you learned while searching background information, will help you form the "backbone" of your search question.
Take a few moments to list your PICO "primary" terms following the table below:
Primary Search Terms
P - Patient / Population
ex. children with cerebral palsy
Primary Search Terms
ex. "cerebral palsy" "children" "pediatrics"
I - Intervention
ex. whole body vibration
Primary Search Terms
ex. "whole body vibration" "vibration"
C - Control / Comparison
ex. conventional therapy
Primary Search Terms
ex. "stretching" "strength training"
O - Outcome
Primary Search Terms
ex. "balance" "gait"
PubMed Clinical Queries
Now that you've put together your primary search concepts, let's conduct an initial search in PubMed's Clinical Queries tool.
The clinical queries tool is designed to provide more efficient access to studies and systematic reviews which correlate with a specific clinical domain. It is not exhaustive! Rather, it is designed to give you more immediate insight into the amount of studies available in your field of study.
As you think about your clinical queries search keep in mind the following:
When you begin formulating a search strategy, aim for a search with high recall rather than precision. In many cases, this will generate a larger number of results than is necessary; however, it is sometimes easier to narrow your search over time instead of doing so from the outset.
Avoid using too many search concepts; concepts are the primary terms that align with your search needs. At the same time, a variety of synonymous search terms should be combined in conjunction with each concept.
IE: Intervention (concept) = hip strengthening | "hip flexor" OR "hip extension" OR "hip exercise" OR "hip stretch" OR ""hip stretches" OR hip stretching" OR "foam roll" OR "foam roller" OR "foam rolling" (search terms)
Familiarize yourself with Boolean operators AND, OR & NOT, and apply them within your search string, both between concepts and between search terms.
AND separates concepts | "cerebral palsy" AND "whole body vibration" narrows your search, such that you receive papers about both cerebral palsy and vibration.
OR separates search terms | "children" OR "pediatrics" broadens your search to include both of these key words.
NOT excludes unwanted concepts | "stroke" NOT ("heat stroke" OR "breast stroke") makes it more likely your search results will be limited to cerebrovascular accidents.
Two other rules to keep in mind involve parentheses and quotation marks:
Parentheses include phrases in your search, but will not limit to exact phrasing.
IE: (disorders of sexual development) will return any combination of those keywords.
Quotation marks limit search results to exact phrasing.
IE: "disorders of sexual development" will return this exact phrase.
A well-constructed initial search question:
"cerebral palsy" AND "children" AND (whole body vibration)
When searching for information in PubMed / MEDLINE, it's generally recommended to include MeSH Terms in your search. These are the "Medical Subject Headings" used by the National Library of Medicine to locate relevant articles.
For help with MeSH, see this short tutorial:
Journals in NCBI Databases
Sometimes, it is helpful to initiate a journal search to find information. This is particularly useful when you:
know which journals are most likely to publish studies similar to your topic;
want to identify the type of studies being published in a specific journal;
want to explore the "impact" of a specific journal within the discipline.
Journals can be searched by:
topic (ie: developmental disabilities)
journal title or abbreviation (ie: title = Transgender Health | abbreviation = Transgend Health)
ISSN (ie: 2380-193X)
If planning to publish a study, it is very important to identify a journal that focuses on the type of research you want to present. In these instances, authors should also check out a journal's home page, which can be found from the journal listing in PubMed.
PubMed Central is the NLM's open-access archive of biomedical literature. PMC indexes published papers, manuscripts, retractions, and other forms of gray literature (conference proceedings, dissertations, etc.). It is an enormous resource, and particularly useful when performing systematic analyses of research, which often require scouring gray literature as well as published studies.
Are the likely benefits worth the potential harms and costs?
Does the intervention impose upon my patient's values and circumstances?
Does this resource help me answer a PICO(T) question well enough to analyze and write about it myself?
Does this study have wider significance to my field?
Can this study be improved upon by further study?
Assessing for bias
Particularly for those conducting reviews (literature, scoping, systematic, etc.), it is important to assess for risk of bias. The following bullets, attributed to the Cochrane Handbook for Systematic Reviews, can help you ascertain the prevalence of bias in a given study:
A bias is a systematic error, or deviation from the truth, in results or inferences. Biases can operate in either direction: different biases can lead to underestimation or overestimation of the true intervention effect. Biases can vary in magnitude: some are small (and trivial compared with the observed effect) and some are substantial (so that an apparent finding may be entirely due to bias). Even a particular source of bias may vary in direction: bias due to a particular design flaw (e.g. lack of allocation concealment) may lead to underestimation of an effect in one study but overestimation in another study. It is usually impossible to know to what extent biases have affected the results of a particular study, although there is good empirical evidence that particular flaws in the design, conduct and analysis of randomized clinical trials lead to bias.
Bias should not be confused with imprecision. Bias refers to systematic error, meaning that multiple replications of the same study would reach the wrong answer on average. Imprecision refers to random error, meaning that multiple replications of the same study will produce different effect estimates because of sampling variation even if they would give the right answer on average. The results of smaller studies are subject to greater sampling variation and hence are less precise. Imprecision is reflected in the confidence interval around the intervention effect estimate from each study and in the weight given to the results of each study in a meta-analysis. More precise results are given more weight.
A study may be performed to the highest possible standards yet still have an important risk of bias. For example, in many situations it is impractical or impossible to blind participants or study personnel to intervention group. It is inappropriately judgmental to describe all such studies as of ‘low quality’, but that does not mean they are free of bias resulting from knowledge of intervention status.
Types of bias
systematic differences between baseline characteristics of the groups that are compared
Systematic differences between groups in the care that is provided, or in exposure to factors other than the interventions of interest.
Systematic differences between groups in how outcomes are determined.
Systematic differences between groups in withdrawals from a study.
Systematic differences between reported and unreported findings.
Research evaluation form
Major Components to Characterize
(Use this column to drill down on the notes in the left-hand column)
Summarize the abstract in 100 words or less:
Who published this study?
What was the social context of the study?
According to the authors, why is this topic important?
According to the authors, what is new in this specific study?
What hypothesis(es) is/are addressed?
What is overall the study design? (ie: RCT, CT, cohort, case study, synthesis, etc.)
Where is this paper likely to be located in the levels of evidence pyramid?
Describe the population and sample
Outcome Measures / Assessment Battery
Describe the Intervention that was used [for Clinical Trials]
Describe the statistical analyses used to measure outcomes:
How successful was the study implementation?
Describe the results:
Summary of findings:
Do the findings support publication?
What are the limitations (both said & unsaid)?
Extrapolation or relevance to the field:
Bias and other potential conflicts
Presence of self-citation?
Presence of conflicts of interest?
What is the journal impact factor?
The GRADE handbook breaks down the official grading rating scaled used for Cochrane reviews. The Handbook itself is lengthy, but it's easy to navigate across sections according to your needs. For appraisal, focus specifically on sections 4 and 5, Summarizing the evidence and Quality of evidence.
See the image below for a typical journey using the GRADE approach. Note that it begins with framing the PICO question, and from there, goes through the literature search into appraisal, grading, and recommendations for guidelines.
A collection of databases that contain evidence, including systematic reviews, to inform healthcare decision-making for clinical treatment decisions. Provides other sources of information, including technology assessments, economic evaluations and individual clinical trials.