Evidence-Based Practice in Continence Care

Assoc Prof Winsome St John RN PhD

Research Centre for Clinical Practice Innovation

School of Nursing and Midwifery, Griffith University, Gold Coast

Quick review of evidence based practice

Debates in evidence based practice

Overview of evidence for continence

Resources

Ways forward

History

Critique of medical practice

The Cochrane Collaboration

Actually, we don’t really base all of the

things we do on good scientific evidence

Evidence shows that some things we have

‘always done’ can even cause harm.

Evidence-based medicine

The conscientious, explicit and judicious use of current best evidence in making the decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett et al, 1996, p. 249-254)

Evidence-based practice

The systematic interconnecting of scientifically generated evidence with the tacit knowledge of the expert practitioner to achieve a change in a particular practice for the benefit of a well defined client / patient group. French, 1999, p. 74

Evidence-Based PracticeCentres

Cochrane Collaboration

Joanna Briggs Institute (JBI)

Campbell Collaboration

Universities

Hospitals

Evidence-Based Journals

Why should clinicians think about EBP?

Providing care based on research / evidence will enable us to:

Keep up to date – accurate information Develop our body of knowledge Provide a basis for clinical judgments & practice

guidelines Provide high quality, cost effective care Eliminate worst practice Remain accountable Validate and justify care, Lobby for resources

How do you know what you know?

Types of information in the literatureTexts, secondary sourcesDescriptionsTheoretical literatureSingle research studiesReviews of the literatureSystematic reviewsMeta-analyses

What is evidence?

Weighing the Evidence

Not all research is well designed, valid, generalisable

The evidence must be appropriate to The questionPractice issueClient group

Not all evidence is equal

Level Intervention 1

I A systematic review of level II studies

II A randomised controlled trial

III-1 A pseudorandomised controlled trial (i.e. alternate allocation or some other method)

III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial▪ Cohort study ▪ Case-control study ▪ Interrupted time series with a control group

III-3 A comparative study without concurrent controls: ▪ Historical control study ▪ Two or more single arm study▪ Interrupted time series without a parallel control group

IV Case series with either post-test or pre-test/post-test outcomes

NHMRC 2008 Evidence Hierarchy: designations of ‘levels of evidence’ according to type of research question

Key Questions

1. Evidence base

2. Consistency

3. Clinical impact

4. Generalisability

5. Applicability

6. Other factors

NHMRC 2008

Critique of this Approach to Weighing Evidence

RCT – effectivenessDoes not necessarily provide answers for Diagnosis, prognosis, harm Patient decision-making, health behaviours, daily-living

management Economic costs

Discounts other forms of evidenceHow and whyTightly controlled studies may not be widely generalisableStudy results may not take account of patient contextJudgments about when the evidence is relevant

JBI Applicability FAME Scale

Feasibility

evidence about the extent to which an activity or intervention is practical.

Appropriateness evidence about the extent to which an activity or intervention is Ethical or culturally apt.

Meaningfulness

evidence about the personal opinions, experiences, values, thoughts, beliefs or interpretations of clients and their families or significant others.

Effectiveness

evidence about the effects of a specific intervention on specific outcomes.

(JBI, 2008)

JBI Model of Evidence-Based Health Care 2008

JBI Levels of Evidence (2008)

Making Evidence Accessible to Busy Clinicians

Systematic reviews

Summaries

Abstracts

Practice sheets

Evidence-based clinical guidelines

A Systematic Review is:

“… a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research” (Cochrane, 2005).

How are they done?A systematic review

Has a focused clinical question, protocolBased on research evidence – not authority, opinionFocuses on a client group, intervention, risk factorExamines benefits, harm, cost effectivenessThe search is exhaustiveExamines rigour of researchIncludes consultations with cliniciansWeighs levels of evidence

When should a systematic review be carried out?

The problem requires a response from health professionalsThere is a recurring practice problemTo investigate a common therapeutic practice or approachTo develop standards or protocolsRecent research generates questions about practice

Exercises, Biofeedback & Electrical StimulationPhysical therapies for prevention of urinary and faecal incontinence in adults J Hay-Smith, P Herbison, S Mørkved 2007

Pelvic floor muscle training for urinary incontinence in women Jean Hay-Smith, Kari Bo, Bary Berghmans, Erik Hendriks, Rob de Bie, Ernst van Waalwijk van Doorn 2008

Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women EJC Hay-Smith, C Dumoulin 2006

Weighted vaginal cones for urinary incontinence P Herbison, N Dean 2002

Pelvic floor muscle training for urinary incontinence in women Jean Hay-Smith, Kari Bo, Bary Berghmans, Erik Hendriks, Rob de Bie, Ernst van Waalwijk van Doorn 2008

Electrical stimulation with non-implanted electrodes for urinary incontinence in adults Berghmans, K Bo, E Hendriks, M van Kampen, R de Bie 2004

Neuromodulation with implanted electrodes for urinary storage and voiding dysfunction in adults P Herbison, E Arnold 2003

Cochrane Library: Systematic Reviews

Bladder retraining & VoidingTimed voiding for the management of urinary incontinence in adults J Ostaszkiewicz, L Johnston, B Roe 2004  

Habit retraining for the management of urinary incontinence in adults J Ostaszkiewicz, T Chestney, B Roe 2004  

Bladder training for urinary incontinence in adults SA Wallace, B Roe, K Williams, M Palmer 2004  

Pharmacological Intervention

Oestrogens for urinary incontinence in women B Moehrer, A Hextall, S Jackson 2003Adrenergic drugs for urinary incontinence in adults A Alhasso, CMA Glazener, R Pickard, J N'Dow 2005Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults P Mariappan, AA Alhasso, A Grant, JMO N'Dow 2005

ManagementCatheter policies for management of long term voiding problems in adults with neurogenic bladder disorders J Jamison, S Maguire, J McCann 2004 Absorbent products for light urinary incontinence in women M Fader, AM Cottenden, K Getliffe 2007

Cochrane Library: Systematic Reviews

Client groupsTreatment of urinary incontinence after stroke in adults LH Thomas, S Cross, J Barrett, B French, M Leathley, CJ Sutton, C Watkins 2008  

Conservative management for postprostatectomy urinary incontinence KF Hunter, KN Moore, CMA Glazener 2007

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children M Brazzelli, P Griffiths 2006

Faecal Incontinence & Constipation

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children M Brazzelli, P Griffiths 2006

Plugs for containing faecal incontinence M Deutekom, A Dobben 2005  

Sacral nerve stimulation for faecal incontinence and constipation in adults G Mowatt, C Glazener, M Jarrett 2007  

Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults C Norton, JD Cody, G Hosker 2006  

Drug treatment for faecal incontinence in adults Mark J Cheetham, Miriam Brazzelli, Christine C Norton, Cathryn MA Glazener 2002  

Electrical stimulation for faecal incontinence in adults G Hosker, JD Cody, CC Norton 2007

Cochrane Library: Systematic Reviews

InvestigationsUrodynamic investigations for management of urinary incontinence in children and adults CMA Glazener, MC Lapitan 2002

Surgical InterventionSurgical management of pelvic organ prolapse in women C Maher, K Baessler, CMA Glazener, EJ Adams, S Hagen 2007  

Open retropubic colposuspension for urinary incontinence in women MC Lapitan, DJ Cody, AM Grant 2005

Surgery for faecal incontinence in adults SR Brown, RL Nelson 2007

Traditional suburethral sling operations for urinary incontinence in women CA Bezerra, H Bruschini, DJ Cody 2005

Minimally invasive sling operations for stress urinary incontinence in women CCB Bezerra, MS Plata 2007

Anterior vaginal repair for urinary incontinence in women CMA Glazener, K Cooper 2001

Bladder neck needle suspension for urinary incontinence in women Cathryn MA Glazener, Kevin Cooper 2004

Cochrane Library: Systematic Reviews

JBI: Systematic ReviewsHaddow, G., Watts, R., Robertson, J. (2005). The effectiveness of a

pelvic floor muscle exercise program on urinary incontinence following childbirth (Technical Report)

The Australian Centre for Rural and Remote Evidence Based Practice. (Completed). Instruments for the Assessment of Faecal Incontinence for Community-dwelling Older Persons. Toowoomba Health Service District, Toowoomba, Queensland, Australia

A systematic review of psychometric evidence and expert opinion regarding the assessment of faecal incontinence in older community-dwelling adults. The University of Queensland/Blue Care Research and Practice Development Centre.

Hodgkinson, B. Hegney, D. Josephs, K. and Leira, E.A (Review in progress). Systematic review of the effect of educational interventions of urinary and faecal incontinence for health care staff/carers/clients on level of knowledge, frequency of incontinence episodes and hours spent on the management of incontinence episodes. The University of Queensland/Blue Care Research and Practice Development Centre.

Evidence-Based Clinical Guidelines

Multi-Disciplinary, Allied Health, NursingNew Zealand Continence Association Guidelines http://www.continence.org.nz/guidelines.html Nocturia, Enuresis, Constipation

New Zealand Guidelines Group http://www.nzgg.org.nz/index.cfm

Auckland District Health Board Jean Hay

Referral guidelines: Female Urinary Incontinence

NMAP: The UK’s gateway to high quality resources in nursing, midwifery and allied health. <http://www.nmap.ac.uk>

Royal College of Nursing (United Kingdom). Clinical guidelines. http://www.rcn.org.uk/resources/guidelines.php

General & Medical

Guidelines International Networkhttp://www.g-i-n.net/

National Institute of Clinical Studies (NICS) (NHMRC)http://www.nhmrc.gov.au/nics/asp/index.asp

Medical Journal of Australia Clinical Guidelines http://www.mja.com.au/public/guides/guides.html

National Guideline Clearinghouse in the United States of America found at http://www.guideline.gov/

Journals

International Journal of Evidence Based Healthcare

The Journal of Evaluation in Clinical Practice

Worldviews on Evidence-based Nursing

Bandolier

Evidence-Based Nursing

What information should I be keeping up with?

Usefulness = Relevance X Validity

Work it takes to find out

J of Fam Pract 1994 38, 505-513

Relevance of Information

Is this research client/practice focused?Will it change my practice / affect clinical decision making?Are these findings applicable to my clients / practice?Was the setting for this research similar to my clients’ setting / practice setting? Is the research valid?Are the results significant?

What does experience and expertise contribute?

Assessment skills

Judgment

Efficiency and effectiveness

More thoughtful, compassionate care

An ability to apply the appropriate knowledge to the right situation

Knowledge that would contribute to improving continence practice:

Effectiveness of continence treatments, therapy and careExperience of and responses to incontinence, therapy, treatment, advertising, product use, etc.Processes for providing continence care, purchasing, etc.Inequities in continence care provision / service provisionSocio-cultural impacts of incontinence, buying patterns, etc.Issues generating conflicting perspectives

The Challenge for Continence Care

Basic research to generate new knowledge about continence treatment & care

Get continence issues on the EBP agenda

Undertake systematic reviews in relation to core practices in continence care

Make this information accessible to practitioners

Provide organisational support for EBP and research

Fund research / access funding

Changes to PracticeQuestion practice decisions based on authority aloneReflect on practiceLook for evidence as a basis for decision-makingUse clinical guidelines based on evidence that have been developed by othersOngoing review of clinical guidelines, based on evidenceEvaluate the outcomes of practiceGenerate questions that need answering

Developing EBP ApproachesDevelop and lobby for clinically-relevant questions for systematic reviewsLearn how to apply the results of studies done by othersShare knowledge / expertise with others eg. attend conferences Learn to read research articles and systematic reviews critically eg. Start a journal clubResources Use the library / databases Develop a library of CATS (critically appraised topics) Subscribe to the JBI, Cochrane

Develop research skills / team up with someone who has research skills

Barriers to EBPAttitudes

Most clinicians do not read research literature, use research findings (eg. Nagy, et al, 1992)

ResourcesAccess to libraries, journals, systematic reviews,

research expertise, etc.Support

Time, financial support to conduct research and disseminate findings

Organisational culture / structureKnowledge

Sources of Information

Different sources are required for different types of evidenceGuidelines – professional organisationsSystematic reviews - Evidence based

practice centresNational or local data - grey literature,

organisational material

WebsitesCochrane Collaborationhttp://www.cochrane.org

Joanna Briggs Institutehttp://www.joannabriggs.edu.au/about/home.php

NHS Centre for Reviews and DisseminationThe Database of Abstracts of Reviews of Effectiveness (DARE)

Campbell Collaborationhttp://www.campbellcollaboration.org

The US Centre for Disease Controlhttp://www.cdc.gov/eval/resources.htm

National Institute for Clinical (NICS)

New Zealand Guideline Grouphttp://www.continence.org.nz/guidelines.html

JBI ResourcesSystematic reviewsBest practice sheetsEvidence utilisationTechnical reportsCOnNECT: Clinical Online Network of Evidence for Care and Therapeutics Online facility providing resources and tools to search,

appraise, summarise, embed, utilise and evaluate evidence-based information

PACES program: Practical Application of Clinical Evidence System An on-line tool for health professionals to conduct an

audit in a large or small health care setting

The FutureClinically-focused researchClinicians developing and shaping their own practice area through research, publicationCollaboration between clinicians and academics to develop knowledge to support evidence based practice eg. Research positions in health agenciesMore research into clinical practice undertaken by/in collaboration with cliniciansStrategic planning for research activity in clinical practiceDevelopment of a library of evidence-based knowledge

Clinically-focused, rigorous research can be used to develop knowledge, enhance practice, and validate the value of practice in continence care.

The outcome of refining and applying knowledge better care is for people with incontinence

Thankyou

References

Sackett DC, Rosenberg WMC, Gray JAM, Haynes RB & Richsrdson WS. (1996) Evidence-based medicine: What it is and What isn’t it. British Journal of Medicine, 312, 71-2.

Popay J, Rogers A, Williams G. (1998). Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res, 8(3), 341-351.

EBP - the next phase?

Effectiveness: RCT, cohort studies etc.Appropriateness: meta-analysis / synthesis of interpretive researchFeasibility: action research, critical approachesBasic research required to generate new knowledgeDevelop rigorous ways of evaluating the findings from non-RCT research

Questions and Critique of EBP in Continence Care

Don’t we do this now?Could become a straight jacket for practiceCould be used as a cost cutting measureWhat counts as evidence? Focuses on the measurable, values outcomes, not processesLimited research evidence in continence careInsufficient research skillsWe have to implement practices right nowWhere does experience and expertise fit?

NHMRC: Levels of Evidence 1995I Evidence obtained from a systematic review

of all relevant randomised controlled (RCT) trials

II Evidence obtained from at least one properlydesigned randomised controlled trial

III.1 Evidence obtained from well-designedcontrolled trials without randomisation

III.2 Evidence obtained from well-designed cohortor case-control analytic studies preferablyfrom more than one centre or research group

III.3 Evidence obtained from multiple time serieswith or without the intervention. Dramaticresults in uncontrolled experiments

IV Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Key Questions

1. Evidence base

A Several Level I or II studies with low risk of bias

B one or two Level II studies with low risk of bias or SR/multiple Level III studies with low risk of bias

C Level III studies with low risk of bias or Level I or II studies with moderate risk of bias

D Level IV studies or Level I to III studies with high risk of bias

2. Consistency

A All studies consistent

B Most studies consistent and inconsistency can be explained

C Some inconsistency, reflecting genuine uncertainty around question

D Evidence is inconsistent

NA Not applicable (one study only)

3. Clinical impact

A Very large

B Moderate

C Slight

D Restricted

4. Generalisability

A Evidence directly generalisable to target population

B Evidence directly generalisable to target population with some caveats

C Evidence not directly generalisable to the target population but could be sensibly applied

D Evidence not directly generalisable to target population and hard to judge whether it is sensible to apply

5. Applicability

A Evidence directly applicable to Australian healthcare context

B Evidence applicable to Australian healthcare context with few caveats

C Evidence probably applicable to Australian healthcare context with some caveats

D Evidence not applicable to Australian healthcare context

Other factors (NHMRC 2008)