Application of Evidence-Based Treatment (EBT) or Evidence-Based Practice (EBP) in Veterinary Fields :  Modus Operandi

Application of Evidence-Based Treatment (EBT) or Evidence-Based Practice (EBP) in Veterinary Fields :  Modus Operandi

 

Evidence-based treatment (EBT) refers to treatment that is backed by scientific evidence. That is, studies have been conducted and extensive research has been documented on a particular treatment, and it has proven to be successful. The goal of EBT is to encourage the use of safe and effective treatments likely to achieve results and lessen the use of unproven, potentially unsafe treatments.

Evidence-Based Treatment (EBT) or Evidence-Based Practice (EBP) refers to the practice of incorporating study results and procedures into everyday practical application by practitioners. While study results may seem like an obvious source of knowledge for practitioners, in reality it has been a difficult procedure to transfer that knowledge from the researcher to the practitioner. Thus, EBT establishes guidelines on finding, critically analyzing, incorporating, and applying the knowledge to practice.

There is a principle in all branches of medicine that dates back to Hippocrates, the ancient Greek physician. It has come to be known as “Primum Non Nocere” – “first, do no harm”. In many ways, this is the basis of all modern veterinary medicine . Before you start any treatment or intervention, make sure that doing it will improve the patient’s state, not worsen it. But how does that research link into the real world of you and your pet?

The EBP Process

Evidence-based practice (EBP) is the process of applying current, best evidence (external and internal scientific evidence), patient perspective, and clinical expertise to make decisions about the care of the individuals you treat.

Follow these steps to initiate and implement EBP into your clinical practice.

• Step 1: Frame Your Clinical Question
• Step 2: Gather Evidence
• Step 3: Assess the Evidence
• Step 4: Make Your Clinical Decision

Step 1: Frame Your Clinical Question

• Evidence-Based Practice
• Step 1: Frame your Clinical Question
• Step 2: Gather Evidence
• Step 3: Assess the Evidence
• Step 4: Make your Clinical Decision

The first step in the evidence-based practice (EBP) process is to identify the clinical problem or question for which you are seeking evidence. Asking a focused and relevant question about your client’s situation will inform your search. One widely used approach to frame a clinical question is known as PICO, which stands for

Population Intervention Comparison Outcome

The PICO elements are as follows:

• Population: What are the characteristics and/or condition of the group? This may include specific diagnoses, ages, or severity levels (e.g., autism spectrum disorder, mild hearing loss).
• Intervention: What is the screening, assessment, treatment, or service delivery model that you are considering (e.g., instrumental swallowing assessment, high-intensity treatment, hearing aids)?
• Comparison: What is the main alternative to the intervention, assessment, or screening approach (e.g., placebo, different technique, different amount of treatment)? Note: In some situations, you may not have a specific comparison in your PICO question.
• Outcome: What do you want to accomplish, measure, or improve (e.g., upgraded diet level, more intelligible speech, better hearing in background noise)?

Once you’ve identified the population, intervention, comparison, and outcome for your situation, you can establish your PICO question.

Quick Tip:

There is no one “correct” way to construct a PICO question. Your clinical question should include elements specific to each client’s unique circumstances and values.

Population	Intervention	Comparison	Outcome	Example PICO Question
Children with severe to profound hearing loss	Cochlear implants	Hearing aids	Speech and language development	For children with severe to profound hearing loss, what is the effect of cochlear implants compared with hearing aids on speech and language development?
Young adult with a stroke	Cognitive rehab	Not applicable	Return to work	What is the effect of cognitive rehabilitation on vocational outcomes in individuals who experience a stroke?

Quick Tip:

Sometimes, you have a clinical situation that may have more than one PICO question. Write them all down to tackle one search at a time. Your clinical question(s) should be specific enough to guide your search—but not too specific that you are unable to find any evidence.

Step 2: Gather Evidence

• Evidence-Based Practice
• Step 1: Frame Your Clinical Question
• Step 2: Gather Evidence
• Step 3: Assess the Evidence
• Step 4: Make Your Clinical Decision

Now that you’ve formulated your PICO question, the next step is to gather evidence that addresses your question. There are two types of evidence to consider: internal evidence and external evidence.

Internal evidence refers to the data that you systematically collect directly from your clients to ensure that they’re making progress. This data may include subjective observations of your client as well as objective performance data compiled across time. Use your clinical expertise to determine what information is most important to track for your client’s specific situation and needs. Armed with internal evidence unique to your client, you are better prepared to find targeted external evidence that will help you make a clinical decision.

External evidence refers to evidence from scientific literature—particularly the results, data, statistical analysis, and conclusions of a study. This evidence helps you determine whether an approach or a service delivery model might be effective at implementing change in individuals like your client.

Below are some things to consider when organizing and completing your search for external evidence:

• How should you plan your search for external evidence?
• What type of external evidence is needed to answer your question?
• Where should you search for external evidence?
• What should you do if you are unable to find external evidence?

How should you plan your search for external evidence?

A well-planned search increases the likelihood that you will find relevant external evidence that answers your PICO question. Below are some tips to help you get started with your search:

Develop a list of search terms.

Create a list of search terms using elements from your PICO question. It may not be necessary to include all PICO elements in your search, but these key concepts are a good place to start.
Example: What is the population, patient, or problem of interest? What is the main intervention or issue being considered? What outcome do you want to accomplish?

Consider synonyms, related terms, and acronyms for each key term. Using synonyms or related words can help you expand your search.
Example: If searching for traumatic brain injury, include “traumatic brain injury”, “TBI”, and “acquired brain injury”.

Set parameters for your search.

Combine keywords and phrases using terms such as “OR” and “AND” (known as Boolean operators) to broaden or narrow your search results.

• Use “OR” to increase your search results and find evidence that contains either term (e.g., “dysphagia OR swallowing”; “teenagers OR adolescents”).
• Use “AND” to limit your search and find evidence that must contain both words (e.g., “stroke AND aphasia”; “children AND hearing loss”).

Apply limits and filters to narrow your search (e.g., date range, language). A date limit may be helpful, particularly when a search retrieves too many results. Date limits may also be helpful if your question involves more recent technology or practice (e.g., “”digital hearing aids”, “telepractice”).

Stay organized.

Write down the key terms searched, the databases used, and the search parameters applied.

Keep track of your search results. This will help you identify the most effective search terms, eliminate duplicate citations, and ultimately save you time.

Translating a PICO Question Into Search Terms

Example Clinical Question—Does cognitive rehabilitation improve cognitive skills in adults with traumatic brain injury?

PICO	PICO Element	Keywords
P	Adult, traumatic brain injury	Adult AND Traumatic brain injury OR TBI OR Brain injury
I	Cognitive rehabilitation	Cognitive rehabilitation OR Cognitive training OR Cognitive treatment
C	Not applicable
O	Improved cognition	Cognition OR Cognitive skills OR Memory OR Attention OR Executive function OR Problem solving

Learn how to turn these keywords into a search strategy for your PICO question.

What type of external evidence is needed to answer your question?

Different questions (e.g., therapy/treatment, diagnostic, prevention) may be better addressed by different study designs. For example, determining the effect of a treatment on a specific patient population compared with an alternative or no treatment may be best addressed by a randomized controlled trial. Knowing the type of clinical question that you are asking can help you limit your search and narrow your results to the most applicable research design for your question.

Synthesized evidence can save time.

In addition to searching for individual study designs, clinicians can save time by looking for synthesized evidence. With synthesized evidence, researchers take a clinical question, gather available evidence, and make conclusions or recommendations about the body of research.

There are various types of synthesized evidence.

A systematic review is a formal assessment of the body of scientific evidence related to a clinical question and describes the extent to which various diagnostic or treatment approaches are supported by the evidence. Systematic reviews that use statistical techniques to pool data and draw conclusions across studies are known as meta-analyses. These documents provide comprehensive summaries of the evidence but stop short of recommending clinical practices.

Alternatively, clinical practice guidelines, developed by a group of topic experts, provide recommendations for managing a specific condition or population to optimize care. Guidelines may also discuss possible benefits and harms of a clinical action and recommend alternative approaches. Guidelines can be evidence based or consensus based.

• Evidence-based guidelines provide recommendations based on an evidence-based systematic review. These recommendations are often rated according to the quality and strength of the evidence.
• Consensus-based guidelines provide recommendations formed by consensus or agreement among topic experts without an evidence-based systematic review.

Quick Tip:

With synthesized evidence, the work is already done for you!

Step 3: Assess the Evidence

• Evidence-Based Practice
• Step 1: Frame Your Clinical Question
• Step 2: Gather Evidence
• Step 3: Assess the Evidence
• Step 4: Make Your Clinical Decision

Now that you’ve identified evidence to address your client’s problem or situation, the next step in the EBP process is to assess the internal and external evidence. When assessing the evidence, keep in mind that each type of evidence serves a unique purpose for your clinical decision making.

Internal evidence, or the data and observations collected on an individual client, is collected both for the accountability of your session and for tracking a client’s performance. When assessing the internal evidence, you are determining whether an intervention has impacted your client. You may analyze your data to address the following questions (adapted from Higginbotham & Satchidanand, 2019):

• Is your client demonstrating a response to the intervention?
• Is that response significant, especially for the client?
• How much longer should you continue the intervention?
• Is it time to change the therapy target, intervention approach, or service delivery model?

External evidence, found in scientific research literature, answers clinical questions such as whether an assessment measures what it intended to measure or whether a treatment approach is effective in causing change in individuals. Because the quality of external evidence is variable, this step of assessing the evidence is crucial and includes determining the reliability, importance, and applicability of the relevant scientific research to your client’s condition and needs.

Critically appraising the external evidence can help you determine if the conclusions from one or more studies can help guide your clinical decision. To assess the external evidence, you should

• determine the relevance to your question,
• appraise the validity and trustworthiness, and
• review the results and conclusions.

Determine the Relevance to Your Question

Relevance refers to how closely connected the study’s elements (e.g., study aim, participants, method, results) are to your clinical question and how well the external evidence fits your needs. Relevant research literature increases the likelihood that you can generalize the results and outcomes to your client.

Ask yourself:

• Does this study investigate a population similar to my client?
• Does the study review an intervention that I could use to advance my client’s goals?
• Are the study’s outcomes related to my question?
• If the study does not perfectly match my PICO elements, can it provide clinically relevant insights to guide clinical decisions?

Use your clinical judgment to decide whether the study’s elements are comparable and/or generalizable to the population, intervention, comparison, and/or outcome in your PICO question.

Example: You are providing cognitive intervention to a teenager with traumatic brain injury, and most studies you’ve found examine cognitive treatments for veterans with blast injuries. You will need to decide whether these studies are clinically relevant and applicable to your client, despite their focus on a somewhat different population.

Quick Tip:

If there’s no relevant research available, you may need to reconsider your PICO question and return to your search, or continue to Step 4 of the EBP process.

Appraise the Validity and Trustworthiness of the Evidence

Appraising the validity of the external evidence means that you have considered whether the study effectively investigates its aim. The study should be transparent about its methodology―the research procedure, the data collection methods, and the analysis of data and outcomes. This helps you decide whether the research evidence is trustworthy and whether you can have confidence in its results.

Ask yourself:

• Will this research design help me answer my question?
• What are the limitations of the research evidence?
• Is the external evidence from a trusted source of information?

Research Design and Study Quality

To appraise the validity of the external evidence for a clinical question, it is necessary to consider both the study design and the methodological quality of the study. Because certain research designs offer better controls against bias, many EBP hierarchies rank study quality solely based on study design. However, these hierarchies often fall short because research design alone does not necessarily equate to good external evidence. Moreover, as noted in Step 2, no one study design can answer all types of PICO questions. The chart below details the types of study designs that are best suited for various types of clinical questions.

Type of Question	Example	Preferred Study Design(s)	Other Relevant Study Design(s)
Screening/Diagnosis Accuracy in differentiating clients with or without a condition	Is an auditory brainstem response screening more accurate than an otoacoustic emissions screening in identifying newborns with hearing loss?	Prospective, blind comparison to reference standard	Cross-sectional
Treatment/Service Delivery Efficacy of an intervention	What is the most effective treatment to improve cognition in adults with traumatic brain injury?	Randomized, controlled trial	Controlled trial; single-subject/single-case experimental design
Etiology Identify causes or risk factors of a condition	What are the risk factors for speech and language disorders?	Cohort	Case control; case series
Quality of Life/Perspective Understand the opinions, experiences, and perspectives of clients, caregivers, and other relevant individuals	How do parents feel about implementing parent-mediated interventions?	Qualitative studies (e.g., case study, case series)	Ethnographic interviews or surveys of the opinions, perspectives, and experiences of clients, their caregivers, and other relevant individuals

Limitations of the Evidence

In addition to considering research design, you should also consider study methodology to identify any limitations of the external evidence. Limitations are the shortcomings or external influences for which the investigators of a study could not, or did not, control. Because study limitations can influence the outcomes of an investigation, it is crucial to identify any sources of bias or systematic errors in methodology.

To help determine what limitations exist, you can appraise the methodological quality of each study using one of many available research design–specific checklists. Depending on the checklist, you can appraise some or all of the following features:

• The study had a clearly stated and focused aim or objective.
• Investigators used methods, such as blinding or random assignment.
• The study clearly described the methods used, the intervention protocol applied, and the participants involved (e.g., age, medical diagnosis, severity of condition).
• The study objectively identified and accounted for any other confounding factors (e.g., restrictions of design, implementation fidelity).

Although other sources of bias exist, they are not typically assessed as part of these checklists. Other sources of bias to consider include conflicts of interest and publication bias.

• Conflict of interest refers to factors that may compromise the investigator’s objectivity in conducting or reporting their research. Financial funding from product developers or employment with the sponsoring organization are common examples of conflicts of interest within research. Be sure to interpret with caution any sources that appear to (a) sensationalize information, (b) lack editorial peer review, or (c) have an alternative agenda.
• Publication bias occurs when the results of a study influence whether or not the study is published. This may result in studies with positive or significant findings being more likely to be published than those with null or negative findings.

When an investigator takes steps to minimize bias, clinicians can have greater confidence in the study findings.

Quick Tip:

Information is abundant and easy to find, but it may not always be trustworthy or valid. Save time by using resources that have reviewed the included studies for quality and bias:

• Synthesized research such as evidence-based systematic reviews, meta-analyses, and guidelines usually include quality and/or bias assessment of the included studies.

Review the Results and Conclusions

Once you determine that the research is applicable and valid, you are ready to examine the findings. The results can tell you if the desired outcome of the study was achieved (i.e., “Was there a benefit from the intervention or assessment, or was there no effect?”) and whether any adverse events occurred (i.e., harm). Knowing the extent of the effects ultimately determines if the results of a study are clinically meaningful and important.

Ask yourself:

• Does the study provide statistical information—such as confidence intervals or effect sizes—about the outcomes?
• Is this information strong enough to help me make a clinical decision?
• Can I generalize the results to my client or clinical situation?

When examining the results and conclusions, consider the study’s

• statistical analyses,
• direction and consistency, and
• applicability and generalizability.

Statistical Analyses

Review the data and/or the statistical outcomes reported in the study to determine the magnitude of the results (i.e., “How large is the treatment effect?”) and whether the results are significant and clinically important. That is, whether the results are due to chance—and, if not, whether they are meaningful enough to consider in clinical practice. Information such as sample size, confidence interval, and effect size allow you to decide how large and precise the intervention effect is. A p value can help you determine whether the results of a study are statistically significant (in other words, they likely did not occur by chance), but it cannot tell you whether the results are clinically significant or clinically important. For example, a study may find a statistically significant difference between the outcomes of two groups, yet the real-life impact for the individuals in each group could be similar. Researchers can use measures such as relative risks and minimally clinically important difference (also referred to as minimally important difference) to report clinical significance.

Direction and Consistency 

Consider the results from individual studies and determine whether the overall conclusions across studies are similar. For example, taken together, are the results from the body of external evidence similarly positive or negative? Does the direction and consistency of the evidence support a change in clinical practice?

Be sure to factor in any details (e.g., participant sample size and heterogeneity of participants) that you identified in the individual studies that may limit the applicability of the results.

Applicability and Generalizability

Although studies reporting definitive outcomes are ideal, sometimes the results from individual studies or the body of external evidence are inconclusive. In other cases, there may be very little to no scientific evidence available. In these instances, it may be valuable to consider research evidence from similar populations or interventions and to determine whether the results are generalizable to your client or clinical situation. In this circumstance, it is even more critical to collect and consider data taken from your client’s performance to determine whether the approach you are taking is having the intended effect.

Quick Tip:

Research results and conclusions require careful consideration to determine whether they could be clinically meaningful to your client.

Step 4: Make Your Clinical Decision 

• Evidence-Based Practice
• Step 1: Frame Your Clinical Question
• Step 2: Gather Evidence
• Step 3: Assess the Evidence
• Step 4: Make Your Clinical Decision

The final step of the EBP process requires you to make a clinical decision. To make an evidence-based decision, clinicians must consider evidence (both internal and external), assess the appropriateness of their clinical experience for the situation, and review the individual client’s perspectives and priorities—the three components of EBP.

Although this complex and nuanced process may seem difficult, the D.E.C.I.D.E. framework can help you easily remember and implement all four steps of the EBP process and can help guide you to a clinical decision.

Define

Define your clinical question, gather external and internal evidence, and determine the validity and trustworthiness of the results. You should complete the first three steps of EBP prior to making any clinical decisions. If you have not yet completed the previous steps of EBP, see the following:

• Step 1: Frame your Clinical Question
• Step 2: Gather Evidence
• Step 3: Assess the Evidence

Extrapolate

Extrapolate clinically applicable information from the external evidence. Although some results may directly align with your client and setting, often, you will need to determine whether the overall results are compelling and meaningful enough to apply to your clinical situation. Sometimes, there is simply a lack of external evidence about your clinical question. If there’s little or no external scientific evidence, then your treatment isn’t necessarily disqualified—it just requires careful consideration and monitoring.

Quick Tip:

A lack of evidence does not equate to evidence of no effect.

Consider

Consider your clinical expertise and the expertise of others. Use your training, knowledge, and clinical experience to collect and analyze internal evidence and to interpret and apply external evidence when making a clinical decision. Refer to the Audiology and Speech-Language Pathology scopes of practice and ASHA’s Code of Ethics, as needed.

Incorporate

Incorporate the needs and perspectives of your client, their caregiver, and/or their family into your assessment and intervention decisions. These needs and perspectives can provide insight into their priorities, values, and expectations. A client’s cultural or linguistic characteristics (e.g., status as an English language learner) can also impact how you interpret the internal evidence and how you apply the external evidence to your clinical decision. Understanding what is important to your client—and considering their unique characteristics when making a clinical decision—can help you develop your treatment plan, increase your client’s participation and engagement, and ensure that their goals are meaningful—not only clinically but also personally.

Develop

Develop an assessment or treatment plan by bringing together the three components of EBP. In some clinical situations, you may need to prioritize one of the EBP components (e.g., external scientific evidence reporting harm or a client’s preference/refusal); however, you should consider all three components.

• Use your clinical expertise to determine how to implement the external and internal evidence into your assessment or intervention sessions (e.g., adapting an evidence-based treatment into an engaging and individualized activity).
• Prioritize your client’s perspectives to make the sessions meaningful. Include goals that are measurable and functional.
• Consider organizational or other barriers when developing your plan (e.g., access to materials, department protocols, transportation, or feasibility of implementation).

Quick Tip:

Be transparent with your client about the treatment plan, rationale, benefits, and potential harms.

Evaluate

Evaluate your clinical decision. Use a trial period, collect internal evidence, and analyze all of the clinical information to (a) ensure that the intervention is appropriate or (b) adjust your treatment plan as needed. EBP is a dynamic process and requires ongoing evaluation. If you don’t see progress, if your client’s needs or circumstances have changed, or if you need to re-prioritize the goals, you should cycle through the EBP process again to find another option that can better serve your client.

Compiled  & Shared by- Team, LITD (Livestock Institute of Training & Development)

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Reference-On Request.