Assignment: Evidence-Based Project, Part 5: Recommending an Evidence-Based Practice Change: The collection of evidence is an activity that occurs with an endgame in mind. For example, law enforcement professionals collect evidence to support a decision to charge those accused of criminal activity. Similarly, evidence-based healthcare practitioners collect evidence to support decisions in pursuit of specific healthcare outcomes.
In this Assignment, you will identify an issue or opportunity for change within your healthcare organization and propose an idea for a change in practice supported by an EBP approach.
To Prepare:
· Reflect on the four peer-reviewed articles you critically appraised in Module 4.
· Reflect on your current healthcare organization and think about potential opportunities for evidence-based change.
The Assignment: (Evidence-Based Project)
Part 5: Recommending an Evidence-Based Practice Change
Create an 8- to 9-slide PowerPoint presentation in which you do the following:
· Briefly describe your healthcare organization, including its culture and readiness for change. (You may opt to keep various elements of this anonymous, such as your company name.)
· Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.
· Propose an evidence-based idea for a change in practice using an EBP approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.
· Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation.
· Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.
· Be sure to provide APA citations of the supporting evidence-based peer reviewed articles you selected to support your thinking.
· Add a lessons learned section that includes the following:
· A summary of the critical appraisal of the peer-reviewed articles you previously submitted
· An explanation about what you learned from completing the evaluation table (1 slide)
· An explanation about what you learned from completing the levels of evidence table (1 slide)
· An explanation about what you learned from completing the outcomes synthesis table (1 slide)
Assignment Resources (attached):
Hoffman, T. C., Montori, V. M., & Del Mar, C. (2014). The connection between evidence-based medicine and shared decision making. Journal of the American Medical Association, 312(13), 1295–1296. doi:10.1001/jama.2014.10186
Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in intensive care units: An American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188–201. doi:10.1097/CCM.0000000000001396
Opperman, C., Liebig, D., Bowling, J., & Johnson, C. S., & Harper, M. (2016). Measuring return on investment for professional development activities: Implications for practice. Journal for Nurses in Professional Development, 32(4), 176–184. doi:10.1097/NND.0000000000000483
Schroy, P. C., Mylvaganam, S., & Davidson, P. (2014). Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making. Health Expectations, 17(1), 27–35. doi:10.1111/j.1369-7625.2011.00730.x
Last weeks’ articles : (not attached)
Ólafsdóttir, J., & Orjasniemi, T. (2018). Depression, anxiety, and stress from substance-use disorder among family members in Iceland. Nordic Studies on Alcoholics and Drugs, 35(8), 165-178.
Tracy, K., & Wallace, S. P. (2016). Benefits of peer support groups in the treatment of addiction. Substance Abuse Rehabilitation, 7, 143–154. doi: 10.2147/SAR.S81535
McQuaid, R. J., Jesseman, R., & Rush, B. (2018). Examining Barriers as Risk Factors for Relapse: A focus on the Canadian Treatment and Recovery System of Care. Canadian Journal of Addiction: 9(3), 5–12. doi:10.1097/CXA.0000000000000022
Staiger, P. K., Kyrios, M., Williams, J. S., Kambouropoulos, N., Howard, A., & Gruenert, S. (2014). Improving the retention rate for residential treatment of substance abuse by sequential intervention for social anxiety. BMC Psychiatry, 14(43), 1-10. Retrieved from https://doi.org/10.1186/1471-244X-14-43
VIEWPOINT
Tammy C. Hoffmann, PhD Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia; and University of Queensland, Brisbane, Australia.
Victor M. Montori, MD, MSc Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota.
Chris Del Mar, MD, FRACGP Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
Viewpoint page 1293
The Connection Between Evidence-Based Medicine and Shared Decision Making
Evidence-based medicine (EBM) and shared decision making (SDM) are both essential to quality health care, yet the interdependence between these 2 approaches is not generally appreciated. Evidence-based medicine should begin and end with the patient: after finding and appraising the evidence and integrating its inferences with their expertise, clinicians attempt a decision that reflects their patient’s values and circum- stances. Incorporating patient values, preferences, and circumstances is probably the most difficult and poorly mapped step—yet it receives the least attention.1 This has led to a common criticism that EBM ignores patients’ values and preferences—explicitly not its intention.2
Shared decision making is the process of clinician and patient jointly participating in a health decision after discussing the options, the benefits and harms, and considering the patient’s values, preferences, and circumstances. It is the intersection of patient-centered communication skills and EBM, in the pinnacle of good patient care (Figure).
One Without the Other?
These approaches, for the most part, have evolved in parallel, yet neither can achieve its aim without the other. Without SDM, authentic EBM cannot occur.3 It is a mechanism by which evidence can be explicitly brought into the consultation and discussed with the patient. Even if clinicians attempt to incorporate patient preferences into decisions, they sometimes erroneously guess them. However, it is through evidence-informed
the best available research evidence. If SDM does not in- corporate this body of evidence, the preferences that patients express may not be based on reliable estimates of the risks and benefits of the options, and the resulting decisions are not truly informed.
Why Is There a Disconnect?
A contributor to the existing disconnect between EBM and SDM may be that leaders, researchers, and teachers of EBM, and those of SDM, originated from, and- historically tended to practice, research, publish, and collaborate, in different clusters. Some forms of SDM have emerged from patient communication, with much of its research presented in conferences and journals in this field. A seminal paper in 19974 conceptualized SDM as a model of treatment decision making and as a patient-clinician communication skill. However, it did so without any connection to EBM—perhaps not surprisingly, be- cause EBM was in its infancy.2
Conversely, with its origins in clinical epidemiology, much of the focus of EBM has been on methods and resources to facilitate locating, appraising and synthesizing evidence. There has been much less focus on dis- cussing this evidence with patients and engaging with them in its use (sometimes even disparagingly referred to as “soft” skills). Most of the EBM attention has involved scandals (eg, unpublished data, results “spin,” conflicts of interest) and high technology milestones (eg, systems to make EBM better and easier). Information about using evidence in decision-making with patients has been scant.
Corresponding Author: Victor M. Montori, MD, MSc, Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First St SW, Plummer 3-35, Rochester, MN 55905 (Montori. victor @mayo.edu).
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deliberations that patients construct informed preferences. For patients who have to implement the decision and live with the consequences, it may be more pertinent to realize that it is through this process that patients incorporate the evidence and expertise of the clinician, along with their values and preferences, into their decision-making. Without SDM, EBM can turn into evidence of tyranny. Without SDM, evidence may poorly translate into practice and improved outcomes.
Likewise, without attention to the principles of EBM, SDM becomes limited because a number of its steps are inextricably linked to the evidence. For example, discussions with patients about the natural history of the condition, the possible options, the benefits and harms of each, and quantification of these must be informed by focusing on forming questions and finding and critically appraising evidence.5 Learning how to apply and integrate the evidence is usually absent or mentioned in passing without skill training.
Realizing the Connection Between EBM and SDM
A logical place to start is by incorporating SDM skill training into EBM training. This will help to address not only the aforementioned deficits in EBM training but also the lack of SDM training opportunities presently available. Additionally, it may facilitate the uptake of SDM and, more broadly, evidence translation. Recent calls for SDM to be routinely incorporated into medical education pre- sent an immediate opportunity to capitalize on closely aligning the approaches.
Without shared decision making, EBM can turn into evidence tyranny.
The disconnect between the 2 approaches is also evident in, and maintained by, the teaching provided to clinicians and students, again often reflecting the backgrounds of their teachers. Opportunities to attend EBM teaching abound with content largely
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Opinion Viewpoint
Figure. The Interdependence of Evidence-Based Medicine and Shared Decision Making and the Need for Both as Part of Optimal Care
recommended in guidelines when the options are closely matched in their advantages and disadvantages, when uncertainty in the evidence impairs the determination of a clearly superior approach, or when the balance of benefits and risks depends on patient activity, such as adherence to medication, monitoring, and diet in patients using warfarin.
Conclusions
Links between EBM and SDM have until recently been largely absent or at best implied. However, encouraging signs of interaction are emerging. For example, there has been some integration of the teaching of both,7 explorations about how guidelines can be adapted to facilitate SDM,8,9 and research and resource tools that recognize both approaches.
Examples of the latter include research agenda and priority setting occurring in partnership with patients and clinicians to help provide relevant evidence for decision making; and a new evidence criterion for the International Patient Decision Aids Standards requiring citation of systematically assembled and up- to-date bodies of evidence, with their trustworthiness appraised,10 thus aligning the development of SDM tools with contemporary re- requirements for the formulation of evidence-based guidelines. Also, independent flagship conferences focused on the practice of evidence-based health care and on the science of shared decision making are now convening joint meetings.
Medicine cannot, and should not, be practiced without up-to- date evidence. Nor can medicine be practiced without knowing and respecting the informed preferences of patients. Clinicians, researchers, teachers, and patients need to be aware of and actively facilitate the interdependent relationship of these approaches. Evidence-based medicine needs SDM, and SDM needs EBM. Patients need both.
Evidence-based medicine
Patient-centered communication skills
Optimal patient care
Shared decision making
Another place to start to bring EBM and SDM together is the development and implementation of clinical practice guidelines. Whereas most guidelines fail to consider patients’ preferences in formulating their recommendations,6 some advise clinicians to talk with patients about the options but provide no guidance about how to do this and communicate the evidence in a way patients will understand. Shared decision making may be strongly
ARTICLE INFORMATION
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.Dr Montori reported serving on the board of the International Society for Evidence-based Healthcare; serving as Chair of the Seventh International Shared Decision Making Conference in 2013; that he is a member of the Steering Committee of the International Patient Decision Aids Standards; and that he is a member of the GRADE Working Group. The KER Unit (Dr Montori’s research group) produces and tests evidence-based shared decision making tools that are freely available at http://shareddecisions.mayoclinic.org.
Dr Hoffmann reported that she is supported by a National Health and Medical Research Council of Australia (NHMRC)/Primary Health Care Research Evaluation and Development Career Development Fellowship (1033038), with funding provided by the Australian Department of Health and Ageing. Drs Hoffmann and Del Mar reported that they are coeditors of a book on evidence-based practice, for which they receive royalties.
Additional Information: Additional information abut evidence-based medicine and shared decision making is available online in Evidence-Based Medicine: An Oral History at http://ebm .jamanetwork.com.
