RESUMO
BACKGROUND: When a new guideline is published there is a need to understand how its recommendations can best be implemented in real-world practice. Yet, guidelines are often published with little to no roadmap for organizations to follow to promote adherence to their recommendations. The purpose of this study was to evaluate the impact of using a common process model to implement a single clinical practice guideline across multiple physical therapy clinical settings. METHODS: Five organizationally distinct sites with physical therapy services for patients with peripheral vestibular hypofunction participated. The Knowledge to Action model served as the foundation for implementation of a newly published guideline. Site leaders conducted preliminary gap surveys and face-to-face meetings to guide physical therapist stakeholders' identification of target-behaviors for improved guideline adherence. A 6-month multimodal implementation intervention included local opinion leaders, audit and feedback, fatigue-resistant reminders, and communities of practice. Therapist adherence to target-behaviors for the 6 months before and after the intervention was the primary outcome for behavior change. RESULTS: Therapist participants at all sites indicated readiness for change and commitment to the project. Four sites with more experienced therapists selected similar target behaviors while the fifth, with more inexperienced therapists, identified different goals. Adherence to target behaviors was mixed. Among four sites with similar target behaviors, three had multiple areas of statistically significantly improved adherence and one site had limited improvement. Success was most common with behaviors related to documentation and offering patients low technology resources to support home exercise. A fifth site showed a trend toward improved therapist self-efficacy and therapist behavior change in one provider location. CONCLUSIONS: The Knowledge to Action model provided a common process model for sites with diverse structures and needs to implement a guideline in practice. Multimodal, active interventions, with a focus on auditing adherence to therapist-selected target behaviors, feedback in collaborative monthly meetings, fatigue-resistant reminders, and developing communities of practice was associated with long-term improvement in adherence. Local rather than external opinion leaders, therapist availability for community building meetings, and rate of provider turnover likely impacted success in this model. TRIAL REGISTRATION: This study does not report the results of a health care intervention on human participants.
Assuntos
Fisioterapeutas , Humanos , Conhecimento , Pesquisa , Pesquisadores , Pessoal Técnico de SaúdeRESUMO
BACKGROUND AND PURPOSE: Despite efforts to translate knowledge into clinical practice, barriers often arise in adapting the strict protocols of a randomized, controlled trial (RCT) to the individual patient. The Locomotor Experience Applied Post-Stroke (LEAPS) RCT demonstrated equal effectiveness of 2 intervention protocols for walking recovery poststroke; both protocols were more effective than usual care physical therapy. The purpose of this article was to provide knowledge-translation tools to facilitate implementation of the LEAPS RCT protocols into clinical practice. METHODS: Participants from 2 of the trial's intervention arms: (1) early Locomotor Training Program (LTP) and (2) Home Exercise Program (HEP) were chosen for case presentation. The two cases illustrate how the protocols are used in synergy with individual patient presentations and clinical expertise. Decision algorithms and guidelines for progression represent the interface between implementation of an RCT standardized intervention protocol and clinical decision-making. OUTCOMES: In each case, the participant presents with a distinct clinical challenge that the therapist addresses by integrating the participant's unique presentation with the therapist's expertise while maintaining fidelity to the LEAPS protocol. Both participants progressed through an increasingly challenging intervention despite their own unique presentation. SUMMARY: Decision algorithms and exercise progression for the LTP and HEP protocols facilitate translation of the RCT protocol to the real world of clinical practice. The two case examples to facilitate translation of the LEAPS RCT into clinical practice by enhancing understanding of the protocols, their progression, and their application to individual participants.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A147).
Assuntos
Tomada de Decisão Clínica , Protocolos Clínicos , Terapia por Exercício , Reabilitação do Acidente Vascular Cerebral , Pesquisa Translacional Biomédica , Caminhada , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função FisiológicaRESUMO
OBJECTIVES: To examine the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation after stroke including assessment of short (1 hour or less) and long (more than one hour) daily treatment duration. DATA SOURCES: MEDLINE, CENTRAL, CINAHL, WOS, KoreaMed, RISS and reference lists from inception to January 2017 Review methods: We considered randomized controlled trials that reported neuromuscular electrical stimulation for the treatment of shoulder subluxation post-stroke. Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted data. RESULTS: Eleven studies were included (432 participants); seven studies were good quality, four were fair. There was a significant treatment effect of neuromuscular electrical stimulation for reduction of subluxation for persons with acute and subacute stroke (SMD:-1.11; 95% CI:-1.53, -0.68) with either short (SMD:-0.91; 95% CI:-1.43, -0.40) or long (SMD:-1.49; 95% CI:-2.31, -0.67) daily treatment duration. The effect for patients with chronic stroke was not significant (SMD:-1.25; 95% CI:-2.60, 0.11). There was no significant effect of neuromuscular electrical stimulation on arm function or shoulder pain. CONCLUSION: This meta-analysis suggests a beneficial effect of neuromuscular electrical stimulation, with either short or long daily treatment duration, for reducing shoulder subluxation in persons with acute and subacute stroke. No significant benefits were observed for persons with chronic stroke or for improving arm function or reducing shoulder pain.
Assuntos
Terapia por Estimulação Elétrica , Hemiplegia/complicações , Luxação do Ombro/terapia , Dor de Ombro/prevenção & controle , Acidente Vascular Cerebral/complicações , Humanos , Luxação do Ombro/etiologiaRESUMO
BACKGROUND AND PURPOSE: Physical therapists strive to integrate research into daily practice. The tablet computer is a potentially transformational tool for accessing information within the clinical practice environment. The purpose of this study was to measure and describe patterns of tablet computer use among physical therapy students during clinical rotation experiences. METHODS: Doctor of physical therapy students (n = 13 users) tracked their use of tablet computers (iPad), loaded with commercially available apps, during 16 clinical experiences (6-16 weeks in duration). RESULTS: The tablets were used on 70% of 691 clinic days, averaging 1.3 uses per day. Information seeking represented 48% of uses; 33% of those were foreground searches for research articles and syntheses and 66% were for background medical information. Other common uses included patient education (19%), medical record documentation (13%), and professional communication (9%). The most frequently used app was Safari, the preloaded web browser (representing 281 [36.5%] incidents of use). Users accessed 56 total apps to support clinical practice. DISCUSSION AND CONCLUSIONS: Physical therapy students successfully integrated use of a tablet computer into their clinical experiences including regular activities of information seeking. Our findings suggest that the tablet computer represents a potentially transformational tool for promoting knowledge translation in the clinical practice environment.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A127).
Assuntos
Computadores de Mão , Fisioterapeutas/educação , Modalidades de Fisioterapia/educação , Especialidade de Fisioterapia/educação , Pesquisa Translacional Biomédica , Humanos , EstudantesRESUMO
OBJECTIVE: To ascertain the existence of discordance between perceived and measured balance in persons with stroke and to examine the impact on walking speed and falls. DESIGN: A secondary analysis of a phase three, multicentered randomized controlled trial examining walking recovery following stroke. SUBJECTS: A total of 352 participants from the Locomotor Experience Applied Post-Stroke (LEAPS) trial. METHODS: Participants were categorized into four groups: two concordant and two discordant groups in relation to measured and perceived balance. Number and percentage of individuals with concordance and discordance were evaluated at two and 12 months. Walking speed and fall incidence between groups were examined. MAIN MEASURES: Perceived balance was measured by the Activities-Specific Balance Confidence scale, measured balance was determined by the Berg Balance Scale and gait speed was measured by the 10-meter walk test. RESULTS: Discordance was present for 35.8% of participants at two months post stroke with no statistically significant change in proportion at 12 months. Discordant participants with high perceived balance and low measured balance walked 0.09 m/s faster at two months than participants with concordant low perceived and measured balance (p < 0.05). Discordant participants with low perceived balance and high measured balance walked 0.15 m/s slower than those that were concordant with high perceived and measured balance (p ⩽ 0.0001) at 12 months. Concordant participants with high perceived and measured balance walked fastest and had fewer falls. CONCLUSIONS: Discordance existed between perceived and measured balance in one-third of individuals at two and 12 months post-stroke. Perceived balance impacted gait speed but not fall incidence.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Equilíbrio Postural , Autoimagem , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Velocidade de Caminhada , Idoso , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/complicações , Reabilitação do Acidente Vascular CerebralRESUMO
BACKGROUND: A primary barrier to the implementation of evidence based practice (EBP) in physical therapy is therapists' limited ability to understand and interpret statistics. Physical therapists demonstrate limited skills and report low self-efficacy for interpreting results of statistical procedures. While standards for physical therapist education include statistics, little empirical evidence is available to inform what should constitute such curricula. The purpose of this study was to conduct a census of the statistical terms and study designs used in physical therapy literature and to use the results to make recommendations for curricular development in physical therapist education. METHODS: We conducted a bibliometric analysis of 14 peer-reviewed journals associated with the American Physical Therapy Association over 12 months (Oct 2011-Sept 2012). Trained raters recorded every statistical term appearing in identified systematic reviews, primary research reports, and case series and case reports. Investigator-reported study design was also recorded. Terms representing the same statistical test or concept were combined into a single, representative term. Cumulative percentage was used to identify the most common representative statistical terms. Common representative terms were organized into eight categories to inform curricular design. RESULTS: Of 485 articles reviewed, 391 met the inclusion criteria. These 391 articles used 532 different terms which were combined into 321 representative terms; 13.1 (sd = 8.0) terms per article. Eighty-one representative terms constituted 90% of all representative term occurrences. Of the remaining 240 representative terms, 105 (44%) were used in only one article. The most common study design was prospective cohort (32.5%). CONCLUSIONS: Physical therapy literature contains a large number of statistical terms and concepts for readers to navigate. However, in the year sampled, 81 representative terms accounted for 90% of all occurrences. These "common representative terms" can be used to inform curricula to promote physical therapists' skills, competency, and confidence in interpreting statistics in their professional literature. We make specific recommendations for curriculum development informed by our findings.
Assuntos
Bibliometria , Revisão da Pesquisa por Pares , Publicações Periódicas como Assunto , Especialidade de Fisioterapia , Estatística como Assunto , Terminologia como Assunto , Humanos , Sociedades Médicas , Estados UnidosRESUMO
BACKGROUND: The majority of reporting guidelines assist researchers to report consistent information concerning study design, however, they contain limited information for describing study interventions. Using a three-stage development process, the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) checklist and accompanying explanatory paper were developed to provide guidance for the reporting of educational interventions for evidence-based practice (EBP). The aim of this study was to complete the final development for the GREET checklist, incorporating psychometric testing to determine inter-rater reliability and criterion validity. METHODS: The final development for the GREET checklist incorporated the results of a prior systematic review and Delphi survey. Thirty-nine items, including all items from the prior systematic review, were proposed for inclusion in the GREET checklist. These 39 items were considered over a series of consensus discussions to determine the inclusion of items in the GREET checklist. The GREET checklist and explanatory paper were then developed and underwent psychometric testing with tertiary health professional students who evaluated the completeness of the reporting in a published study using the GREET checklist. For each GREET checklist item, consistency (%) of agreement both between participants and the consensus criterion reference measure were calculated. Criterion validity and inter-rater reliability were analysed using intra-class correlation coefficients (ICC). RESULTS: Three consensus discussions were undertaken, with 14 items identified for inclusion in the GREET checklist. Following further expert review by the Delphi panelists, three items were added and minor wording changes were completed, resulting in 17 checklist items. Psychometric testing for the updated GREET checklist was completed by 31 participants (n = 11 undergraduate, n = 20 postgraduate). The consistency of agreement between the participant ratings for completeness of reporting with the consensus criterion ratings ranged from 19 % for item 4 Steps of EBP, to 94 % for item 16 Planned delivery. The overall consistency of agreement, for criterion validity (ICC 0.73) and inter-rater reliability (ICC 0.96), was good to almost perfect. CONCLUSION: The final GREET checklist comprises 17 items which are recommended for reporting EBP educational interventions. Further validation of the GREET checklist with experts in EBP research and education is recommended.
Assuntos
Lista de Checagem , Prática Clínica Baseada em Evidências/educação , Guias de Prática Clínica como Assunto , Ensino , Adulto , Lista de Checagem/normas , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto/normas , Psicometria , Reprodutibilidade dos Testes , Adulto JovemRESUMO
BACKGROUND: Evidence is needed to develop effective educational programs for promoting evidence based practice (EBP) and knowledge translation (KT) in physical therapy. This study reports long-term outcomes from a feasibility assessment of an educational program designed to promote the integration of research evidence into physical therapist practice. METHODS: Eighteen physical therapists participated in the 6-month Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program. The participant-driven active learning program consisted of four consecutive, interdependent components: 1) acquiring managerial leadership support and electronic resources in three clinical practices, 2) a 2-day learner-centered EBP training workshop, 3) 5 months of guided small group work synthesizing research evidence into a locally relevant list of, actionable, evidence-based clinical behaviors for therapists treating persons with musculoskeletal lumbar conditions--the Best Practices List, and 4) review and revision of the Best Practices List, culminating in participant agreement to implement the behaviors in practice. Therapists' EBP learning was assessed with standardized measures of EBP-related attitudes, self-efficacy, knowledge and skills, and self-reported behavior at baseline, immediately-post, and 6 months following conclusion of the program (long-term follow-up). Therapist adherence to the Best Practice List before and after the PEAK program was assessed through chart review. RESULTS: Sixteen therapists completed the long-term follow-up assessment. EBP self-efficacy and self-reported behaviors increased from baseline to long-term follow-up (p < 0.001 and p = 0.002, respectively). EBP-related knowledge and skills showed a trend for improvement from baseline to long-term follow-up (p = 0.05) and a significant increase from immediate-post to long-term follow-up (p = 0.02). Positive attitudes at baseline were sustained throughout (p = 0.208). Eighty-nine charts were analyzed for therapist adherence to the Best Practices List. Six clinical behaviors had sufficient pre- and post-PEAK charts to justify analysis. Of those, one behavior showed a statistically significant increase in adherence, one had high pre- and post-PEAK adherence, and four were change resistant, starting with low adherence and showing no meaningful improvement. CONCLUSIONS: This study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists' EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists' adherence to the participant generated Best Practices List in day-to-day patient care indicates a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should provide ongoing monitoring, feedback, and problem-solving to successfully promote behavior change for knowledge translation.
Assuntos
Medicina Baseada em Evidências/educação , Especialidade de Fisioterapia/educação , Pesquisa Translacional Biomédica/educação , Adulto , Atitude do Pessoal de Saúde , California , Competência Clínica , Estudos de Viabilidade , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Aprendizagem Baseada em Problemas , Avaliação de Programas e Projetos de Saúde , Autoeficácia , AutorrelatoRESUMO
BACKGROUND: Few studies have been performed to inform how best to teach evidence-based medicine (EBM) to medical trainees. Current evidence can only conclude that any form of teaching increases EBM competency, but cannot distinguish which form of teaching is most effective at increasing student competency in EBM. This study compared the effectiveness of a blended learning (BL) versus didactic learning (DL) approach of teaching EBM to medical students with respect to competency, self-efficacy, attitudes and behaviour toward EBM. METHODS: A mixed methods study consisting of a randomised controlled trial (RCT) and qualitative case study was performed with medical students undertaking their first clinical year of training in EBM. Students were randomly assigned to receive EBM teaching via either a BL approach or the incumbent DL approach. Competency in EBM was assessed using the Berlin questionnaire and the 'Assessing Competency in EBM' (ACE) tool. Students' self-efficacy, attitudes and behaviour was also assessed. A series of focus groups was also performed to contextualise the quantitative results. RESULTS: A total of 147 students completed the RCT, and a further 29 students participated in six focus group discussions. Students who received the BL approach to teaching EBM had significantly higher scores in 5 out of 6 behaviour domains, 3 out of 4 attitude domains and 10 out of 14 self-efficacy domains. Competency in EBM did not differ significantly between students receiving the BL approach versus those receiving the DL approach [Mean Difference (MD)=-0.68, (95% CI-1.71, 0.34), p=0.19]. No significant difference was observed between sites (p=0.89) or by student type (p=0.58). Focus group discussions suggested a strong student preference for teaching using a BL approach, which integrates lectures, online learning and small group activities. CONCLUSIONS: BL is no more effective than DL at increasing medical students' knowledge and skills in EBM, but was significantly more effective at increasing student attitudes toward EBM and self-reported use of EBM in clinical practice. Given the various learning styles preferred by students, a multifaceted approach (incorporating BL) may be best suited when teaching EBM to medical students. Further research on the cost-effectiveness of EBM teaching modalities is required.
Assuntos
Educação de Graduação em Medicina/métodos , Avaliação Educacional , Medicina Baseada em Evidências/educação , Ensino/métodos , Análise de Variância , Currículo , Feminino , Grupos Focais , Humanos , Aprendizagem , Masculino , Estatísticas não Paramétricas , Estudantes de Medicina/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Locomotor training, including the use of body-weight support in treadmill stepping, is a physical therapy intervention used to improve recovery of the ability to walk after stroke. The effectiveness and appropriate timing of this intervention have not been established. METHODS: We stratified 408 participants who had had a stroke 2 months earlier according to the extent of walking impairment--moderate (able to walk 0.4 to <0.8 m per second) or severe (able to walk <0.4 m per second)--and randomly assigned them to one of three training groups. One group received training on a treadmill with the use of body-weight support 2 months after the stroke had occurred (early locomotor training), the second group received this training 6 months after the stroke had occurred (late locomotor training), and the third group participated in an exercise program at home managed by a physical therapist 2 months after the stroke (home-exercise program). Each intervention included 36 sessions of 90 minutes each for 12 to 16 weeks. The primary outcome was the proportion of participants in each group who had an improvement in functional walking ability 1 year after the stroke. RESULTS: At 1 year, 52.0% of all participants had increased functional walking ability. No significant differences in improvement were found between early locomotor training and home exercise (adjusted odds ratio for the primary outcome, 0.83; 95% confidence interval [CI], 0.50 to 1.39) or between late locomotor training and home exercise (adjusted odds ratio, 1.19; 95% CI, 0.72 to 1.99). All groups had similar improvements in walking speed, motor recovery, balance, functional status, and quality of life. Neither the delay in initiating the late locomotor training nor the severity of the initial impairment affected the outcome at 1 year. Ten related serious adverse events were reported (occurring in 2.2% of participants undergoing early locomotor training, 3.5% of those undergoing late locomotor training, and 1.6% of those engaging in home exercise). As compared with the home-exercise group, each of the groups receiving locomotor training had a higher frequency of dizziness or faintness during treatment (P=0.008). Among patients with severe walking impairment, multiple falls were more common in the group receiving early locomotor training than in the other two groups (P=0.02). CONCLUSIONS: Locomotor training, including the use of body-weight support in stepping on a treadmill, was not shown to be superior to progressive exercise at home managed by a physical therapist. (Funded by the National Institute of Neurological Disorders and Stroke and the National Center for Medical Rehabilitation Research; LEAPS ClinicalTrials.gov number, NCT00243919.).
Assuntos
Terapia por Exercício , Reabilitação do Acidente Vascular Cerebral , Caminhada , Acidentes por Quedas , Idoso , Peso Corporal , Método Duplo-Cego , Terapia por Exercício/efeitos adversos , Terapia por Exercício/instrumentação , Feminino , Serviços de Assistência Domiciliar , Humanos , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Acidente Vascular Cerebral/fisiopatologiaRESUMO
BACKGROUND: Many healthcare professionals use smartphones and tablets to inform patient care. Contemporary research suggests that handheld computers may support aspects of clinical diagnosis and management. This systematic review was designed to synthesise high quality evidence to answer the question; Does healthcare professionals' use of handheld computers improve their access to information and support clinical decision making at the point of care? METHODS: A detailed search was conducted using Cochrane, MEDLINE, EMBASE, PsycINFO, Science and Social Science Citation Indices since 2001. Interventions promoting healthcare professionals seeking information or making clinical decisions using handheld computers were included. Classroom learning and the use of laptop computers were excluded. Two authors independently selected studies, assessed quality using the Cochrane Risk of Bias tool and extracted data. High levels of data heterogeneity negated statistical synthesis. Instead, evidence for effectiveness was summarised narratively, according to each study's aim for assessing the impact of handheld computer use. RESULTS: We included seven randomised trials investigating medical or nursing staffs' use of Personal Digital Assistants. Effectiveness was demonstrated across three distinct functions that emerged from the data: accessing information for clinical knowledge, adherence to guidelines and diagnostic decision making. When healthcare professionals used handheld computers to access clinical information, their knowledge improved significantly more than peers who used paper resources. When clinical guideline recommendations were presented on handheld computers, clinicians made significantly safer prescribing decisions and adhered more closely to recommendations than peers using paper resources. Finally, healthcare professionals made significantly more appropriate diagnostic decisions using clinical decision making tools on handheld computers compared to colleagues who did not have access to these tools. For these clinical decisions, the numbers need to test/screen were all less than 11. CONCLUSION: Healthcare professionals' use of handheld computers may improve their information seeking, adherence to guidelines and clinical decision making. Handheld computers can provide real time access to and analysis of clinical information. The integration of clinical decision support systems within handheld computers offers clinicians the highest level of synthesised evidence at the point of care. Future research is needed to replicate these early results and to identify beneficial clinical outcomes.
Assuntos
Computadores de Mão/estatística & dados numéricos , Sistemas de Apoio a Decisões Clínicas/estatística & dados numéricos , HumanosRESUMO
BACKGROUND: There is a need for theoretically grounded and evidence-based interventions that enhance the use of research evidence in physical therapist practice. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists' integration of research evidence into clinical decision-making. The pedagogical foundations for the PEAK educational program include Albert Bandura's social cognitive theory and Malcolm Knowles's adult learning theory. Additionally, two complementary frameworks of knowledge translation, the Promoting Action on Research Implementation in Health Services (PARiHS) and Knowledge to Action (KTA) Cycle, were used to inform the organizational elements of the program. Finally, the program design was influenced by evidence from previous attempts to facilitate the use of research in practice at the individual and organizational levels. DISCUSSION: The 6-month PEAK program consisted of four consecutive and interdependent components. First, leadership support was secured and electronic resources were acquired and distributed to participants. Next, a two-day training workshop consisting of didactic and small group activities was conducted that addressed the five steps of evidence based practice. For five months following the workshop, participants worked in small groups to review and synthesize literature around a group-selected area of common clinical interest. Each group contributed to the generation of a "Best Practices List" - a list of locally generated, evidence-based, actionable behaviors relevant to the groups' clinical practice. Ultimately, participants agreed to implement the Best Practices List in their clinical practice. SUMMARY: This, first of two companion papers, describes the underlying pedagogical theories, knowledge translation frameworks, and research evidence used to derive the PEAK program - an educational program designed to promote the use of research evidence to inform physical therapist practice. The four components of the program are described in detail. The companion paper reports the results of a mixed methods feasibility analysis of this complex educational intervention.
Assuntos
Medicina Baseada em Evidências/educação , Especialidade de Fisioterapia/educação , Currículo , Humanos , Modalidades de Fisioterapia/normas , Pesquisa Translacional Biomédica/educaçãoRESUMO
BACKGROUND: While a variety of instruments have been developed to assess knowledge and skills in evidence based medicine (EBM), few assess all aspects of EBM - including knowledge, skills attitudes and behaviour - or have been psychometrically evaluated. The aim of this study was to develop and validate an instrument that evaluates medical trainees' competency in EBM across knowledge, skills and attitude. METHODS: The 'Assessing Competency in EBM' (ACE) tool was developed by the authors, with content and face validity assessed by expert opinion. A cross-sectional sample of 342 medical trainees representing 'novice', 'intermediate' and 'advanced' EBM trainees were recruited to complete the ACE tool. Construct validity, item difficulty, internal reliability and item discrimination were analysed. RESULTS: We recruited 98 EBM-novice, 108 EBM-intermediate and 136 EBM-advanced participants. A statistically significant difference in the total ACE score was observed and corresponded to the level of training: on a 0-15-point test, the mean ACE scores were 8.6 for EBM-novice; 9.5 for EBM-intermediate; and 10.4 for EBM-advanced (p < 0.0001). Individual item discrimination was excellent (Item Discrimination Index ranging from 0.37 to 0.84), with internal reliability consistent across all but three items (Item Total Correlations were all positive ranging from 0.14 to 0.20). CONCLUSION: The 15-item ACE tool is a reliable and valid instrument to assess medical trainees' competency in EBM. The ACE tool provides a novel assessment that measures user performance across the four main steps of EBM. To provide a complete suite of instruments to assess EBM competency across various patient scenarios, future refinement of the ACE instrument should include further scenarios across harm, diagnosis and prognosis.
Assuntos
Competência Clínica/normas , Educação Médica/normas , Avaliação Educacional/métodos , Medicina Baseada em Evidências/educação , Competência Clínica/estatística & dados numéricos , Estudos Transversais , Educação Médica/estatística & dados numéricos , Avaliação Educacional/normas , Medicina Baseada em Evidências/normas , Humanos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Clinicians need innovative educational programs to enhance their capacity for using research evidence to inform clinical decision-making. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists' integration of research evidence into clinical decision-making. This, second of two, papers reports a mixed methods feasibility study of the PEAK program among physical therapists at three university-based clinical facilities. METHODS: A convenience sample of 18 physical therapists participated in the six-month educational program. Mixed methods were used to triangulate results from pre-post quantitative data analyzed concurrently with qualitative data from semi-structured interviews and focus groups. Feasibility of the program was assessed by evaluating change in participants' attitudes, self-efficacy, knowledge, skills, and self-reported behaviors in addition to their perceptions and reaction to the program. RESULTS: All 18 therapists completed the program. The group experienced statistically significant improvements in evidence based practice self-efficacy and self-reported behavior (p < 0.001). Four themes were supported by integrated quantitative and qualitative results: 1. The collaborative nature of the PEAK program was engaging and motivating; 2. PEAK participants experienced improved self-efficacy, creating a positive cycle where success reinforces engagement with research evidence; 3. Participants' need to understand how to interpret statistics was not fully met; 4. Participants believed that the utilization of research evidence in their clinical practice would lead to better patient outcomes. CONCLUSIONS: The PEAK program is a feasible educational program for promoting physical therapists' use of research evidence in practice. A key ingredient seems to be guided small group work leading to a final product that guides local practice. Further investigation is recommended to assess long-term behavior change and to compare outcomes to alternative educational models.
Assuntos
Medicina Baseada em Evidências/educação , Especialidade de Fisioterapia/educação , Adulto , Currículo , Humanos , Pessoa de Meia-Idade , Modalidades de Fisioterapia/normas , Avaliação de Programas e Projetos de Saúde , Pesquisa Translacional Biomédica/educaçãoRESUMO
BACKGROUND: Undertaking a Delphi exercise is recommended during the second stage in the development process for a reporting guideline. To continue the development for the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) a Delphi survey was undertaken to determine the consensus opinion of researchers, journal editors and educators in evidence-based practice (EBP) regarding the information items that should be reported when describing an educational intervention for EBP. METHODS: A four round online Delphi survey was conducted from October 2012 to March 2013. The Delphi panel comprised international researchers, educators and journal editors in EBP. Commencing with an open-ended question, participants were invited to volunteer information considered important when reporting educational interventions for EBP. Over three subsequent rounds participants were invited to rate the importance of each of the Delphi items using an 11 point Likert rating scale (low 0 to 4, moderate 5 to 6, high 7 to 8 and very high >8). Consensus agreement was set a priori as at least 80 per cent participant agreement. Consensus agreement was initially calculated within the four categories of importance (low to very high), prior to these four categories being merged into two (<7 and ≥7). Descriptive statistics for each item were computed including the mean Likert scores, standard deviation (SD), range and median participant scores. Mean absolute deviation from the median (MAD-M) was also calculated as a measure of participant disagreement. RESULTS: Thirty-six experts agreed to participate and 27 (79%) participants completed all four rounds. A total of 76 information items were generated across the four survey rounds. Thirty-nine items (51%) were specific to describing the intervention (as opposed to other elements of study design) and consensus agreement was achieved for two of these items (5%). When the four rating categories were merged into two (<7 and ≥7), 18 intervention items achieved consensus agreement. CONCLUSION: This Delphi survey has identified 39 items for describing an educational intervention for EBP. These Delphi intervention items will provide the groundwork for the subsequent consensus discussion to determine the final inclusion of items in the GREET, the first reporting guideline for educational interventions in EBP.
Assuntos
Prática Clínica Baseada em Evidências/educação , Guias como Assunto/normas , Consenso , Coleta de Dados , Técnica Delphi , Prática Clínica Baseada em Evidências/normas , Feminino , Humanos , MasculinoRESUMO
BACKGROUND: The aim of this systematic review was to identify which information is included when reporting educational interventions used to facilitate foundational skills and knowledge of evidence-based practice (EBP) training for health professionals. This systematic review comprised the first stage in the three stage development process for a reporting guideline for educational interventions for EBP. METHODS: The review question was 'What information has been reported when describing educational interventions targeting foundational evidence-based practice knowledge and skills?'MEDLINE, Academic Search Premier, ERIC, CINAHL, Scopus, Embase, Informit health, Cochrane Library and Web of Science databases were searched from inception until October - December 2011. Randomised and non-randomised controlled trials reporting original data on educational interventions specific to developing foundational knowledge and skills of evidence-based practice were included.Studies were not appraised for methodological bias, however, reporting frequency and item commonality were compared between a random selection of studies included in the systematic review and a random selection of studies excluded as they were not controlled trials. Twenty-five data items were extracted by two independent reviewers (consistency > 90%). RESULTS: Sixty-one studies met the inclusion criteria (n = 29 randomised, n = 32 non-randomised). The most consistently reported items were the learner's stage of training, professional discipline and the evaluation methods used (100%). The least consistently reported items were the instructor(s) previous teaching experience (n = 8, 13%), and student effort outside face to face contact (n = 1, 2%). CONCLUSION: This systematic review demonstrates inconsistencies in describing educational interventions for EBP in randomised and non-randomised trials. To enable educational interventions to be replicable and comparable, improvements in the reporting for educational interventions for EBP are required. In the absence of a specific reporting guideline, there are a range of items which are reported with variable frequency. Identifying the important items for describing educational interventions for facilitating foundational knowledge and skills in EBP remains to be determined. The findings of this systematic review will be used to inform the next stage in the development of a reporting guideline for educational interventions for EBP.
Assuntos
Prática Clínica Baseada em Evidências/educação , Competência Clínica/normas , Ensaios Clínicos como Assunto/normas , Prática Clínica Baseada em Evidências/normas , Guias como Assunto , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto/normasRESUMO
OBJECTIVE: To assess the relationship between exercise tolerance test (ETT) performance at 6 weeks poststroke and subsequent performance in a treadmill and overground locomotor training program (LTP). DESIGN: Prospective cohort study. SETTING: Exercise testing laboratory in either a primary care hospital or outpatient clinic. PARTICIPANTS: Community-dwelling individuals (N=469), 54.9±19.0 days poststroke, enrolled in the Locomotor Experience Applied Post-Stroke randomized controlled trial. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: For participants randomly assigned to LTP, the number of sessions needed to attain the training goal of 20 minutes of treadmill stepping was determined. Regression analyses determined the contribution of ETT performance (cycling duration), age, and 6-minute walk test (6MWT) distance to attainment of the stepping duration goal. RESULTS: Age, 6MWT, and ETT performance individually accounted for 10.74%, 10.82%, and 10.76%, respectively, of the variance in the number of sessions needed to attain 20 minutes of stepping. When age and 6MWT were included in the model, the additional contribution of ETT performance was rendered nonsignificant (P=.150). CONCLUSIONS: To the extent that ETT performance can be viewed as a measure of cardiovascular fitness rather than neurologic impairment, cardiovascular fitness at the time of the ETT did not make a significant unique contribution to the number of sessions needed to achieve 20 minutes of stepping. The 6MWT, which involves less intensive exercise than the ETT and therefore is likely to be predominantly affected by neurologic impairment and muscular condition, appeared to account for as much variance as the ETT.
Assuntos
Teste de Esforço/métodos , Tolerância ao Exercício , Avaliação de Resultados em Cuidados de Saúde/métodos , Modalidades de Fisioterapia , Reabilitação do Acidente Vascular Cerebral , Fatores Etários , Idoso , Pressão Sanguínea , Feminino , Frequência Cardíaca , Humanos , Locomoção , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , CaminhadaRESUMO
BACKGROUND: Handheld computers and mobile devices provide instant access to vast amounts and types of useful information for health care professionals. Their reduced size and increased processing speed has led to rapid adoption in health care. Thus, it is important to identify whether handheld computers are actually effective in clinical practice. OBJECTIVE: A scoping review of systematic reviews was designed to provide a quick overview of the documented evidence of effectiveness for health care professionals using handheld computers in their clinical work. METHODS: A detailed search, sensitive for systematic reviews was applied for Cochrane, Medline, EMBASE, PsycINFO, Allied and Complementary Medicine Database (AMED), Global Health, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. All outcomes that demonstrated effectiveness in clinical practice were included. Classroom learning and patient use of handheld computers were excluded. Quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A previously published conceptual framework was used as the basis for dual data extraction. Reported outcomes were summarized according to the primary function of the handheld computer. RESULTS: Five systematic reviews met the inclusion and quality criteria. Together, they reviewed 138 unique primary studies. Most reviewed descriptive intervention studies, where physicians, pharmacists, or medical students used personal digital assistants. Effectiveness was demonstrated across four distinct functions of handheld computers: patient documentation, patient care, information seeking, and professional work patterns. Within each of these functions, a range of positive outcomes were reported using both objective and self-report measures. The use of handheld computers improved patient documentation through more complete recording, fewer documentation errors, and increased efficiency. Handheld computers provided easy access to clinical decision support systems and patient management systems, which improved decision making for patient care. Handheld computers saved time and gave earlier access to new information. There were also reports that handheld computers enhanced work patterns and efficiency. CONCLUSIONS: This scoping review summarizes the secondary evidence for effectiveness of handheld computers and mhealth. It provides a snapshot of effective use by health care professionals across four key functions. We identified evidence to suggest that handheld computers provide easy and timely access to information and enable accurate and complete documentation. Further, they can give health care professionals instant access to evidence-based decision support and patient management systems to improve clinical decision making. Finally, there is evidence that handheld computers allow health professionals to be more efficient in their work practices. It is anticipated that this evidence will guide clinicians and managers in implementing handheld computers in clinical practice and in designing future research.
Assuntos
Pessoal de Saúde , Revisões Sistemáticas como Assunto , Computadores de Mão , Avaliação de Programas e Projetos de SaúdeRESUMO
BACKGROUND: Evidence based practice (EBP) requires that health professionals are competent in integrating the best evidence in their decision making. Being 'evidence-based' requires skills and knowledge in epidemiology, biostatistics and information literacy. EBP is commonly taught in medical and health sciences degrees, yet there is little evidence to guide educators as to the best teaching modality to increase learner competency in EBP. METHODS/DESIGN: This study is mixed methods in design. A randomised controlled trial will examine the effectiveness of blended learning versus didactic approach of teaching EBP to medical students. The primary outcome of the RCT is EBP competency as assessed by the Berlin tool. Focus groups will be conducted to explore student perceptions and attitudes towards implementing a blended learning approach in teaching EBP. A concurrent triangulation design will be implemented, permitting quantitative data to inform the effectiveness of the intervention and qualitative data to contextualise the results. DISCUSSION: This study will provide novel evidence on the effectiveness of blended learning in teaching EBP to a cohort of undergraduate and graduate-entry medical students.
Assuntos
Medicina Baseada em Evidências/educação , Ensino/métodos , Currículo , Avaliação Educacional , Humanos , Desenvolvimento de Programas , Avaliação de Programas e Projetos de SaúdeRESUMO
BACKGROUND AND PURPOSE: Better understanding of fall risk poststroke is required for developing screening and prevention programs. This study characterizes falls in the Locomotor Experience Applied Post-Stroke (LEAPS) randomized clinical trial, describes the impact of 2 walking recovery interventions on falls, and examines the value of clinical assessments for predicting falls. METHODS: Community-dwelling ambulatory stroke survivors enrolled in LEAPS were assessed 2 months poststroke. Falls were monitored until 12 months poststroke and participants were characterized as multiple or injurious (M/I); single, noninjurious; or nonfallers. Incidence and time to M/I falls were compared across interventions (home exercise and locomotor training initiated 2 months [early-LTP] or 6 months [late-LTP] poststroke). Predictive value of 2-month clinical assessments for falls outcome was assessed. RESULTS: Among the 408 participants, 36.0% were M/I, 21.6% were single, noninjurious, and 42.4% were nonfallers. Most falls occurred at home in the first 3 months after assessment. Falls incidence was highest for those with severe walking impairment who received early-LTP (P=0.025). Berg Balance Scale score ≤ 42/56 was the single best predictor of M/I falls. CONCLUSIONS: As individuals with stroke improve in walking capacity, risk for M/I falls remains high. Individuals walking <0.4 m/s are at higher risk for M/I falls if they receive early-LTP training. Berg Balance Scale score at 2 months poststroke is useful for informing falls risk, but it cannot account for the multifactorial nature of the problem. Falls prevention in stroke will require multifactorial risk assessment and management provided concomitantly with exercise interventions to improve mobility. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00243919.